January 4, 2001 
Dear State Health Official: 
The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA - the 
Act) (Public Law 106-354) amends Title XIX of the Social Security Act to give States 
enhanced matching funds to provide Medicaid eligibility to a new group of individuals 
previously not eligible under the program. The new option allows states to provide 
full Medicaid benefits to uninsured women under age 65 who are identified through 
the Centers for Disease Control and Prevention's (CDC) National Breast and Cervical 
Cancer Early Detection Program (NBCCEDP) and are in need of treatment for breast 
or cervical cancer, including pre-cancerous conditions and early stage cancer. The 
Act also allows states to extend presumptive eligibility to applicants in order to 
ensure that needed treatment begins as early as possible. The Act has an effective 
date of October 1, 2000. 
The Health Care Financing Administration (HCFA) and CDC are committed to 
facilitating states' efforts to improve access to needed breast and cervical cancer 
treatment for uninsured women identified under the NBCCEDP as needing such 
treatment. This letter is a first step in support of that commitment. It provides a 
brief overview of CDC's NBCCEDP program and outlines the basic provisions of the 
new Medicaid coverage option. 
Overview of CDC's National Breast and Cervical Cancer Early Detection 
Program (CDC Program)
During 2001, almost 50,000 women are expected to die from breast or cervical 
cancer in the United States despite the fact that earlier detection and treatment of 
these diseases could substantially decrease this mortality. Many of these deaths, 
which will occur disproportionately among women of racial and ethnic minority and 
low?income groups, could be avoided by making cancer screening services available 
to all women at risk. Recognizing the value of screening and early detection, 
Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990. 
This Act established the NBCCEDP, which authorizes CDC to promote breast and 
cervical cancer screening and to pay for screening services for eligible women. 
The NBCCEDP operates in all 50 states, the District of Columbia, 6 U.S. Territories, 
and 12 American Indian/Alaska Native organizations. Through cooperative 
agreements with state and territorial Health Departments, the District of Columbia 
Health Department, and American Indian/Alaskan Native Health Agencies, CDC's 
NBCCEDP builds the infrastructure for breast and cervical cancer early detection by 
supporting public and provider education, quality assurance, surveillance, and 
evaluation activities critical to achieving maximum utilization of the Program's 
screening, diagnostic and case management services. 
Screening services provided by the NBCCEDP include clinical breast examinations, 
mammograms, pelvic examinations, and Papanicolaou (Pap) tests. Screening 
services also include diagnostic services, such as surgical consultation and biopsy to 
ensure that all women with abnormal screening results receive timely and adequate 
diagnostic evaluation and treatment referrals. The law does not, however, allow CDC  to pay for treatment services for women who are diagnosed with breast or cervical 
cancer. 
As a condition of participation in the CDC program, 42 U.S.C.300n(a) requires states 
to agree that low-income women will be given priority in the provision of services. 
Over the past 10 years, the NBCCEDP has provided more than 2 million screening 
exams to underserved women, including older women, women with low incomes, 
and women of racial and ethnic minority groups. The program has diagnosed more 
than 8,600 breast cancers, over 39,000 pre-cancerous cervical lesions, and 660 
cervical cancers. The overall goal of the NBCCEDP is to reduce mortality from breast 
and cervical cancers, and the success of this effort hinges on the identification and 
treatment of pre-cancerous conditions and early stage cancers. 
Medicaid Program Requirements
It is difficult for many uninsured women who are screened and diagnosed through 
the CDC program to obtain timely access to treatment services. The BCCPTA allows 
States to provide coverage to these women under Medicaid. The following outlines 
the basic rules regarding the new eligibility option. 
Eligibility. The BCCPTA adds a new optional categorically needy eligibility group 
(Section 1902(a)(10)(A)(ii)(XVIII), which is comprised of individuals described in 
1902(aa)). In order to qualify under this new optional category, the Act requires 
that a woman will need to meet the following eligibility requirements: 
1.  The woman must have been screened for breast or cervical cancer1 under the 
CDC Breast and Cervical Cancer Early Detection Program established under 
Title XV of the Public Health Service (PHS) Act, and found to need treatment 
for either breast or cervical cancer; and  
2.  She must be uninsured, that is, she must not otherwise have creditable 
coverage (including current enrollment in Medicaid), as the term is used 
under the Health Insurance Portability and Accountability Act (HIPAA) 
(2701(c) of the PHS Act (42 U.S.C. 300gg(c)), and she must not be eligible 
under any of the mandatory Medicaid eligibility groups. There is no 
requirement that there be a waiting period of prior uninsurance before a 
woman who has been screened under the CDC program can become eligible 
for Medicaid under this new option; and  
3.  She must be under age 65.  
 
Breast and cervical cancer treatment programs have varied from state to state. 
