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.

Section 1 - Single State Agency Organization

Name Subsection : 1 (3) State Plan : Part 1 (1) Designation and Authority 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 1 (1) Organization and Administration 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) State Plan : Part 1 (1) Statewide Operation Subsection : 4 (1) State Plan : Part 1 (1) State Medical Care Advisory Committee Subsection : 5 (1) State Plan : Part 1 (1) Pediatric Immunization Program Subsection : 19 (1) State Plan : Part 1 (1) Attachment 4.19b Item 13d - Community-based comprehensive psychiatric rehabilitation and support services program; telehealth; Assertive Community Tr

Section 2 - Coverage and Eligibility

Name Subsection : 1 (1) State Plan : Part 1 (1) Application, Determination of Eligibility and Furnishing Medicaid Subsection : 2 (4) State Plan : Part 1 (1) Coverage and Conditions of Eligibility State Plan : Part 2-3 (3) 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 : 3 (1) State Plan : Part 1 (1) Residence Subsection : 4 (1) State Plan : Part 1 (1) Blindness Subsection : 5 (1) State Plan : Part 1 (1) Disability Subsection : 6 (26) State Plan : Part 1 (1) Financial Eligibility State Plan : Part 2-3 (25) Supplement 1 - Income Eligibility Levels - Categorically Needy, Medically Needy and Qualified Medicare Beneficiaries Attachment 2.6a - Eligibility Conditions and Requirements 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) State Plan : Part 1 (1) Medicaid Furnished out of State

 

Section 2 - MMDL System Approvals

​Medicaid Eligibility

Name A1-A3 Medicaid Administration S10 - MAGI-Based Income Methodologies S14 - AFDC Income Standards S21 - Presumptive Eligibility by Hospitals 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 S94 - General Eligibility Requirements - Eligibility Process

​​Alternative Benefit Plan

Name NE – ABP1 Alternative Benefit Plan Populations NE – ABP2a Voluntary Benefit Package Selection Assurances NE – ABP3.1 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package NE – ABP4 Alternative Benefit Plan Cost-Sharing NE – ABP5 Benefits Description NE – ABP7 Benefits Assurances NE – ABP8 Service Delivery Systems NE – ABP9 Employer Sponsored Insurance and Payment of Premiums NE – ABP10 General Assurances NE – ABP11 Payment Methodology

Section 2 - MACPro System Approvals

Name NE 19-0002 Eligibility for Adult Group NE 19-0005 Eligibility Disregards NE 23-0004 Former Foster Care Children NE 24-0003 Postpartum Coverage NE 23-0014 1902(r)(2) Vehicle Disregard

Section 3 - Services: General Provisions

Name Subsection : 1 (56) State Plan : Part 1 (1) Amount, Duration, and Scope of Services State Plan : Part 2-3 (55) 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 2c - Limitations - Federally Qualified Health Centers Item 2b - Limitations - Rural Health Clinic Services 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 Supplement 5 - MAT Attachment 3.1b - Amount, Duration, and Scope of Services Provided Medically Needy Groups Supplement 6 - MAT 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) State Plan : Part 1 (1) 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 Subsection : 3 (1) State Plan : Part 1 (1) Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases Subsection : 4 (1) State Plan : Part 1 (1) Special Requirements Applicable to Sterilization Procedures Subsection : 5 (1) State Plan : Part 1 (1) Families Receiving Extended Medicaid Benefits

 

