Source: http://dhhs.ne.gov/Pages/Medicaid-State-Plan.aspx
Timestamp: 2020-08-14 02:48:33
Document Index: 496441610

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Medicaid State Plan (Title XIX)
​​​The State Plan is the official document describing the nature and scope of the Nebraska Medicaid Program. There are seven sections that comprise the State Plan (Part 1) as well as many accompanying attachments and amendments (Parts 2 and 3). Each part was developed by Nebraska and approved by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS).
Questions regarding the Nebraska State Plan may be sent to DHHS.MedicaidSPA@nebraska.gov.
The State Plan is available in 3 large sections (Parts 1-3), located at the bottom of the page.
Subsection : 1 ‎(3)
State Plan : Part 1 ‎(1)
State Plan : Part 2-3 ‎(2)
Attachment 1.1a - Attorney General's Certification
Attachment 1.1b - Waiver(s) of the Single State Agency Requirement Granted Under the Intergovernmental Cooperation Act
Subsection : 2 ‎(4)
State Plan : Part 2-3 ‎(3)
Attachment 1.2a - Organization and Functions of the Medicaid Agency
Attachment 1.2b - Organization and Function of the Medical Assistance Unit
Attachment 1.2c - Medical Professionals Involved in the Administration of the Medical Assistance Program
Subsection : 3 ‎(1)
Subsection : 4 ‎(1)
State Medical Care Advisory Committee
Subsection : 5 ‎(1)
Subsection : 1 ‎(1)
Application, Determination of Eligibility and Furnishing Medicaid
Coverage and Conditions of Eligibility
Attachment 2.2a - Groups Covered and Agencies Responsible for Eligibility Determinations
Supplement 1 - Reasonable Classifications of Individuals under the Age of 21, 20, 19 and 18
Supplement 3 - Method of Determining Cost Effectiveness of Caring for Certain Disabled Children at Home
Subsection : 6 ‎(26)
State Plan : Part 2-3 ‎(25)
Attachment 2.6a - Eligibility Conditions and Requirements
Supplement 1 - Income Eligibility Levels - Categorically Needy, Medically Needy and Qualified Medicare Beneficiaries
Supplement 2 - Resource Levels - Categorically Needy, Including Groups with Income Up to a Percentage of the Federal Poverty Level, Medically Needy, and Other Optional Groups
Supplement 3 - Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered Under Medicaid
Supplement 4 - Section 1902(f) Methodologies for Treatment of Income that Differ from Those of the SSI Program
Supplement 5 - Section 1902(f) Methodologies for Treatment of Resources that Differ from Those of the SSI Program
Supplement 5a - Methodologies for Treatment of Resources for Individuals With Incomes Up to a Percentage of the Federal Poverty Level
Supplement 6 - Standards for Optional State Supplementary Payments
Supplement 7 - Income Levels for 1902(f) States - Categorically Needy Who are Covered under Requirements More Restrictive Than SSI
Supplement 8 - Resource Standards for 1902(f) States - Categorically Needy
Supplement 8a - More Liberal Methods of Treating Income Under Section 1902(r)(2) of the Act
Supplement 8b - More Liberal Methods of Treating Resources Under Section 1902(r)(2) of the Act
Supplement 8c - State Long-Term Care Insurance Partnership
Supplement 9 - Transfer of Resources
Supplement 9a - Transfer of Assets
Supplement 9b - Transfer of Assets
Supplement 10 - Consideration of Medicaid Qualifying Trusts- Undue Hardship
Supplement 11 - Cost-Effective Methods for COBRA Groups
Supplement 12 - Eligibility Under Section 1931 of the Act
Supplement 13 - Section 1924 Provisions
Supplement 14 - Qualified Disabled and Working Individuals
Supplement 15 - Variations From the Basic Personal Needs Allowance
Supplement 16 - Asset Verification System
Supplement 17 - Disqualifications for Long-Term Care Assistance for Individuals with Substantial Home Equity