Some states have run programs separate from Title XV and may wish to combine 
those programs with Title XV. It is anticipated that variations among states will 
continue and programs will continue to evolve. 
We have been advised by CDC that a woman has been "screened under the 
program" if she comes under any of the following three categories: 
1.  CDC Title XV funds paid for all or part of the costs of her screening services.   2.  The woman is screened under a state Breast and Cervical Cancer Early 
Detection Program in which her particular clinical service has not been paid 
for by CDC Title XV funds, but the service was rendered by a provider and/or 
an entity funded at least in part by CDC Title XV funds; the service was within 
the scope of a grant, sub-grant or contract under that State program; and the 
State CDC Title XV grantee has elected to include such screening activities by 
that provider as screening activities pursuant to CDC Title XV.  
3.  The woman is screened by any other provider and/or entity and the state CDC 
Title XV grantee has elected to include screening activities by that provider as 
screening activities pursuant to CDC Title XV. For example, if a family 
planning or community health center provides breast or cervical cancer 
screening or diagnostic services, the state would have the option of including 
the provider's screening activities as part of overall CDC Title XV activities.  
 
As long as the screening was performed by a provider under the state's Breast and 
Cervical Cancer Early Detection Program as defined above, the woman meets the 
Medicaid eligibility requirement. The programs operating in states under the CDC 
program will be able to provide Medicaid agencies with verification that the woman 
was screened under the CDC program. 
In the context of BCCPTA, a woman is considered to "need treatment" if, in the 
opinion of the individual's treating health professional (i.e., the individual who 
conducts the screen or any other health professional with whom the individual 
consults), the screen (and diagnostic evaluation following the clinical screening) 
indicates that the woman is in need of treatment services. These services include 
diagnostic services that may be necessary to determine the extent and proper course 
of treatment, as well as treatment itself. 
In addition to meeting these criteria, the woman will also need to meet any other 
general coverage requirements applicable to Medicaid beneficiaries (e.g., state 
residency and citizenship or immigration status). There are no Medicaid income or 
resource limitations imposed by federal law for this new Medicaid eligibility group2, 
and no authority for states to impose such limitations. 
Eligibility Period. As with other mandatory and optional eligibility categories, under 
1902(a)(34) of the Act, a woman's eligibility for coverage under this new option 
begins up to three months prior to the month in which she applied for Medicaid, if as 
of this earlier date, she would have met relevant program requirements as described 
in the eligibility section of this letter. Her eligibility for coverage ends when her 
course of treatment is completed, or the state has determined that she no longer 
meets the criteria for this eligibility category (for example, because she has attained 
age 65 or has creditable coverage) and has determined in accordance with 42 C.F.R. 
435.916 that she does not remain eligible for Medicaid under an alternate eligibility 
category. 
A woman is not limited to one period of eligibility. A new period of eligibility and 
coverage would commence each time a woman who has been screened under the 
CDC program has been found to need treatment of breast or cervical cancer, and 
meets other eligibility criteria.  Coverage. A woman whose eligibility is based on this new option is entitled to full 
Medicaid coverage; coverage is not limited to coverage for treatment of breast and 
cervical cancer. 
As is the case with Medicaid coverage in general, states may use administrative 
methods, such as prior review and approval requirements, to ensure that services 
furnished to women under this new option are medically necessary. Services 
furnished under this new option should be, to the maximum extent possible, 
consistent with optimal standards of practice. Such practice guidelines are located at 
the National Guideline Clearinghouse, Agency for Health Care Research and Quality: 
http://www.ahrq.gov. With respect to experimental treatments, States may cover 
experimental treatments although they are not required to do so. Furthermore, 
routine covered costs associated with the experimental intervention may be covered. 
Presumptive Eligibility. Presumptive eligibility is a Medicaid option that allows 
states to enroll Medicaid applicants for a limited period of time before full Medicaid 
applications are filed and processed, based on a determination by a Medicaid 
provider of likely Medicaid eligibility. States have the option to use the presumptive 
eligibility procedure to facilitate the prompt enrollment and immediate access to 
services for women who are in need of treatment for breast or cervical cancer. 