Section 4 - General Program Administration

Name Subsection : 1 (1) State Plan : Part 1 (1) Methods of Administration Subsection : 2 (1) State Plan : Part 1 (1) Hearings for Applicants and Recipients Subsection : 3 (1) State Plan : Part 1 (1) Safeguarding Information on Applicants and Recipients Subsection : 4 (1) State Plan : Part 1 (1) Medicaid Quality Control Subsection : 5 (2) State Plan : Part 1 (1) Medicaid Agency Fraud Detection and Investigation Program State Plan : Part 2-3 (1) Medicaid Recovery Audit Contractor Program Subsection : 6 (1) State Plan : Part 1 (1) Records Subsection : 7 (1) State Plan : Part 1 (1) Maintenance of Records Subsection : 8 (1) State Plan : Part 1 (1) Availability of Agency Program Manuals Subsection : 9 (1) State Plan : Part 1 (1) Reporting Provider Payments to the Internal Revenue Service Subsection : 10 (1) State Plan : Part 1 (1) Free Choice of Providers Subsection : 11 (2) State Plan : Part 1 (1) Relations with Standard-Setting and Survey Agencies State Plan : Part 2-3 (1) Attachment 4.11a - Standards for Institution Subsection : 12 (1) State Plan : Part 1 (1) Consultation to Medical Facilities Subsection : 13 (1) State Plan : Part 1 (1) Required Provider Agreement Subsection : 14 (1) State Plan : Part 1 (1) Utilization and Quality Control Subsection : 15 (1) State Plan : Part 1 (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) State Plan : Part 1 (1) Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees State Plan : Part 2-3 (1) Attachment 4.16a - Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees Subsection : 17 (2) State Plan : Part 1 (1) Liens and Adjustments or Recoveries State Plan : Part 2-3 (1) Attachment 4.17a - Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home – Liens and Adjustments or Recoveries Subsection : 18 (8) State Plan : Part 1 (1) Cost Sharing and Similar Charges State Plan : Part 2-3 (7) 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 Supplement 2 Methods and Standards for Establishing Payment Rates Subsection : 19 (56) State Plan : Part 1 (1) Payment for Services State Plan : Part 2-3 (55) Attachment 4.19a - Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care Attachment 4.19a Supplement 1 – Supplemental Graduate Medical Education Payments 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 Item 28 - Rehabilitation Substance Use Disorder Services; MMIW Attachment 4.19b Supplement 1 - Methods and Standards for Establishing Payment Rates for Title XVIII Deductible and Coinsurance Attachment 4.19b Supplement 2 - Methods and Standards for Establishing Payment Rates Attachment 4.19b Supplement 3 – Supplemental Graduation Medical Education Payments Attachment 4.19c - Payments for Reserved Beds Attachment 4.19d - Rates for Nursing Facility Services Attachment 4.19e - Timely-Claims Payment - Definition of Claim Subsection : 20 (1) State Plan : Part 1 (1) Direct Payments to Certain Recipients for Physicians’ or Dentists’ Services Subsection : 21 (1) State Plan : Part 1 (1) Prohibition Against Reassignment of Provider Claims Subsection : 22 (5) State Plan : Part 1 (1) Third Party Liability 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) State Plan : Part 1 (1) Use of Contracts Subsection : 24 (1) State Plan : Part 1 (1) Standards for Payments for Nursing Facility and Intermediate Care Facility for the Developmentally Disabled Services Subsection : 25 (1) State Plan : Part 1 (1) Program for Licensing Administrators of Nursing Homes Subsection : 26 (1) State Plan : Part 1 (1) Drug Utilization Review Programs Subsection : 27 (1) State Plan : Part 1 (1) Disclosure of Survey Information and Provider or Contractor Evaluation Subsection : 28 (1) State Plan : Part 1 (1) Appeals Process (Long-Term Care Facilities) Subsection : 29 (1) State Plan : Part 1 (1) Conflict of Interest Provisions Subsection : 30 (2) State Plan : Part 1 (1) Exclusion of Providers and Suspension of Practitioners and Other Individuals State Plan : Part 2-3 (1) Attachment 4.30 - Sanctions for Psychiatric Hospitals Subsection : 31 (1) State Plan : Part 1 (1) Disclosure of Information by Providers and Fiscal Agents (4.31) and Income and Eligibility Verification System (4.32) Subsection : 32 (1) State Plan : Part 2-3 (1) Attachment 4.32a - Income and Eligibility Verification System Procedures Requests to Other State Agencies Subsection : 33 (2) State Plan : Part 1 (1) Medicaid Eligibility Cards for Homeless Individuals State Plan : Part 2-3 (1) Attachment 4.33a - Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals Subsection : 34 (2) State Plan : Part 1 (1) Systematic Alien Verification for Entitlements State Plan : Part 2-3 (1) Attachment 4.34a - Requirements for Advance Directives for State Plans for Medical Assistance Subsection : 35 (2) State Plan : Part 1 (1) Enforcement of Compliance for Nursing Facilities State Plan : Part 2-3 (1) Attachments 4.35a-h - Eligibility Conditions and Requirements Enforcement of Compliance for Nursing Facilities Subsection : 36 (1) State Plan : Part 1 (1) Required Coordination Between the Medicaid and WIC Programs Subsection : 38 (3) State Plan : Part 1 (1) Nurse Aide Training and Competency Evaluation for Nursing Facilities State Plan : Part 2-3 (2) Attachment 4.38 - Disclosure of Additional Registry Information Attachment 4.38a - Collection of Additional Registry Information Subsection : 39 (3) State Plan : Part 1 (1) Preadmission Screening and Annual Resident Review in Nursing Facilities State Plan : Part 2-3 (2) Attachment 4.39 - Definition of Specialized Services Attachment 4.39a - Categorical Determinations Subsection : 40 (6) State Plan : Part 1 (1) Survey and Certification Process 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) State Plan : Part 1 (1) Resident Assessment for Nursing Facilities Subsection : 42 (2) State Plan : Part 1 (1) Employee Education About False Claims Recoveries State Plan : Part 2-3 (1) Attachment 4.42 - P.S. 109-171, Section 6032 - Monitoring Provider Compliance Subsection : 43 (1) State Plan : Part 1 (1) Cooperation with Medicaid Integrity Program Efforts Subsection : 44 (1) State Plan : Part 1 (1) Medicaid Prohibition on Payments to Institutions or Entities Located Outside of the United States Subsection : 45 (1) State Plan : Part 1 (1) RESERVED (4.45) Subsection : 46 (1) State Plan : Part 1 (1) Provider Screening and Enrollment