Supplement 18 - Methodology for Identification of Applicable FMAP Rates
Subsection : 7 ‎(1)
Medicaid Furnished out of State
Section 2 - MMDL System Approvals
A1-A3 Medicaid Administration
S25 - Mandatory Coverage - Parents and Other Caretaker Relatives
S28 - Mandatory Coverage - Pregnant Women
S30 - Mandatory Coverage - Infants and Children Under Age 19
S33 - Mandatory Coverage - Former Foster Care Children
S50 - Options for Coverage - Individuals above 133 FPL
S51 - Options for Coverage - Optional Coverage of Parents and Other Caretaker Relatives
S52 - Options for Coverage - Reasonable Classification of individuals Under Age 21
S53 - Options for Coverage - Children with Non IV-E Adoption Assistance
S54 - Options for Coverage - Optional Targeted Low Income Children
S55 - Options for Coverage - Individuals with Tuberculosis
S57 - Options for Coverage - Independent Foster Care Adolescents
S59 - Options for Coverage - Individuals Eligible for Family Planning Services
S88 - Non-Financial Eligibility State Residency
S89 - Non-Financial Eligibility Citizenship and Non-citizen Eligibility
​Alternative Benefit Plan
ABP 1 - Alternative Benefit Plan Populations (Basic)
ABP 2a - Voluntary Benefit Package Selection Assurances (Basic)
ABP 3.1 - Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package (Basic)
ABP 4 - Alternative Benefit Plan Cost-Sharing 9 (Basic)
ABP 5 - Benefits Description (Basic)
ABP 7 - Benefits Assurances (Basic)
ABP 8 - Service Delivery Systems (Basic)
ABP 9 - Employer Sponsored Insurance and Payment of Premiums (Basic)
ABP 10 - General Assurances (Basic)
ABP 11 - Payment Methodology (Basic)
ABP 1 - Alternative Benefit Plan Populations (Prime)
ABP 2a - Voluntary Benefit Package Selection Assurances (Prime)
ABP 2c - Enrollment Assurances - Mandatory Participants (Prime)
APB 3.1 - Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package (Prime)
ABP 4 - Alternative Benefit Plan Cost-Sharing (Prime)
ABP 5 - Benefits Description (Prime)
ABP 7 - Benefits Assurances (Prime)
ABP 8 - Service Delivery Systems (Prime)
ABP 10 - General Assurances (Prime)
ABP 11 - Payment Methodology (Prime)
Section 2 - MACPro System Approvals
NE 19-0002 Eligibility for Adult Group
NE 19-0005 Eligibility Disregards
Subsection : 1 ‎(54)
Amount, Duration, and Scope of Services
State Plan : Part 2-3 ‎(53)
Attachment 3.1a - Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy
Item 1 - Limitations - Inpatient Hospitals
Item 2a - Limitations - Outpatient Hospitals
Item 2b - Limitations - Rural Health Clinic Services
Item 2c - Limitations - Federally Qualified Health Centers
Item 3 - Limitations - Other Laboratory and X-Ray Services
Item 4a - Limitations - Assessments of Developmentally Disabled Person in SNF
Item 4b - Limitations - Early and Periodic Screening and Diagnosis and Treatment of Conditions Found
Item 5 - Limitations - Physician’s Services
Item 6a - Limitations - Podiatrists’ Services
Item 6b - Limitations - Optometrists’ Services
Item 6c - Limitations - Chiropractic Services
Item 6d - Limitations - Other Practitioners Services
Item 7a - Limitations - Home Health Nursing Services
Item 7b - Limitations - Home Health Agencies - Home Health Aide Services
Item 7c - Limitations - Medical Supplies, Equipment, and Appliances Suitable for Use in the Home
Item 7d - Limitations - Home Health Services - Physical Therapy, Occupational Therapy, and Speech Pathology and Audiology
Item 8 - Limitations - Private Duty Nursing Services
Item 9 - Limitations - Clinic Services
Item 10 - Limitations - Dental Services
Item 11a - Limitations - Physical Therapy
Item 11b - Limitations - Occupational Therapy
Item 11c - Limitations - Services for Individuals with Speech, Hearing, and Language Disorders