Under this option, states can certify entities that are eligible for payment under a 
state's Medicaid program that the state determines are capable of making 
presumptive eligibility determinations. A certified entity can enroll women who 
appear to be eligible in Medicaid on a temporary basis. 
Presumptive eligibility begins on the date that a qualified entity determines that the 
woman appears to meet the eligibility criteria described above. Presumptive eligibility 
ends on the earlier of the following two dates: the date on which a formal 
determination is made on the woman's application for Medicaid; or, in the case of a 
woman who fails to apply for Medicaid following the presumptive eligibility 
determination, the last day of the month following the month in which presumptive 
eligibility begins. Federal financial participation is allowed for services provided 
during this presumptive eligibility period regardless of whether or not the woman 
applies for Medicaid or is later found eligible for Medicaid. 
Citizenship and Alienage. The usual rules which govern citizenship and alienage 
apply to the new optional Medicaid eligibility group. In general, to be eligible for 
Medicaid an individual must either be a citizen or a qualified alien. (See the web site 
at http://aspe.hss.gov/hsp/immigration/restrictions-sum.htm for a definition of 
"qualified alien" and a discussion of the restrictions on immigrants receiving federal 
public benefits, including Medicaid, and for a list of exceptions to these restrictions.) 
Most states have elected to provide Medicaid to qualified aliens. However, many 
qualified aliens who arrived in the United States after August 21, 1996 are barred 
from receiving Medicaid for 5 years beginning with their date of entry with a qualified 
alien status. The 5 year bar does not apply to certain refugees, asylees, and certain 
other groups. Otherwise eligible qualified aliens who are subject to the 5 year ban as 
well as otherwise eligible non-qualified aliens may receive Medicaid coverage for 
treatment of an emergency medical condition but not including organ transplants and 
transplant-related services.  Women who do not meet the immigration-related eligibility criteria may still be able 
to receive Medicaid coverage related to an "emergency condition", other than 
services related to an organ transplant. Section 1903(v) of the Act permits states to 
obtain Federal match for services related to an "emergency medical condition" when 
furnished to an otherwise eligible individual. The term "emergency medical condition" 
means a medical condition manifesting itself by acute symptoms of sufficient severity 
(including severe pain) such that the absence of immediate medical attention could 
reasonably be expected to result in: (A) placing the patient's health in serious 
jeopardy; (B) serious impairment of bodily functions, or (C) serious dysfunction of 
any bodily part. 
Breast or cervical cancers may be identified at various stages. Some women in need 
of treatment for breast or cervical cancer will have an emergency condition. As with 
other examples of emergency medical conditions, medical judgement and the facts 
of a particular case will form the basis for identifying those conditions in screened 
women that amount to an emergency medical condition. 
Requirement to Submit a State Plan Amendment. In order to be eligible for 
payment under this new Act, a state or territory must submit a state plan 
amendment electing this optional categorically needy eligibility group and/or to 
provide presumptive eligibility. We enclose state plan preprint language that should 
be used by states electing these new options. 
Matching Rate. The Federal matching rate for the new eligibility group is equal to 
the enhanced Federal Medical Assistance Percentage (FMAP) used in the State 
Children's Health Insurance Program (SCHIP) (described in 2105(b) of the Social 
Security Act (the Act)). That rate is published periodically in the Federal Register, 
and is posted on web site http://aspe.os.dhhs.gov/health/fmap.htm. 
Participation of Territories. Territories that operate Medicaid programs (Puerto 
Rico, Virgin Islands, American Samoa, Guam and the Northern Marianas Islands) 
may choose this new option. However, federal payments to those territories are 
capped by statute. To the extent that these territories already receive the maximum 
federal payment permitted, the new law would not result in any additional federal 
funding. If the cap on federal payments has not been reached, federal funds at the 
enhanced matching rate could be available for the new eligibility group. 
Treatment of American Indian and Alaska Native (AI/AN) Women. Under 
Section 2701(c) of the Public Health Service Act, a medical care program of the 
Indian Health Service (IHS) or an Indian tribal organization is considered creditable 
coverage, as the term is used under HIPAA. But not all AI/AN women are "covered 
under" this creditable coverage. The term "covered under" implies reasonable access 
to such a program. In consultation with IHS and the tribes, we intend to develop 
standards to determine whether individuals are "covered under" such a program. 
