Source: https://healthlaw.org/resource/aca-clarifies-the-definition-of-nmedical-assistance/
Timestamp: 2019-04-25 20:35:55+00:00

Document:
Fact sheet that clarifies that states must operate their programs to ensure that beneficiaries actually receive covered services with reasonable promptness, not simply be reimbursed if they manage to acquire services on their own.
We have quoted the legislative history of the provision fully below. We have prepared and inserted a number of footnotes into the history to explain the congressional references. The reader must understand that the footnotes do not appear in the actual legislative history.
services and the provision of the services themselves. These opinions have read the term to refer only to payment; this reading makes some aspects of the rest of Title XIX difficult and, in at least one case, absurd. If the term meant only payments, the statutory requirement that medical assistance be furnished with reasonable promptness “to all eligible individuals” in a system in which virtually no beneficiaries receive direct payments from the state or federal governments would be nearly incomprehensible. Other courts have held the term to be payment as well as the actual provision of the care and services, as it has long been understood. The Circuit Courts are split on this issue and the Supreme Court has declined to review the question. To correct any misunderstandings as to the meaning of the term, and to avoid additional litigation, the bill would revise section 1905(a) ” [text of amendment omitted”. This technical correction is made to conform this definition to the longstanding administrative use and understanding of the term. It is effective on enactment. H.R. Rep. No. 299, 111th Cong., 1st Sess. 2009, at 649-50, 2009 WL 3321420 (Oct. 14, 2009). (footnotes added).
providers. It does, however, re-affirm the states’ obligations as commonly understood prior to the recent circuit court decisions.
1 For example, when amending the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provisions in 1989, the House Committee stated that “[t]he EPSDT benefit is, in effect, the Nation’s largest preventive health program for children and that the EPSDT provisions require that “each state must provide, at a minimum,” EPSDT services.” H.R. Rep. No. 247, 101st Cong.,1st Sess. 398-399 (1989), reprinted in 1989 U.S.C.C.A.N. 2124-25 (emphasis added). Accord S. Rep. 89-404, S. Rep No. 404, 89th Cong., 1st Sess. 1965, reprinted in 1965 U.S.C.C.A.N. 1943, 1950-51 (stating that “best interest of recipient” provision, 42 U.S.C. §1396a(a)(19), was included “in order to provide some assurance that the State will not administer the provisions for services in a way which adversely affects the availability or the quality of the care to be provided”).
2 See, e.g., 42 C.F.R. § 440.210(a) (“A State plan must specify that, at a minimum, categorically needy recipients are furnished the following services.”); Id. at § 440.220 (same, with respect to medically needy beneficiaries); Id. at § 440.230(a) (requiring state to “specify the amount, duration, and scope of each service that it provides”) (emphasis added).
3 See Equal Access for El Paso v. Hawkins, 562 F.3d 724, 728 (5th Cir. 2009) (finding reasonable promptness provision only required state to make reasonably prompt payments for services received and did not require state to take steps to ensure that recipients actually receive prompt medical care and services); Okla. Chap. of the Am. Acad. of Pediatrics v. Fogerty, 472 F.3d 1208, 1215 (10th Cir. 2006), cert. denied, 552 U.S. 813 (2007); Mandy R. v. Owens, 464 F.3d 1139 (10th Cir. 2006), cert. denied, 549 U.S. 1305 (2007); Westside Mothers v. Olszewski, 454 F.3d 532 (6th Cir. 2006) (remanding to allow plaintiffs to re-plead complaint); Bruggeman v. Blagojevich, 324 F.3d 906, 910 (7th Cir. 2003) (dicta, stating that “statutory reference to “assistance” appears to have reference to financial assistance rather than to actual medical services”).
4 For example, 42 U.S.C. § 1396a(a)(23) requires that a state must “provide that (A) any individual eligible for medical assistance may obtain such assistance from any institution, agency, community pharmacy, or person, qualified to perform the service or services required.”) In this context, “medical assistance” can only mean services, for if it also meant payment, the statute would require participating providers to make payments to eligible individuals. This ignores that Medicaid is a vendor payment program that, for the most part, does not make direct payments to individuals; and, it is absurd. Similarly, § 1396a(a)(65), which requires states to “issue provider numbers for all suppliers of medical assistance consisting of durable medical equipment,” would mean that the state would issue provider numbers for suppliers of payments consisting of medical equipment. Again, an absurd result.
6 See, e.g., Bryson v. Shumway, 308 F.3d 79 (1st Cir. 2002); Doe v. Chiles, 136 F.3d 709 (11th Cir. 1998); see also, e.g., Katie A. v. Los Angeles Co., 481 F.3d 1150, 1162 (9th Cir. 2007); Brown v. Tennessee Dept. of Finan. & Admin., 649 F.Supp.2d 780, 798-99 (M.D. Tenn. 2009) (finding State attempt to use medical assistance as payment argument was “a revisionist view of the litigation”).

References: §1396
 § 440
 § 440
 § 440
 v. 
 v. 
 v. 
 v. 
 v. 
 § 1396
 § 1396
 v. 
 v. 
 v. 
 v.