Item 12a - Limitations - Prescribed Drugs
Item 12b - Limitations - Dentures
Item 12c - Limitations - Prosthetic Devices
Item 12d - Limitations - Eye Glasses
Item 13b - Limitations - Screening Services
Item 13c - Limitations - Preventative Services
Item 13d - Limitations - Rehabilitative Services
Item 14a - Limitations - Services for Individuals Age 65 or Older in Institutions for Mental Diseases - Inpatient Hospital Services
Item 14b - Limitations - Services for Individuals Age 65 or Older in Institutions for Mental Diseases - Skilled Nursing Facility Services
Item 14c - Services for Individuals Age 65 or Older in Institutions for Mental Diseases - Intermediate Care Facility Services
Item 15 - ICF-DD Services
Item 16 - Inpatient Psychiatric Facility Services for Individuals Under Age 21
Item 17 - Nurse-Midwife Services
Item 18 - Medical and Remedial Care and Services
Item 20a - Limitations - Pregnancy -related and Postpartum Services for 60 Days After the Pregnancy Ends
Item 20b - Limitations - Services for Any Other Medical Conditions that May Complicate Pregnancy
Item 23 - Limitations - Certified Pediatric or Family Nurse Practitioners’ Services
Item 24a - Limitations - Transportation
Item 24d - Limitations - Nursing Facility Services for Patients Under 21 Years of Age
Item 24e - Limitations - Emergency Hospital Services
Item 24f - Limitations - Critical Access Hospitals
Item 26 - Limitations - Personal Assistance Services
Item 27 - Limitations - Freestanding Birth Center Services
Supplements 1-3 - Case Management Services
Supplement 4 - PACE
Attachment 3.1b - Amount, Duration, and Scope of Services Provided Medically Needy Groups
Attachment 3.1c - Standards and Methods of Assuring High Quality Care
Attachment 3.1d - Transportation
Attachment 3.1e - Standards for the Coverage of Organ Transplant Services
Attachment 3.1f - MCO and enhanced PCCM programs (replaced with the 1915(b) Waiver)
Subsection : 2 ‎(2)
Coordination of Medicaid with Medicare and Other Insurance
State Plan : Part 2-3 ‎(1)
Attachment 3.2a - Coordination of Title XIX with Part B of Title XVIII
Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases
Special Requirements Applicable to Sterilization Procedures
Families Receiving Extended Medicaid Benefits
Subsection : 2 ‎(1)
Hearings for Applicants and Recipients
Safeguarding Information on Applicants and Recipients
Medicaid Agency Fraud Detection and Investigation Program
Subsection : 6 ‎(1)
Subsection : 8 ‎(1)
Availability of Agency Program Manuals
Subsection : 9 ‎(1)
Reporting Provider Payments to the Internal Revenue Service
Subsection : 10 ‎(1)
Subsection : 11 ‎(2)
Relations with Standard-Setting and Survey Agencies
Attachment 4.11a - Standards for Institution
Subsection : 12 ‎(1)
Consultation to Medical Facilities
Subsection : 13 ‎(1)
Required Provider Agreement
Subsection : 14 ‎(1)
Subsection : 15 ‎(1)
Inspection of Care in Intermediate Care Facilities for the Developmentally Disabled, Facilities Providing Inpatient Psychiatric Services for Individuals Under 21, and Mental Hospitals
Subsection : 16 ‎(2)
Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees
Attachment 4.16a - Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees
Subsection : 17 ‎(2)
Attachment 4.17a - Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home – Liens and Adjustments or Recoveries
Subsection : 18 ‎(7)
Cost Sharing and Similar Charges
State Plan : Part 2-3 ‎(6)
Attachment 4.18a - Charges Imposed on Categorically Needy
Attachment 4.18b - Medically Needy - Premium
Attachment 4.18c - Charges Imposed on Medically Needy and Other Optional Groups
Attachment 4.18d - Premiums Imposed on Low Income Pregnant Women and Infants
