(1) The amount is deducted for not more than a 6-month period; and

(2) A physician has certified that the individual is likely to return to his home within that period.

[45 FR 24888, Apr. 11, 1980]

MEDICALLY NEEDY RESOURCE STANDARDS

§ 436.840 Medically needy resource standards.

(a) To determine eligibility of individuals and families under Subpart E of this part, the agency must use resource standards that are at least equal to the most liberal standard for resources used to determine eligibility for OAA, AFDC, AB, APTD, or AABD on or after January 1, 1966.

(b) The standards for liquid assets must increase by family size.

DETERMINING ELIGIBILITY ON THE BASIS OF RESOURCES

§ 436.845 Medically needy resource eligibility.

To determine eligibility on the basis of resources for medically needy individuals, the agency must

(a) Consider only the individual's resources and those that are considered available to him under the financial responsibility requirements for relatives under § 436.821;

(b) Consider only resources available during the period for which income is computed under § 436.831(a);

(c) Deduct the value of resources that would be deducted in determining eligibility under the State's plan for OAA, AFDC, AB, APTD, or AABD; and

(d) Apply the resource standards established under § 436.840.

Subpart J-Eligibility in Guam, Puerto

Rico, and the Virgin Islands

SOURCE: 44 FR 17939, Mar. 23, 1979, unless otherwise noted.

§ 436.900 Scope.

This subpart sets forth requirements for processing applications, determining eligibility, and furnishing Medicaid.

§ 436.901 General requirements.

The Medicaid agency must comply with all the requirements of Part 435, Subpart J, of this subchapter, except those specified in § 435.909.

§ 436.909 Automatic entitlement to Medicaid following a determination of eligibility under other programs.

The agency may not require a separate application for Medicaid from an individual if the individual receives cash assistance under a State plan for OAA, AFDC, AB, APTD, or AABD.

Subpart K-Federal Financial Participation (FFP)

§ 436.1000 Scope.

This subpart specifies when, and the extent to which, FFP is available in expenditures for determining eligibility and for Medicaid services to individuals determined eligible under this part, and prescribes limitations and conditions on FFP for those expenditures.

FFP FOR EXPENDITURES FOR DETERMINING ELIGIBILITY AND PROVIDING SERVICES

§ 436.1001 FFP for administration.

(a) FFP is available in the necessary administrative costs the State incurs in determining and redetermining Medicaid eligibility and in providing Medicaid to eligible individuals.

(b) Administrative costs include any costs incident to an eye examination or medical examination to determine whether an individual is blind or disabled.

§ 436.1002 FFP for services.

(a) FFP is available in expenditures for Medicaid services for all recipients whose coverage is required or allowed under this part.

(b) FFP is available in expenditures for services provided to recipients who were eligible for Medicaid in the month in which the medical care or services were provided, except that, for recipients who establish eligibility for Medicaid by deducting incurred medical expenses from income, FFP is

not available for expenses that are the recipient's liability.

[43 FR 45218, Sept. 29, 1978, as amended at 44 FR 17940, Mar. 23, 1979]

§ 436.1003 Recipients overcoming certain conditions of eligibility.

FFP is available for a temporary period specified in the State plan 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.

[45 FR 24888, Apr. 11, 1980]

§ 436.1004 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 provided 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 pyschiatric 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.

§ 436.1005 Definitions relating to institutional status.

For purposes of FFP, the definitions in § 435.1009 of this subchapter apply to this part.

440.1 Basis and purpose.

440.2 Specific definitions; definitions of services for FFP purposes.

440.10 Inpatient hospital services, other than services in an institution for tuberculosis or mental diseases.

440.20 Outpatient hospital services and rural health clinic services.

440.30 Other laboratory and X-ray services.

440.40 Skilled nursing facility services for individuals age 21 or older (other than services in an institution for tuberculosis or mental diseases). EPSDT, and family planning services and supplies.

440.50 Physicians' services.

440.60 Medical or other remedial care provided by licensed practitioners.

440.70 Home health services.

440.80 Private duty nursing services. 440.90 Clinic services.

440.110 Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders.

440.120 Prescribed drugs, dentures, prosthetic devices, and eyeglasses. 440.130 Diagnostic, screening, preventive, and rehabilitative services.

