C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 431—STATE ORGANIZATION AND GENERAL ADMINISTRATION › Subpart A—Single State Agency

42 C.F.R. § 431.10

Single State agency

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(a) Basis, purpose, and definitions. (1) This section implements section 1902(a)(4) and (5) of the Act.

(2) For purposes of this part—

Appeals decision means a decision made by a hearing officer adjudicating a fair hearing under subpart E of this part.

Exchange has the meaning given to the term in 45 CFR 155.20.

Exchange appeals entity has the meaning given to the term “appeals entity,” as defined in 45 CFR 155.500.

Medicaid agency is the single State agency for the Medicaid program.

(b) Designation and certification. A State plan must—

(1) Specify a single State agency established or designated to administer or supervise the administration of the plan; and

(2) Include a certification by the State Attorney General, citing the legal authority for the single State agency to—

(i) Administer or supervise the administration of the plan; and

(ii) Make rules and regulations that it follows in administering the plan or that are binding upon local agencies that administer the plan.

(3) The single State agency is responsible for determining eligibility for all individuals applying for or receiving benefits in accordance with regulations in part 435 of this chapter and for fair hearings filed in accordance with subpart E of this part.

(c) Delegations. (1) Subject to the requirement in paragraph (c)(2) of this section, the Medicaid agency—

(i)(A) May, in the approved state plan, delegate authority to determine eligibility for all or a defined subset of individuals to—

(1) The single State agency for the financial assistance program under title IV-A (in the 50 States or the District of Columbia), or under title I or XVI (AABD), in Guam, Puerto Rico, or the Virgin Islands;

(2) The separate Children's Health Insurance Program agency;

(3) The Basic Health Program agency;

(4) The Federal agency administering the supplemental security income program under title XVI of the Act; or

(5) The Exchange.

(B) Must in the approved state plan specify to which agency, and the individuals for which, authority to determine eligibility is delegated.

(ii) Delegate authority to conduct fair hearings under subpart E of this part for denials of eligibility for individuals whose income eligibility is determined based on the applicable modified adjusted gross income standard described in § 435.911(c) of this chapter, to an Exchange or Exchange appeals entity, provided that individuals who have requested a fair hearing of such a denial are given a choice to have their fair hearing instead conducted by the Medicaid agency.

(2) The Medicaid agency may delegate authority to make eligibility determinations or to conduct fair hearings under this section only to a government agency which maintains personnel standards on a merit basis.

(3) The Medicaid agency—

(i) Must ensure that any agency to which eligibility determinations or appeals decisions are delegated—

(A) Complies with all relevant Federal and State law, regulations and policies, including, but not limited to, those related to the eligibility criteria applied by the agency under part 435 of this chapter; prohibitions against conflicts of interest and improper incentives; and safeguarding confidentiality, including regulations set forth at subpart F of this part.

(B) Informs applicants and beneficiaries how they can directly contact and obtain information from the agency; and

(ii) Must exercise appropriate oversight over the eligibility determinations and appeals decisions made by such agencies to ensure compliance with paragraphs (c)(2) and (c)(3)(i) of this section and institute corrective action as needed, including, but not limited to, rescission of the authority delegated under this section.

(iii) If authority to conduct fair hearings is delegated to the Exchange or Exchange appeals entity under paragraph (c)(1)(ii) of this section, the agency may establish a review process whereby the agency may review fair hearing decisions made under that delegation, but that review will be limited to the proper application of federal and state Medicaid law and regulations, including sub-regulatory guidance and written interpretive policies, and must be conducted by an impartial official not directly involved in the initial determination.