Attachment 4.18e - Premiums Imposed on Qualified Disabled and Working Individuals
Attachment 4.18f - Premiums for Families Above 100 percent of FPL
Subsection : 19 ‎(52)
State Plan : Part 2-3 ‎(51)
Attachment 4.19a - Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care
Attachment 4.19b Item 1 - General statement on fee schedules
Attachment 4.19b Item 1c - Payment Adjustment for Provider Preventable Conditions
Attachment 4.19b Item 2a - Outpatient hospital and emergency room; hospital-affiliated ambulatory surgical centers, out-of-state hospital; telehealth
Attachment 4.19b Item 2b - Rural Health Centers-Clinic; telehealth
Attachment 4.19b Item 2c - Federally-qualified health centers; telehealth
Attachment 4.19b Item 2d - Indian Health Service and Tribal health facilities; telehealth
Attachment 4.19b Item 3 - Other laboratory and x-ray services; telehealth
Attachment 4.19b Item 4a - Skilled nursing facilities
Attachment 4.19b Item 4b - EPSDT; telehealth
Attachment 4.19b Item 4c - Family Planning Services; telehealth
Attachment 4.19b Item 5 - Physicians’ services; telehealth
Attachment 4.19b Item 6a - Podiatrists’ services; telehealth
Attachment 4.19b Item 6b - Optometrists’ services; telehealth
Attachment 4.19b Item 6c - Chiropractors' services; telehealth
Attachment 4.19b Item 6d - Other practitioner services - Certified registered nurse anesthetists; telehealth
Attachment 4.19b Item 7 - Home Health Services; telehealth
Attachment 4.19b Item 7c - Medical supplies, equipment, and appliances for suitable use in the home
Attachment 4.19b Item 8 - Private duty nursing services
Attachment 4.19b Item 9 - Clinic services and outpatient mental health services; telehealth; ambulatory surgical centers
Attachment 4.19b Item 10 - Dental Services; telehealth
Attachment 4.19b Item 11a - Physical Therapy; telehealth
Attachment 4.19b Item 11b - Occupational Therapy; telehealth
Attachment 4.19b Item 11c - Speech, hearing, and Language services
Attachment 4.19b Item 12a - Prescribed drugs
Attachment 4.19b Item 12b - Dentures
Attachment 4.19b Item 12c - Prosthetic devices
Attachment 4.19b Item 12d - Eyeglasses
Attachment 4.19b Item 13b - Screening services; telehealth
Attachment 4.19b Item 13c - Preventative Services
Attachment 4.19b Item 13d - Community-based comprehensive psychiatric rehabilitation and support services program; telehealth; Assertive Community Treatment
Attachment 4.19b Item 14a - Services for Individuals Age 65 or Older in Institutions for Tuberculosis
Attachment 4.19b Item 14b - Individuals age 65 or older in institutions for mental diseases
Attachment 4.19b Item 15 - Intermediate Care Facility Services
Attachment 4.19b Item 16 - Inpatient psychiatric facilities for individuals age 21 or younger; telehealth
Attachment 4.19b Item 17 - Nurse midwife services
Attachment 4.19b Item 18 - Medical and remedial care and services
Attachment 4.19b Item 19 - Case Management services
Attachment 4.19b Item 20 - Extended services to pregnant women; telehealth
Attachment 4.19b Item 21- Ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period; telehealth
Attachment 4.19b Item 23 - Pediatric or family nurse practitioners
Attachment 4.19b Item 23a - Ambulance and Other Medical Transportation
Attachment 4.19b Item 24a - Transportation
Attachment 4.19b Item 24d - Skilled nursing facility services for patients under 21 years of age
Attachment 4.19b Item 24e - Emergency hospital services
Attachment 4.19b Item 26 - Personal Care Aid services
Attachment 4.19b Item 27 - Freestanding Birth Center Services
Attachment 4.19b Supplement 1 - Methods and Standards for Establishing Payment Rates for Title XVIII Deductible and Coinsurance
Attachment 4.19c - Payments for Reserved Beds