Section 5 - Personnel Administration

Name Subsection : 1 (1) State Plan : Part 1 (1) Standards of Personnel Administration Subsection : 2 (1) State Plan : Part 1 (1) RESERVED (5.2) Subsection : 3 (1) State Plan : Part 1 (1) Training Programs; Subprofessional and Volunteer Programs

Section 6 - Financial Administration

Name Subsection : 1 (1) State Plan : Part 1 (1) Fiscal Policies and Accountability Subsection : 2 (1) State Plan : Part 1 (1) Cost Allocation Subsection : 3 (1) State Plan : Part 1 (1) State Financial Participation

Section 7 - General Provisions  

Name Subsection : 1 (1) State Plan : Part 1 (1) Plan Amendments Subsection : 2 (2) State Plan : Part 1 (1) Nondiscrimination State Plan : Part 2-3 (1) Attachment 7.2a - Non-discrimination - Civil Rights Act (Title VI) Subsection : 3 (1) State Plan : Part 1 (1) RESERVED (7.3) Subsection : 4 (1) State Plan : Part 1 (1) State Governor's Review Subsection : 5 (4) State Plan : Part 1 (4) Attachment 7.7-A Vaccine and Vaccine Administration Attachment 7.7-B COVID-19 Testing Attachment 7.7-C COVID-19 Treatment Medicaid Disaster Relief for the COVID-19 National Emergency

State Plan Parts 1-3 

Part 1 (Sections 1-7)

Part 2 (Attachments 1.1a through 4.17a)

Part 3 (Attachments 4.18a through 7.7c)​