§ 435.1004 Recipients overcoming certain conditions of eligibility. (a) FFP is available, as specified in paragraph (b) of this section, in expenditures for services provided to recipients who are overcoming certain eligibility conditions, including blindness, disability, continued absence or incapacity of a parent, or unemployment of a parent. (b) FFP is available for a period not to exceed (1) The period during which a recipient of AFDC, SSI or an optional State supplement continues to receive cash payments while these conditions are being overcome; or (2) For recipients eligible for Medicaid only and recipients of AFDC, SSI or an optional State supplement who do not continue to receive cash payments, the second month following the month in which the recipient's Medicaid eligibility would have been terminated. [43 FR 45204, Sept. 29, 1978, as amended at 45 FR 24887, Apr. 11, 1980] LIMITATIONS ON FFP § 435.1005 Recipients in institutions eligible under special outside standard. For recipients in institutions whose Medicaid eligibility is based on a special income standard established under § 435.231, FFP is available in expenditures for services provided to those individuals only if their income before deductions does not exceed 300 percent of the SSI benefit amount payable under section 1611(b)(1) of the Act to an individual in his own home who has no income or resources. § 435.1006 Recipients of optional State supplements only. FFP is available in expenditures for services provided to individuals receiving optional State supplements but not receiving SSI, if their income before deductions, as determined by SSI budget methodology, does not exceed 300 percent of the SSI benefit amount payable under section 1611(b)(1) of the Act to an individual who has no income and resources. [45 FR 24887, Apr. 11, 1980] § 435.1007 Medically needy. (a) FFP is available in expenditures for services provided to medically needy recipients whose annual income after deductions specified in § 436.831 (a) and (c) and § 436.832 does not exceed the following amounts, rounded to the next higher multiple of $100: (1) For couples and families of two or more, 133 percent of the highest money payment that would ordinarily be made under the State's AFDC plan to a family of the same size without income and resources. If the State's AFDC plan specifies a maximum family size beyond which there is no increase in benefits, the medically needy income levels for families whose size exceeds that maximum will be determined by adding an amount for each family member over the maximum size. These amounts must be reasonably related to the amounts by which the State's AFDC plan increases benefits for additional family members in families below the maximum size. (2) For individuals, 133% percent of an amount reasonably related to the highest money payment which would ordinarily be made under the State's AFDC plan to a family of two without income and resources. § 435.1008 Institutionalized individuals. (a) Except as provided in paragraph (b) of this section, FFP is not available in expenditures for services provided to (1) Individuals who are inmates of public institutions as defined in § 435.1009; or (2) Individuals under age 65 who are patients in an institution for tuberculosis or mental diseases unless they are under age 22 and are receiving inpatient psychiatric services under § 440.160 of this subchapter. (b) FFP is available in expenditures for services furnished to eligible individuals during the month in which they become inmates of a public institution or patients in an institution for tuberculosis or mental diseases. (c) An individual on conditional release or convalescent leave from an institution for mental diseases is not considered to be a patient in that institution. However, such an individual who is under age 22 and has been receiving inpatient psychiatric services under § 440.160 of this subchapter is considered to be a patient in the institution until he is unconditionally released or, if earlier, the date he reaches age 22. § 435.1009 Definitions relating to institutional status. care, and consideration of alternate methods of care. (e) An individual postinstitutional plan, as part of the individual plan of care, developed before discharge by a qualified mental retardation professional and other appropriate professionals. This must include provision for appropriate services, protective supervision, and other follow-up services in the For purposes of FFP, the following resident's new environment. definitions apply: "Active treatment in institutions for the mentally retarded" requires the following: (a) The individual's regular participation, in accordance with an individual plan of care, in professionally developed and supervised activities, experiences, or therapies. (b) An individual written plan of care that sets forth measurable goals cr objectives stated in terms of desirable behavior and that prescribes an integrated program of activities, experiences or therapies necessary for the individual to reach those goals or objectives. The overall purpose of the plan is to help the individual function at the greatest physical, intellectual, social, or vocational level he can presently or potentially achieve. (c) An interdisciplinary professional evaluation that— (1) Is completed, for a recipient, before admission to the institution but not more than 3 months before and, for an individual applying for Medicaid after admission, before the institution requests payment; (2) Consists of complete medical, social, and psychological diagnosis and evaluations and an evaluation of the individual's need for institutional care; and (3) Is made by a physician, a social worker and other professionals, at least one of whom is a qualified mental retardation professional as defined in § 442.401 of this subchapter. (d) Reevaluation medically, socially, and psychologically at least annually by the staff involved in carrying out the resident's individual plan of care. This must include review of the individual's progress toward meeting the plan objectives, the appropriateness of the individual plan of care, assessment of his continuing need for institutional “In an institution” refers to an individual who is admitted to live there and receive treatment or services provided there that are appropriate to