Attachment 4.19d - Methods and Standards for Establishing Payment Rates - Skilled Nursing and Intermediate Care Facility Services
Attachment 4.19e - Timely-Claims Payment - Definition of Claim
Subsection : 20 ‎(1)
Direct Payments to Certain Recipients for Physicians’ or Dentists’ Services
Subsection : 21 ‎(1)
Prohibition Against Reassignment of Provider Claims
Subsection : 22 ‎(5)
State Plan : Part 2-3 ‎(4)
Attachment 4.22a - Requirements for Third Party Liability - Identifying Liable Resources
Attachment 4.22b - Requirements for Third Party Liability - Payment of Claims
Attachment 4.22c - State Methodology on Cost-Effectiveness of Employer-Based Group Health Plans
Supplement to 4.22 - State Laws Regarding Third Party Liability
Subsection : 23 ‎(1)
Subsection : 24 ‎(1)
Standards for Payments for Nursing Facility and Intermediate Care Facility for the Developmentally Disabled Services
Subsection : 25 ‎(1)
Program for Licensing Administrators of Nursing Homes
Subsection : 26 ‎(1)
Subsection : 27 ‎(1)
Disclosure of Survey Information and Provider or Contractor Evaluation
Subsection : 28 ‎(1)
Appeals Process (Long-Term Care Facilities)
Subsection : 29 ‎(1)
Subsection : 30 ‎(2)
Exclusion of Providers and Suspension of Practitioners and Other Individuals
Attachment 4.30 - Sanctions for Psychiatric Hospitals
Subsection : 31 ‎(1)
Disclosure of Information by Providers and Fiscal Agents (4.31) and Income and Eligibility Verification System (4.32)
Subsection : 32 ‎(1)
Attachment 4.32a - Income and Eligibility Verification System Procedures Requests to Other State Agencies
Subsection : 33 ‎(2)
Medicaid Eligibility Cards for Homeless Individuals
Attachment 4.33a - Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals
Subsection : 34 ‎(2)
Attachment 4.34a - Requirements for Advance Directives for State Plans for Medical Assistance
Subsection : 35 ‎(2)
Enforcement of Compliance for Nursing Facilities
Attachments 4.35a-h - Eligibility Conditions and Requirements Enforcement of Compliance for Nursing Facilities
Subsection : 36 ‎(1)
Required Coordination Between the Medicaid and WIC Programs
Subsection : 38 ‎(3)
Nurse Aide Training and Competency Evaluation for Nursing Facilities
Attachment 4.38 - Disclosure of Additional Registry Information
Attachment 4.38a - Collection of Additional Registry Information
Subsection : 39 ‎(3)
Preadmission Screening and Annual Resident Review in Nursing Facilities
Attachment 4.39 - Definition of Specialized Services
Attachment 4.39a - Categorical Determinations
Subsection : 40 ‎(6)
State Plan : Part 2-3 ‎(5)
Attachment 4.40a - Survey and Certification Education Program
Attachment 4.40b - Process for the Investigation of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property
Attachment 4.40c - Procedures for Scheduling and Conduct of Standard Surveys
Attachment 4.40d - Programs to Measure and Reduce Inconsistency
Attachment 4.40e - Process of Investigations of Complaints and Monitoring - Nursing Facilities
Subsection : 41 ‎(1)
Resident Assessment for Nursing Facilities
Subsection : 42 ‎(2)
Attachment 4.42 - P.S. 109-171, Section 6032 - Monitoring Provider Compliance
Subsection : 43 ‎(1)
Cooperation with Medicaid Integrity Program Efforts
Subsection : 44 ‎(1)
Medicaid Prohibition on Payments to Institutions or Entities Located Outside of the United States
Subsection : 45 ‎(1)
RESERVED (4.45)
Subsection : 46 ‎(1)
Standards of Personnel Administration
RESERVED (5.2)
Training Programs; Subprofessional and Volunteer Programs
Attachment 7.2a - Non-discrimination - Civil Rights Act (Title VI)
RESERVED (7.3)
State Plan Parts 1-3
Part 1 (Sections 1-7)
Part 2 (Attachments 1.1a through 4.17a)
Part 3 (Attachments 4.18a through 7.2a)​