Overview of Implementation
Successful implementation of the new benefit will require a coordinated effort 
between state Medicaid and public health agencies. State breast and cervical cancer 
programs have been in place for several years so they may be able to provide to  state Medicaid agencies important data on the numbers of women screened and 
diagnosed within a state. 
At the federal level, HCFA will be working closely with CDC to help facilitate 
implementation of the new coverage group. To assist states as they move forward, 
we are developing the state plan materials, instructions and more detailed questions 
and answers regarding the new benefit. 
We believe that states will be able to design application procedures that are simple 
and that are closely tied to the case management services offered by most state 
breast and cervical cancer programs. A simple process will help ensure that women 
with cancer receive the treatment they need. 
We encourage you to submit state plan amendments to your HCFA regional office as 
quickly as possible. HCFA staff will gladly offer technical assistance to any state that 
requests it. If you have questions about issues not addressed in this letter, please 
contact Marlene Jones at HCFA (410) 786-3290 for Medicaid-related issues and 
Steve Reynolds at CDC (770) 488-3075 for issues concerning NBCCEDP. 
Sincerely, 
/s/ 
Timothy M. Westmoreland  
Director 
 
 
Footnotes:  
(1) A woman is considered to have been screened under the CDC program and 
eligible for the new Medicaid optional group if she has received a screening 
mammogram, clinical breast exam, or Pap test; or she has received diagnostic 
services following an abnormal clinical breast exam, mammogram, or Pap test; and 
she has received a diagnosis of breast or cervical cancer or of a pre-cancerous 
condition of the breast or cervix as the result of the screening or diagnostic service. 
(2) Public Law 106 - 554, included the Medicare, Medicaid and SCHIP Benefits 
Improvement and Protection Act of 2000 which, at section 710, provides a technical 
correction that the limitation under section 1903 (f) of the Social Security Act which 
limits federal matching funds to individuals with incomes below 133 1/3% of the 
payment ordinarily made under the former Aid to Families with Dependent Children 
(AFDC) program to a family of the same size does not apply to this eligibility group. 
The effective date of the technical correction is October 1, 2000. States may cover all 
women who are screened through the CDC program and determined eligible for the 
new Medicaid option regardless of income. 
 
 
Enclosure  cc:  
HCFA Regional Administrators  
HCFA Associate Regional Administrators for Medicaid and State Operations  
Centers for Disease Control and Prevention Grantees  
Nancy Lee - Centers for Disease Control and Prevention  
Steve Reynolds - Centers for Disease Control and Prevention  
Kathy Cahill - Centers for Disease Control and Prevention  
Don Shriber - Centers for Disease Control and Prevention, State Chronic Disease 
Directors  
Lee Partridge - Director, Health Policy Unit, American Public Human Services 
Association  
Joy Wilson - Director, Health Committee, National Conference of State Legislatures  
Matt Salo - Director of Health Legislation, National Governors' Association  
Heather Mizeru - Director of State Affairs, National Association of Community Health 
Centers, Inc. 
 
 
DRAFT 
ATTACHMENT 2-2-A  
PAGE 23b 
STATE:_________________________________ 
Citation Group Covered 
B. Optional Coverage Other Than the Medically Needy (Continued) 
1902 (a) (10) (A)  
(ii) (XVIII) of the Act ____[24]. Women who: 
a. have been screened for breast or cervical cancer under the Centers for Disease 
Control and Prevention Breast and Cervical Cancer Early Detection Program 
established under title XV of the Public Health Service Act in accordance with the 
requirements of section 1504 of that Act and need treatment for breast or cervical 
cancer, including a pre-cancerous condition of the breast or cervix; 
b. are not otherwise covered under creditable coverage, as defined in section 2701 
(c) of the Public Health Service Act; 
c. are not eligible for Medicaid under any mandatory categorically needy eligibility 
group; and 
d. have not attained age 65. 
1920B of the Act ____ [25]. Women who are determined by a "qualified entity" (as 
defined in 1920B (b) based on preliminary information, to be a woman described in 
1902 (aa) the Act related to certain breast and cervical cancer patients.  The presumptive period begins on the day that the determination is made. The 
period ends on the date that the State makes a determination with respect to the 
woman's eligibility for Medicaid, or if the woman does not apply for Medicaid (or a 
Medicaid application was not made on her behalf) by the last day of the month 
following the month in which the determination of presumptive eligibility was made, 
the presumptive period ends on that last day. 
___________________________________________________________________
_____ 
TN No._______ Approval Date:________ Effective Date:_______ 
Supersedes  
TN No.________