his requirements. “Inmate of a public institution” means a person who is living in a public institution. An individual is not considered an inmate if— (1) He is in a public educational or vocational training institution for purposes of securing education or vocational training; or (2) He is in a public institution for a temporary period pending other arrangements appropriate to his needs. "Inpatient" means a patient who has been admitted to a medical institution on recommendation of a physician or dentist and is receiving room, board, and professional services in the institution on a continuous 24-hour-a-day basis. "Institution" means an establishment that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more persons unrelated to the proprietor. "Institution for mental diseases" means an institution that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for the mentally retarded is not an institution for mental diseases. “Institution for the mentally retarded or persons with related conditions" means an institution (or distinct part of an institution) that (1) Is primarily for the diagnosis, treatment, or rehabilitation of the mentally retarded or persons with related conditions; and (2) Provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration of health or rehabilitative services to help each individual function at his greatest ability. "Institution for tuberculosis" means an institution that is primarily engaged in providing diagnosis, treatment, or care of persons with tuberculosis, including medical attention, nursing care, and related services. Whether an institution is an institution for tuberculosis is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of tuberculosis, whether or not it is licensed as such. "Medical institution" means an institution that (1) Is organized to provide medical care, including nursing and convalescent care; (2) Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of patients on a continuing basis in accordance with accepted standards; (3) Is authorized under State law to provide medical care; and (4) Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. The services must include adequate and continual medical care and supervision by a physician; registered nurse or licensed practical nurse supervision and services and nurses' aid services, sufficient to meet nursing care needs; and a physician's guidance on the professional aspects of operating the institution. "Patient" means an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward maintenance, improvement, or protection of health, or lessening of illness, disability, or pain. "Persons with related conditions" means individuals who have epilepsy, cerebral palsy, or other developmental disabilities as defined under part C of the Developmental Disabilities Services and Facilities Construction Act, Pub. L. 91-517 (enacted Oct. 30, 1970), as amended. "Public institution" means an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control. The term “public institution" does not include a medical institution as defined in this section, an intermediate care facility as defined in §§ 440.140 and 440.150 of this chapter, or a publicly operated community residence that serves no more than 16 residents, as defined in this section. "Publicly operated community residence that serves no more than 16 residents" is defined in 20 CFR 416.231(b)(6)(i). A summary of that definition is repeated here for the information of readers. (1) In general, a publicly operated community residence means (i) It is publicly operated as defined in 20 CFR 416.231(b)(2). (ii) It is designed or has been changed to serve no more than 16 residents and it is serving no more than 16: and (iii) It provides some services beyond food and shelter such as social services, help with personal living activities, or training in socialization and life skills. Occasional medical or remedial care may also be provided as defined in 45 CFR 228.1; and (2) A publicly operated community residence does not include the following facilities, even though they accommodate 16 or fewer residents: (i) Residential facilities located on the grounds of, or immediately adjacent to, any large institution or multiple purpose complex. (ii) Educational or vocational training institutions that primarily provide an approved, accredited, or recognized program to individuals residing there. (iii) Correctional or holding facilities for individuals who are prisoners, have been arrested or detained pending disposition of charges, or are held under court order as material witnesses or juveniles. (iv) Hospitals, skilled nursing facilities, and intermediate care facilities. "Resident of an intermediate care facility" is an individual who is (1) In need of and receiving professional services to maintain, improve, or protect health or lessen disability or pain under the direction of a practitioner of the healing arts; (2) Admitted to an intermediate care facility in accordance with §§ 450.370 through 450.381 of this subchapter; (3) Under care and supervision 24 hours a day; and (4) If he is in an institution for the mentally retarded, receiving active treatment as defined in this section. REQUIREMENTS FOR STATE SUPPLEMENTS § 435.1010 Requirement for mandatory State supplements. (a) Except as specified in paragraph (b) of this section, FFP is not available in Medicaid expenditures in any quarter in which the State does not have in effect an agreement with the Secretary under section 212 of Pub. L. 93-66 (July 9, 1973) for minimum mandatory State supplements of the basic SSI benefit. (b) This section does not apply to any State that meets the conditions of section 212(f) of Pub. L. 93-66. § 435.1011 Requirement for maintenance of optinal State supplement expenditures. (a) This section applies to States that make optional State supplement payments under section 1616(a) of the Act and mandatory supplement payments under section 212(a) of Pub. L. 93-66. (b) FFP in Medicaid expenditures is not available in the following periods, if the State does not have in effect an agreement with the Secretary under section 1618 of the Act to maintain its December 1976 supplementary payment expenditure ievels: (1) Any calendar quarter after June 30, 1977; or (2) If later, any calendar quarter after the one in which the State first makes supplementary payments. |