§ 440.180 Home or community-based services. (a) "Home or community-based services" means services that are furnished under a waiver granted under the provisions of Part 441, Subpart G of this subchapter. The services may consist of any of the following services as defined by the agency (but not including room and board except as specifically provided for in paragraph (b) of this section): (1) Case management services; (3) Home health aide services; (8) Other services requested by the Medicaid agency and approved by HCFA as cost-effective. (b) FFP for home community-based services described in paragraph (a) of this section is not available in expenditures for the cost of room and board except when provided as part of respite care in a facility approved by the State that is not a private residence. For purposes of this provision, "board" means three meals a day or any other full nutritional regimen and does not include meals provided as part of a program of adult day health services. [46 FR 48540, Oct. 1, 1981] Subpart B-Requirements and Limits Applicable to All Services § 440.200 Basis, purpose, and scope. (a) This subpart implements(1) Section 1902(a)(10), regarding comparability of services for groups of recipients, and the amount, duration, and scope of services described in section 1905(a) of the Act that the State plan must provide for recipients; (2) Section 1902(a)(22)(D), which provides for standards and methods to assure quality of services; (3) Section 1907 on observance of religious beliefs; and (4) Section 1915 on exceptions to section 1902(a)(10) and waivers of other requirements of section 1902 of the Act. (b) The requirements and limits of this subpart apply for all services defined in Subpart A of this part. [46 FR 48528, Oct. 1, 1981] § 440.210 Required services for the categorically needy. A State plan must specify that, as a minimum, categorically needy recipients are provided the services as specified in §§ 440.10 through 440.50, 440.70, and (to the extent nurse-midwives are authorized to practice under State law or regulation) 440.165. [47 FR 21050, May 17, 1982] § 440.220 Required services for the medically needy. A State plan that includes the medically needy must specify that the medically needy are provided, as a minimum, the following services: (a) Prenatal care and delivery services for pregnant women. (b) Ambulatory services, as defined in the State plan, for (1) Individuals under age 18; and (2) Individuals entitled to institutional services. (c) Home health services (§ 440.70) to any individual entitled to skilled nursing facility services. (d) If the State plan includes services in an institution for mental diseases (§ 440.140 or § 440.160) or in an intermediate care facility for the mentally retarded (§ 440.150(c)) for any group of medically needy, either of the following sets of services to each of the medically needy groups: (1) The services contained in §§ 440.10 through 440.50 and (to the extent nurse-midwives are authorized to practice under State law or regulation) 440.165; or (2) The services contained in any seven of the sections in §§ 440.10 through 440.165. [46 FR 47992, Sept. 30, 1981; 46 FR 54744, Nov. 4, 1981, as amended at 47 FR 21050, May 17, 1982] § 440.230 Sufficiency of amount, duration, and scope. (a) The plan must specify the amount, duration, and scope of each service that it provides for (1) The categorically needy; and (2) Each covered group of medically needy. (b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose. (c) The Medicaid agency may not arbitrarily deny or reduce the amount, duration, or scope of a required service under §§ 440.210 and 440.220 to an otherwise eligible recipient solely because of the diagnosis, type of illness, or condition. (d) The agency may place appropriate limits on a service based on such criteria as medical necessity or on utiization control procedures. 46 FR 47993, Sept. 30, 1981] 440.240 Comparability of services for groups. Except as limited in § 440.250 (a) The plan must provide that the services available to any categorically needy recipient under the plan are not ess in amount, duration, and scope han those services available to a nedically needy recipient; and (b) The plan must provide that the services available to any individual in the following groups are equal in amount, duration, and scope for all recipients within the group: (1) The categorically needy. (2) A covered medically needy group. [46 FR 47993, Sept. 30, 1981] $440.250 Limits on comparability of services. (a) Skilled nursing facility services (8440.40(a)) may be limited to recipients age 21 or older. (b) Early and periodic screening, diagnosis, and treatment (§ 440.40(b)) must be limited to recipients under age 21. (c) Family planning services and supplies must be limited to recipients of childbearing age, including minors who can be considered sexually active and who desire the services and supplies. (d) If covered under the plan, services to recipients in institutions for tu berculosis or mental diseases (§ 440.140) must be limited to those age 65 or older. (e) If covered under the plan, inpatient psychiatric services (§ 440.160) must be limited to recipients under age 22 as specified in § 441.151(c) of this subchapter. (f) If Medicare benefits under Part B of title XVIII are made available to recipients through a buy-in agreement or payment of premiums, or part or all of the deductibles, cost sharing or similar charges, they may be limited to recipients who are covered by the agreement or payment. (g) If services in addition to those offered under the plan are made available under a contract between the agency or political subdivision and an organization providing comprehensive health services, those additional services may be limited to recipients who reside in the geographic area served by the contracting organization and who elect to receive services from it. (h) Ambulatory services for the medically needy (§ 440.220(b)) may be limited to (1) Individuals under age 18; and (2) Individuals entitled to institutional services. (i) Services provided under an exception to requirements allowed under § 431.54 may be limited as provided under that exception. (j) If HCFA has approved a waiver of Medicaid requirements under § 431.55, services may be limited as provided by the waiver. (k) If the agency has been granted a waiver of the requirements of § 440.240 (Comparability of services) in order to provide home or community-based services under § 440.180, the services provided under the waiver need not be comparable for all individuals within a group. (1) If the agency imposes cost sharing on recipients in accordance with 447.53, the imposition of cost sharing on an individual who is not exempted by one of the conditions in section 