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 B—General Administrative Requirements

42 C.F.R. § 431.51

Free choice of providers

Read at: eCFRecfr.gov CornellLII GovInfogovinfo.gov CasesGoogle Scholar

(a) Statutory basis. This section is based on sections 1902(a)(23), 1902(e)(2), and 1915(a) and (b) and 1932(a)(3) of the Act.

(1) Section 1902(a)(23) of the Act provides that beneficiaries may obtain services from any qualified Medicaid provider that undertakes to provide the services to them.

(2) Section 1915(a) of the Act provides that a State shall not be found out of compliance with section 1902(a)(23) solely because it imposes certain specified allowable restrictions on freedom of choice.

(3) Section 1915(b) of the Act authorizes waiver of the section 1902(a)(23) freedom of choice of providers requirement in certain specified circumstances, but not with respect to providers of family planning services.

(4) Section 1902(a)(23) of the Act provides that a beneficiary enrolled in a primary care case management system or Medicaid managed care organization (MCO) may not be denied freedom of choice of qualified providers of family planning services.

(5) Section 1902(e)(2) of the Act provides that an enrollee who, while completing a minimum enrollment period, is deemed eligible only for services furnished by or through the MCO or PCCM, may, as an exception to the deemed limitation, seek family planning services from any qualified provider.

(6) Section 1932(a) of the Act permits a State to restrict the freedom of choice required by section 1902(a)(23), under specified circumstances, for all services except family planning services.

(b) State plan requirements. A State plan, except the plan for Puerto Rico, the Virgin Islands, or Guam, must provide as follows:

(1) Except as provided under paragraph (c) of this section and part 438 of this chapter, a beneficiary may obtain Medicaid services from any institution, agency, pharmacy, person, or organization that is—

(i) Qualified to furnish the services; and

(ii) Willing to furnish them to that particular beneficiary.

This includes an organization that furnishes, or arranges for the furnishing of, Medicaid services on a prepayment basis.

(2) A beneficiary enrolled in a primary care case-management system, a Medicaid MCO, or other similar entity will not be restricted in freedom of choice of providers of family planning services.

(c) Exceptions. Paragraph (b) of this section does not prohibit the agency from—

(1) Establishing the fees it will pay providers for Medicaid services;

(2) Setting reasonable standards relating to the qualifications of providers; or

(3) Subject to paragraph (b)(2) of this section, restricting beneficiaries' free choice of providers in accordance with one or more of the exceptions set forth in § 431.54, or under a waiver as provided in § 431.55; or

(4) Limiting the providers who are available to furnish targeted case management services defined in § 440.169 of this chapter to target groups that consist solely of individuals with developmental disabilities or with chronic mental illness. This limitation may only be permitted so that the providers of case management services for eligible individuals with developmental disabilities or with chronic mental illness are capable of ensuring that those individuals receive needed services.

(d) Certification requirement—(1) Content of certification. If a State implements a project under one of the exceptions allowed under § 431.54 (d), (e) or (f), it must certify to CMS that the statutory safeguards and requirements for an exception under section 1915(a) of the Act are met.

(2) Timing of certification. (i) For an exception under § 431.54(d), the State may not institute the project until after it has submitted the certification and CMS has made the findings required under the Act, and so notified the State.

(ii) For exceptions under § 431.54 (e) or (f), the State must submit the certificate by the end of the quarter in which it implements the project.