(d) Agreement with Federal, State or local entities making eligibility determinations or appeals decisions. The plan must provide for written agreements between the Medicaid agency and the Exchange or any other State or local agency that has been delegated authority under paragraph (c)(1)(i) of this section to determine Medicaid eligibility and for written agreements between the agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings under paragraph (c)(1)(ii) of this section. Such agreements must be available to the Secretary upon request and must include provisions for:

(1) The relationships and respective responsibilities of the parties, including but not limited to the respective responsibilities to effectuate the fair hearing rules in subpart E of this part;

(2) Quality control and oversight by the Medicaid agency, including any reporting requirements needed to facilitate such control and oversight;

(3) Assurances that the entity to which authority to determine eligibility or conduct fair hearings will comply with the provisions set forth in paragraph (c)(3) of this section.

(4) For appeals, procedures to ensure that individuals have notice and a full opportunity to have their fair hearing conducted by either the Exchange or Exchange appeals entity or the Medicaid agency.

(e) Authority of the single State agency. The Medicaid agency may not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters.

[44 FR 17930, Mar. 23, 1979, as amended at 77 FR 17202, Mar. 23, 2012; 78 FR 42300, July 15, 2013; 89 FR 22865, Apr. 2, 2024]
Notes of Decisions
Cited in 126 cases (20 in the last 5 years), 1982–2026 · leading case: RCJ Med. Servs., Inc. v. Bonta´, 2001 Cal. Daily Op. Serv. 7384 (Cal. Ct. App. 2001).
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RCJ Med. Servs., Inc. v. Bonta´, 2001 Cal. Daily Op. Serv. 7384 (Cal. Ct. App. 2001). · cites it 17× “42 C.F.R. § 431.10 (e)(l)(ii). . . . [T]he ‘single state agency’ requirement derives from a desire to focus accountability for plan operation, Hillburn by Hillburn v.”
Melissa Wilson v. Darin Gordon, 822 F.3d 934 (6th Cir. 2016). · cites it 5× “42 C.F.R. §§ 431.10 (c)(1)(i), 435.1200(c) & (d); 45 C.”
K.C. Ex Rel. Africa H. v. Shipman, 716 F.3d 107 (4th Cir. 2013). · cites it 7× “§ 1396a(a)(5), requires each state to designate a “single State agency” to administer its Medicaid plan (here, the NCDHHS) and a regulation prohibits PBH from “chang[ing] or disapproving] any administrative decision of that agency,” 42 C.F.R. § 431.10 (e)(3). Yet PBH seeks to do…”
Lisnitzer v. Zucker, 983 F.3d 578 (2d Cir. 2020). · cites it 4× “244(f); see also 42 C.F.R. § 431.10 (b)(1), and does not specify any 3 1 particular component or delegate of the agency, we also hold that such eligibility 2 determinations may be made in hearing decisions or on remand to local agencies.”
Morcos S. Azer Doctor's Med. Lab'y, Inc. v. Kathleen Connell John Chen Steven Fujimori Joseph P. Munso Al Schaden, 306 F.3d 930 (9th Cir. 2002). · cites it 2× “See 42 C.F.R. § 431.10 (e). However, the single state agency may subcontract certain functions that do not involve a delegation of discretionary authority.”
San Lazaro Ass'n v. Connell, 286 F.3d 1088 (9th Cir. 2002). · cites it 11× “42 C.F.R. § 431.10 (e). 2. Payment and verification of provider claims Under the Medicaid Act, “[t]he state plan is required to establish .”
Guggenberger ex rel. Guggenberger v. State, 198 F. Supp. 3d 973 (D. Minnesota 2016). · cites it 2× “See 42 C.F.R. §§ 431.10 (b), 431.10(e), 435.903; see also Minn.”
