(a) Statutory basis. Section 1902(a)(16) of the Act authorizes the Secretary to prescribe State plan requirements for furnishing Medicaid to State residents who are absent from the State.
(b) Payment for services. A State plan must provide that the State will pay for services furnished in another State to the same extent that it would pay for services furnished within its boundaries if the services are furnished to a beneficiary who is a resident of the State, and any of the following conditions is met:
(1) Medical services are needed because of a medical emergency;
(2) Medical services are needed and the beneficiary's health would be endangered if he were required to travel to his State of residence;
(3) The State determines, on the basis of medical advice, that the needed medical services, or necessary supplementary resources, are more readily available in the other State;
(4) It is general practice for beneficiaries in a particular locality to use medical resources in another State.
(c) Cooperation among States. The plan must provide that the State will establish procedures to facilitate the furnishing of medical services to individuals who are present in the State and are eligible for Medicaid under another State's plan.
Notes of Decisions
West Virginia Univ. Hospitals, Inc. v. Casey, 885 F.2d 11 (3rd Cir. 1989).
· cites it 2× “It is simply irrational and arbitrary, not too mention patently unfair, to refuse to do so when the result is a system that varies so wildly in its reimbursement rates for hospitals whose “[m]edical services are needed,” 42 C.F.R. § 431.52 (b), to serve Pennsylvanians.”
Asante v. California Dep't of Health Care Servs., 155 F. Supp. 3d 1008 (N.D. Cal. 2015).
· cites it 5× “§ 1396a(a)(16) ' and 42 C.F.R. § 431.52 ). Plaintiffs seek a declaration that the Department violates these provisions and an injunction enjoining the Department from enforcing the law.”
West Virginia Univ. Hospitals, Inc. v. Casey, 701 F. Supp. 496 (M.D. Penn. 1988).
· cites it 2× “Defendants argue it is reasonable to classify out-of-state hospitals differently based on that characteristic of being an out-of-state hospital alone because: “they are eligible for payment only in limited circumstances ( 42 C.F.R. § 431.52 (b)), provide services infrequently,…”
Shagalow v. State, Dep't of Human Servs., 725 N.W.2d 380 (Minn. Ct. App. 2006).
· cites it 2× “42 C.F.R. § 431.52 (b) (2005). Thus, the federal regulation expressly requires Medicaid payments to out-of-state providers in limited circumstances.”
Asante v. Robert F. Kennedy Jr., 133 F.4th 97 (D.C. Cir. 2025).
· cites it 19× “The plaintiff hospitals’ last argument is that California’s QAF program violates an HHS regulation, 42 C.F.R. § 431.52 . Section 431.52 reads as follows: 11 (a) Statutory basis.”
Asante v. Azar (D.D.C. 2023).
· cites it 6× “§ 1396a(a)(16) and its implementing regulation, 42 C.F.R. § 431.52 . Id. ¶ 7 . Plaintiffs and Defendants have both moved for summary judgment.”
Pereira v. Kozlowski, 805 F. Supp. 361 (E.D. Va. 1992).
“42 C.F.R. § 431.52 (b)(3). Although availability is subject to change in emergency situations, the medical services are presently available at both hospitals.”
Child.'s Seashore House v. Waldman, 197 F.3d 654 (3rd Cir. 1999).
“A State Plan must provide for payment for covered services supplied by out- *657 of-state hospitals to the state’s own Medicaid program enrollees.”
Mary Hitchcock Mem. Hosp. v. Cohen, 2016 DNH 080 (D.N.H. 2016).
· cites it 2× “§ 706 (2)(A) and (B), because the federal defendants allowed Vermont to violate the dormant Commerce Clause, the Equal Protection Clause, and 42 C.F.R. § 431.52 (b). 2 Section 1983 provides a cause of action against state actors who deprive a person of “of any rights,…”
— 42 C.F.R. § 431.52(c) — 1 case
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