[56 FR 8847, Mar. 1, 1991, as amended at 67 FR 41094, June 14, 2002; 72 FR 68091, Dec. 4, 2007]
Notes of Decisions
Cited in 53 cases (7 in the last 5 years), 1980–2025 · leading case: Planned Parenthood of Indiana, Inc. v. Comm'r of Indiana State Dep't of Health, 699 F.3d 962 (7th Cir. 2012).
Sort: Relevance Newest Treatment
Planned Parenthood of Indiana, Inc. v. Comm'r of Indiana State Dep't of Health, 699 F.3d 962 (7th Cir. 2012). · cites it 4× “and [w]illing to furnish them to that particular recipient”). This is known as the free-ehoice-of-provider requirement.”
Planned Parenthood of Kan. v. Andersen, 882 F.3d 1205 (10th Cir. 2018). · cites it 2× “See 42 C.F.R. § 431.51 (c)(2) (stating that a recipient's right to the services of any provider qualified and willing to perform the services does not prohibit states from "[s]etting reasonable standards relating to the qualifications of providers").”
Planned Parenthood of Gulf Coast, Inc. v. Gee, 862 F.3d 445 (5th Cir. 2017). · cites it 2× “” 61 The Medicaid statute does not define the term “qualified,” but LDHH concedes that, as held by the Seventh and Ninth Circuits, “[t]o be ‘qualified’ in the relevant sense is to be capable of performing the needed medical services in a professionally competent, safe, legal,…”
O'Bannon v. Town Court Nursing Ctr., 447 U.S. 773 (1980). · cites it 2× “" The same "free choice of providers" is also guaranteed by 42 CFR § 431.51 (1979). [9] Title 42 CFR § 405.”
Planned Parenthood v. Joshua Baker, 941 F.3d 687 (4th Cir. 2019). · cites it 2× “§ 1396a(p)(1), or on certain state-law grounds, see 42 C.F.R. § 431.51 (c)(2). B. This dispute arose following South Carolina’s termination of two Planned Parenthood centers as Medicaid providers.”
Samuel v. California Dep't of Health Servs., 570 F. Supp. 566 (N.D. Cal. 1983). · cites it 6× “204, and 42 C.F.R. section 431.51. Plaintiffs in No.”
Gary Dube & a. v. New Hampshire Dep't of Health & Human Servs. & a., 166 N.H. 358 (N.H. 2014). · cites it 5× “” 42 C.F.R. § 431.51 (c)(2) (2013). In formulating its Medicaid program, each state may elect to provide certain optional services or may extend services to certain populations that might not otherwise be covered.”
Miller v. Gorski Wladyslaw Est., 547 F.3d 273 (5th Cir. 2008). · cites it 2× “§ 1396a(a)(23) and 42 C.F.R. § 431.51 (b)(1)). 7 Barney adds: Because the remuneration provided under Medicaid is often significantly less than that provided by private insurers or Medicare, health care providers, either in the interest of higher profits or merely to remain…”
Bussoletti v. Dep't of Pub. Welfare, 59 A.3d 682 (Pa. Commw. Ct. 2012). · cites it 5× “Citing a federal regulation, 42 C.F.R. § 431.51 , and the Waiver, the ALJ determined Recipient can select any “willing and qualified provider” to furnish Waiver services included in his ISP.”
Medina v. Planned Parenthood South Atl., 606 U.S. 357 (2025). “5, 18 (1925); 42 CFR §431.51 (c)(2) (2024). But every- one acknowledges that, if a State fails “to comply substan- tially” with this (or any) congressionally specified condition, the Secretary may withhold some or all of the State’s fed- eral funding until he is “satisfied that…”
Planned Parenthood of Grt TX v. Courtney Ph, 981 F.3d 347 (5th Cir. 2020). “at 563 (quoting 42 C.F.R. § 431.51 (c)(2)). Indeed, the previously prevailing standard in this circuit acknowledged that “states retain broad authority to define provider qualifications and to exclude providers on that basis.”
King Ex Rel. King v. Sullivan, 776 F. Supp. 645 (D.R.I. 1991). · cites it 2× “§ 1396a(a)(23) and 42 C.F.R. § 431.51 (b). Additionally, Plaintiffs claim three general procedural violations of the Medicaid Act.”
Show all 53 citing cases →
— 42 C.F.R. § 431.51(a) — 1 case
Linton Ex Rel. Arnold v. Carney Ex Rel. Kimble, 779 F. Supp. 925 (M.D. Tenn. 1990).
— 42 C.F.R. § 431.51(b) — 1 case
Samuel v. California Dep't of Health Servs., 570 F. Supp. 566 (N.D. Cal. 1983). “204, and 42 C.F.R. section 431.51. Plaintiffs in No.”
— 42 C.F.R. § 431.51(b)(l)(ii) — 1 case
Conlan v. Shewry, 2005 Cal. Daily Op. Serv. 7288 (Cal. Ct. App. 2005).
Annotations are extracted automatically from the opinions in the Syfert caselaw corpus and ranked by authority, recency, and treatment. Dots show Syfertize treatment of the citing case itself.