Hawkins v. El Paso First Health Plans, Inc., 214 S.W.3d 709 (Tex. App. 2007). · cites it 2× “§ 1396a(a)(5) (“determination of eligibility for medical assistance under the [state Medicaid] plan shall be made by the State or local agency”), § 1397bb(b) (state CHIP plan shall include methods of establishing eligibility); 42 C.F.R. §§ 431.10 , 435.916 (2005) (single state…”
Derek Waskul v. Washtenaw Cnty. Cmty. Mental Health, 979 F.3d 426 (6th Cir. 2020). “§ 1396a(a)(5) (requiring that each state “provide for the establishment or designation of a single State agency to administer or to supervise the administration of” their plan); 42 C.F.R. § 431.10 (b)(1). The Department then contracts with regional prepaid inpatient health plans…”
San Lazaro Ass'n v. Connell, 278 F.3d 932 (9th Cir. 2002). · cites it 11× “(3) If other State or local agencies or offices perform services for the Medicaid agency, they must not have the authority to change or disapprove any administrative decision of that agency, or otherwise substitute their judgment for that of the Medicaid agency with respect to…”
California Pharmacists Ass'n v. Maxwell-Jolly, 596 F.3d 1098 (9th Cir. 2010). · cites it 2× “” 42 C.F.R. § 431.10 . The Defendant-Appellee’s agency, the Department, “is the state agency responsible for the administration of California’s version of Medicaid, the Medi-Cal program.”
N.C. Dep't of Health & Human Servs. v. Parker Home Care, LLC, 784 S.E.2d 552 (N.C. Ct. App. 2016). · cites it 5× “In addition, 42 C.F.R. 431.10(b)(1) specifies that a "State plan must" "(1) Specify a single State agency established or designated to administer or supervise the administration of the plan[.”
Show all 126 citing cases →
— 42 C.F.R. § 431.10(b) — 2 cases
Jeffery R. Mckee v. Paratransit Servs. (Wash. Ct. App. 2020).
Jeffery R. Mckee v. Paratransit Servs. (Wash. Ct. App. 2020).
— 42 C.F.R. § 431.10(b)(1) — 5 cases
N.C. Dep't of Health & Human Servs. v. Parker Home Care, LLC, 784 S.E.2d 552 (N.C. Ct. App. 2016). “In addition, 42 C.F.R. 431.10(b)(1) specifies that a "State plan must" "(1) Specify a single State agency established or designated to administer or supervise the administration of the plan[.”
Kevin Wiesner v. Washtenaw Cnty. Cmty. Mental Health (Mich. Ct. App. 2022).
Kevin Wiesner v. Washtenaw Cnty. Cmty. Mental Health (Mich. Ct. App. 2022).
N.C. Dep't Of Health & Hum. Servs. v. Parker Home Care (N.C. Ct. App. 2016).
Div. Of Med. Assistance v. Parker Home Care (N.C. Ct. App. 2016).
— 42 C.F.R. § 431.10(b)(3) — 1 case
Nb v. Dist. of Columbia (D.D.C. 2025).
— 42 C.F.R. § 431.10(c) — 2 cases
Jeffery R. Mckee v. Paratransit Servs. (Wash. Ct. App. 2020).
Jeffery R. Mckee v. Paratransit Servs. (Wash. Ct. App. 2020).
— 42 C.F.R. § 431.10(c)(2) — 1 case
Forloine v. Persily (S.D.W. Va 2024).
— 42 C.F.R. § 431.10(e) — 5 cases
N.C. Dep't of Health & Human Servs. v. Parker Home Care, LLC, 784 S.E.2d 552 (N.C. Ct. App. 2016). “In addition, 42 C.F.R. 431.10(b)(1) specifies that a "State plan must" "(1) Specify a single State agency established or designated to administer or supervise the administration of the plan[.”
N.C. Dep't Of Health & Hum. Servs. v. Parker Home Care (N.C. Ct. App. 2016).
Div. Of Med. Assistance v. Parker Home Care (N.C. Ct. App. 2016).
Jeffery R. Mckee v. Paratransit Servs. (Wash. Ct. App. 2020).
Jeffery R. Mckee v. Paratransit Servs. (Wash. Ct. App. 2020).
— 42 C.F.R. § 431.10(e)(3) — 3 cases
Grier v. Goetz, 402 F. Supp. 2d 876 (M.D. Tenn. 2005).
Jeffery R. Mckee v. Paratransit Servs. (Wash. Ct. App. 2020).
Jeffery R. Mckee v. Paratransit Servs. (Wash. Ct. App. 2020).
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