US Code

Public Law 119-73 (01/23/2026)

42 U.S.C. § 1396e

Enrollment of individuals under group health plans

(a)

Requirements of each State plan; guidelines

Each State plan—
(1)
may implement guidelines established by the Secretary, consistent with subsection (b), to identify those cases in which enrollment of an individual otherwise entitled to medical assistance under this subchapter in a group health plan (in which the individual is otherwise eligible to be enrolled) is cost-effective (as defined in subsection (e)(2));
(2)
may require, in case of an individual so identified and as a condition of the individual being or remaining eligible for medical assistance under this subchapter and subject to subsection (b)(2), notwithstanding any other provision of this subchapter, that the individual (or in the case of a child, the child’s parent) apply for enrollment in the group health plan; and
(3)
osection 1396a(a)(25) of this title in the case of such enrollment (except as provided in subsection (c)(1)(B)), shall provide for payment of all enrollee premiums for such enrollment and all deductibles, coinsurance, and other cost-sharing obligations for items and services otherwise covered under the State plan under this subchapter (exceeding the amount otherwise permitted under section 1396 of this title), and shall treat coverage under the group health plan as a third party liability (under ).
(b)

Timing of enrollment; failure to enroll

(1)
In establishing guidelines under subsection (a)(1), the Secretary shall take into account that an individual may only be eligible to enroll in group health plans at limited times and only if other individuals (not entitled to medical assistance under the plan) are also enrolled in the plan simultaneously.
(2)
If a parent of a child fails to enroll the child in a group health plan in accordance with subsection (a)(2), such failure shall not affect the child’s eligibility for benefits under this subchapter.
(c)

Premiums considered payments for medical assistance; eligibility

(1)
(A)
section 1396b(a) of this title In the case of payments of premiums, deductibles, coinsurance, and other cost-sharing obligations under this section shall be considered, for purposes of , to be payments for medical assistance.
(B)
If all members of a family are not eligible for medical assistance under this subchapter and enrollment of the members so eligible in a group health plan is not possible without also enrolling members not so eligible—
(i)
payment of premiums for enrollment of such other members shall be treated as payments for medical assistance for eligible individuals, if it would be cost-effective (taking into account payment of all such premiums), but
(ii)
payment of deductibles, coinsurance, and other cost-sharing obligations for such other members shall not be treated as payments for medical assistance for eligible individuals.
(2)
section 1396a(a)(25) of this title The fact that an individual is enrolled in a group health plan under this section shall not change the individual’s eligibility for benefits under the State plan, except insofar as provides that payment for such benefits shall first be made by such plan.
(d)

Pub. L. 105–33, title IV, § 4741(b)(2)111 Stat. 523 Repealed. , ,

(e)

Definitions

In this section:
(1)
42 U.S.C. 300bb–11
1 See References in Text note below.
The term “group health plan” has the meaning given such term in section 5000(b)(1) of the Internal Revenue Code of 1986, and includes the provision of continuation coverage by such a plan pursuant to title XXII of the Public Health Service Act [ et seq.], section 4980B of the Internal Revenue Code of 1986, or title VI  of the Employee Retirement Income Security Act of 1974.
(2)
section 1397ee(c)(3)(A) of this title The term “cost-effective” has the meaning given that term in .

Aug. 14, 1935, ch. 531Pub. L. 101–508, title IV, § 4402(a)(2)104 Stat. 1388–161Pub. L. 105–33, title IV, § 4741(b)111 Stat. 523Pub. L. 111–148, title X, § 10203(b)(1)124 Stat. 927(, title XIX, § 1906, as added , , ; amended , , ; , , .)

Editorial Notes

References in Text

The Internal Revenue Code of 1986, referred to in subsec. (e)(1), is classified generally to Title 26, Internal Revenue Code.

act July 1, 1944, ch. 37358 Stat. 682section 201 of this titleThe Public Health Service Act, referred to in subsec. (e)(1), is , . Title XXII of the Act is classified generally to subchapter XX (§ 300bb–1 et seq.) of chapter 6A of this title. For complete classification of this Act to the Code, see Short Title note set out under and Tables.

Pub. L. 93–40688 Stat. 829section 1001 of Title 29The Employee Retirement Income Security Act of 1974, referred to in subsec. (e)(1), is , , . Title VI of the Act probably means part 6 of subtitle B of title I of the Act which is classified generally to part 6 (§ 1161 et seq.) of subtitle B of subchapter I of chapter 18 of Title 29, Labor, because the Act has no title VI. For complete classification of this Act to the Code, see Short Title note set out under and Tables.

Prior Provisions

act Aug. 14, 1935, ch. 531, title XIX, § 1906Pub. L. 90–248, title II, § 22681 Stat. 903Pub. L. 92–603, title II, § 28786 Stat. 1457A prior section 1396e, , as added , , , created Advisory Council on Medical Assistance, set forth composition of Council, term of membership of members, and purposes of Council, and provided for compensation of members, prior to repeal by , , , effective on the first day of the third calendar month following .

Amendments

Pub. L. 111–148section 1397ee(c)(3)(A) of this title2010—Subsec. (e)(2). substituted “has the meaning given that term in .” for “means, as established by the Secretary, that the reduction in expenditures under this subchapter with respect to an individual who is enrolled in a group health plan is likely to be greater than the additional expenditures for premiums and cost-sharing required under this section with respect to such enrollment.”

Pub. L. 105–33, § 4741(b)(1)section 1396a(a)(25)(G) of this title1997—Subsec. (a). , in introductory provisions, substituted “Each” for “For purposes of and subject to subsection (d) of this section, each” and, in pars. (1) and (2), substituted “may” for “shall”.

Pub. L. 105–33, § 4741(b)(2)Subsec. (d). , struck out subsec. (d) which read as follows:

section 1315 of this title“(1) In the case of any State which is providing medical assistance to its residents under a waiver granted under , the Secretary shall require the State to meet the requirements of this section in the same manner as the State would be required to meet such requirement if the State had in effect a plan approved under this subchapter.

section 1396a(a)(25)(G) of this title“(2) This section, and , shall only apply to a State that is one of the 50 States or the District of Columbia.”

Statutory Notes and Related Subsidiaries

Effective Date of 2010 Amendment

Pub. L. 111–148, title X, § 10203(b)124 Stat. 927section 10203(b)(1) of Pub. L. 111–148Pub. L. 111–3, , , provided that the amendment made by is effective as if included in the enactment of the Children’s Health Insurance Program Reauthorization Act of 2009 ().

Effective Date

section 4402 of Pub. L. 101–508section 4402(e) of Pub. L. 101–508section 1396a of this titleSection applicable, except as otherwise provided, to payments under this subchapter for calendar quarters beginning on or after , without regard to whether or not final regulations to carry out the amendments by have been promulgated by such date, see , set out as an Effective Date of 1990 Amendment note under .