447.53(b) shall not require the State to impose copayments on an individual who is eligible for such exemption. [43 FR 45224, Sept. 29, 1978, as amended at 45 FR 24889, Apr. 11, 1980; 46 FR 48541, Oct. 1, 1981; 48 FR 5735, Jan. 8, 1983] § 440.260 Methods and standards to assure quality of services. The plan must include a description of methods and standards used to assure that services are of high quality. § 440.270 Religious objections. (a) Except as specified in paragraph (b) of this section, the agency may not require any individual to undergo any medical service, diagnosis, or treatment or to accept any other health service provided under the plan if the individual objects, or in the case of a child, a parent or guardian objects, on religious grounds. (b) If a physical examination is necessary to establish eligibility based on disability or blindness, the agency may not find an individual eligible for Medicaid unless he undergoes the examination. PENALTY FOR FAILURE TO PROVIDE EPSDT SERVICES 441.70 Imposition of penalty. 441.71 Application of penalty. 441.75 Informing a family of availability of EPSDT services. 441.80 Providing for EPSDT services. 441.85 Referral for services not in the State plan. 441.90 Documentation. Subpart C-Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases 441.100 Basis and purpose. 441.101 State plan requirements. 441.102 Plan of care for institutionalized recipients. 441.103 Alternate plans of care. 441.105 Methods of administration. 441.106 Comprehensive mental health pro scribed drugs. 441.30 Optometric services. Subpart E-Abortions 441.40 End-stage renal disease. 441.200 Basis and purpose. This subpart is based on the following sections of the Act which state requirements and limits on the services specified or provide Secretarial authority to prescribe regulations relating to services: (a) Sections 1902(a)(10)(D) and 1905(a)(7) for home health services (§ 441.15). (b) Section 1905(a)(4)(C) for family planning (§ 441.20). (c) Section 1905(a)(12) and (e) for optometric services (§ 441.30). (d) Section 1102 for end-stage renal disease (§ 441.40). (f) Section 1903(i)(5) for certain prescribed drugs (§ 441.25). (g) Section 1903(i)(6) which prohibits (except in emergency situations) FFP in expenditures for inpatient hospital tests that are not ordered by the attending physician or other licensed practitioner (§ 441.12). (h) Section 1905 (a)(17) and (m) for nurse-midwife services (§ 441.21). [43 FR 45229, Sept. 29, 1978, as amended at 45 FR 24889, Apr. 11, 1980; 46 FR 47993, Sept. 30, 1981; 46 FR 48554, Oct. 1, 1981; 47 FR 21051, May 17, 1982; 47 FR 31878, July 23, 1982] § 441.11 Continuation of FFP for institutional services. (a) If a Medicaid agency terminates or fails to renew a provider agreement for the services specified in paragraph (c) of this section because the services no longer meet the applicable definitions, FFP may be continued for a period specified in paragraph (b) of this section, only— (1) For payment for individuals admitted to the facility before the provider agreement terminated or was not renewed; and (2) If the agency makes reasonable efforts to transfer the individuals to another facility or to alternate care. (b) FFP may be continued under the conditions specified in paragraph (a) of this section, for no more than 30 days from (1) The termination or expiration date by HCFA of the facility's provider agreement under Medicare; (2) The termination or expiration date by the agency of its provider agreement; or (3) For a facility or program providing inpatient psychiatric services for individuals under age 21, the earlier of either (i) The effective date of its loss of accreditation by the Joint Commission on Accreditation of Hospitals; or (ii) The termination by the agency of its provider agreement. (c) FFP may be continued, as specified in this section, for the following services: (1) Inpatient hospital services as defined in § 440.10 of this subchapter. (2) Inpatient hospital services for individuals age 65 or older in an institution for tuberculosis or mental diseases, as defined in § 440.140 of this subchapter. (3) Skilled nursing facility services for individuals age 21 or older, as defined in § 440.40(a) of this subchapter. (4) Skilled nursing facility services for individuals age 65 or older in an institution for tuberculosis or mental diseases, as defined in § 440.140 of this subchapter. (5) Intermediate care facility services, as defined in § 440.150 of this subchapter. (6) Intermediate care facility services for individuals age 65 or older in an institution for tuberculosis mental diseases, as defined in § 440.140 of this subchapter. or (7) Inpatient psychiatric services for individuals under age 21, as defined in § 440.160 of this subchapter. § 441.12 Inpatient hospital tests. Except in an emergency situation (see § 440.170(e)(1) of this chapter for definition), FFP is not available in expenditures for inpatient hospital tests unless the tests are specifically ordered by the attending physician or other licensed practitioner, acting within the scope of practice as defined under State law, who is responsible for the diagnosis or treatment of a particular patient's condition. [46 FR 48554, Oct. 1, 1981] § 441.13 Prohibitions on FFP: Institutionalized individuals. (a) FFP is not available in expenditures for services for (1) Any individual who is in a public institution, as defined in § 435.1009 of this subchapter; or (2) Any individual who is under age 65 and is in an institution for tuberculosis or mental diseases, except an individual who is under age 22 and receiving inpatient psychiatric services under Subpart D of this part. (b) Payments to institutions for the mentally retarded or persons with re lated conditions and to psychiatric facilities or programs providing inpatient psychiatric services to individuals under age 21 may not include reimbursement for vocational training and educational activities. § 441.15 Home health services. With respect to the services defined in § 440.70 of this subchapter, a State plan must provide that— (a) Home health services include, as a minimum (1) Nursing services; (2) Home health aide services; and (3) Medical supplies, equipment, and appliances. (b) The agency provides home health services to (1) Categorically needy recipients age 21 or over; (2) Categorically needy recipients under age 21, if the plan provides skilled nursing facility services for them; individuals; and (3) Medically needy recipients to whom skilled nursing facility services are provided under the plan. (c) The eligibility of a recipient to receive home health services does not depend on his need for or discharge from institutional care. [43 FR 45229, Sept. 29, 1978, as amended at 45 FR 24889, Apr. 11, 1980] |