440.140 Inpatient hospital services, skilled nursing facility services, and intermediate care facility services for individuals age 65 or older in institutions for tuberculosis or mental diseases.

440.150 Intermediate care facility services, other than in institutions for tuberculosis or mental diseases.

440.160 Inpatient pyschiatric services for individuals under age 21.

440.170 Any other medical or remedial care recognized under State law and specified by the Secretary.

§ 440.2 Specific definitions; definitions of services for FFP purposes.

(a) Specific definitions. “Outpatient" means a patient who is receiving professional services at an organized medical facility, or distinct part of such a facility, which is not providing him with room and board and professional services on a continuous 24hour-a-day basis.

"Patient" means an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward the maintenance, improvement, or protection of health, or lessening of illness, disability, or pain. (See also § 435.1009 of this subchapter for definitions relating to institutional care.)

(b) Definitions of services for FFP purposes. Except as limited in Part 441, FFP is available in expenditures under the State plan for medical or remedial care and services as defined in this subpart.

§ 440.10 Inpatient hospital services, other than services in an institution for tuberculosis or mental diseases. "Inpatient hospital services" means services that are ordinarily furnished in a hospital for the care and treatment of an inpatient under the direction of a physician or dentist and that are furnished in an institution that

(a) Is maintained primarily for the care and treatment of patients with disorders other than tuberculosis or mental diseases;

(b) Is licensed or formally approved as a hospital by an officially designated authority for State standard-setting;

(c) Meets the requirements for participation in Medicare; and

(d) Has in effect a utilization review plan, applicable to all Medicaid patients, that meets the requirements of § 405.1035 of this chapter, unless a waiver has been granted by the Secretary.

§ 440.20 Outpatient hospital services and rural health clinic services.

(a) "Outpatient hospital services” means preventive, diagnostic, therapeutic, rehabilitative, or palliative services provided to an outpatient, by or under the direction of a physician or dentist, by an institution that

(1) Is licensed or formally approved as a hospital by an officially designated authority for State standard-setting; and

(2) Meets the requirements for participation in Medicare.

(b) Rural health clinic services. If nurse practitioners or physician assistants (as defined in § 481.1 of this chapter) are not prohibited by State law from furnishing primary health care, "rural health clinic services" means the following services when furnished by a rural health clinic that has been certified in accordance with Part 481 of this chapter.

(1) Services furnished by a physician within the scope of practice of his profession under State law, if the physician performs the services in the clinic or the services are furnished away from the clinic and the physician has an agreement with the clinic providing that he will be paid by it for such services.

(2) Services furnished by a physician assistant, nurse practitioner, nurse midwife or other specialized nurse practitioner (as defined in §§ 405.2401 and 481.2 of this chapter) if the services are furnished in accordance with the requirements specified

§ 405.2414(a) of this chapter.

in

(3) Services and supplies that are furnished as an incident to professional services furnished by a physician, physician assistant, nurse practitioner, nurse midwife, or specialized nurse practitioner. (See §§ 405.2413 and 405.2415 of this chapter for the criteria for determining whether services

and supplies are included under this paragraph.)

(4) Part-time or intermittent visiting nurse care and related medical supplies (other than drugs and biologicals) if:

(i) The clinic is located in an area in which the Secretary has determined that there is a shortage of home health agencies (see § 405.2417 of this chapter):

(ii) The services are furnished by a registered nurse or licensed practical nurse or a licensed vocational nurse employed by, or otherwise compensated for the services by, the clinic;

(iii) The services are furnished under a written plan of treatment that is established and reviewed at least every 60 days by a supervising physician of the clinic or that is established by a physician, physician assistant, nurse practitioner, nurse midwife, or specialized nurse practitioner and reviewed and approved at least every 60 days by a supervising physician of the clinic; and

(iv) The services are furnished to a homebound recipient. For purposes of visiting nurse care, a “homebound" recipient means one who is permanently or temporarily confined to his place of residence because of a medical or health condition. He may be considered homebound if he leaves the place of residence infrequently. For this purpose, "place of residence" does not include a hospital or a skilled nursing facility.

(c) Other ambulatory services furnished by a rural health clinic. If the State plan covers rural health clinic services, other ambulatory services means ambulatory services other than rural health clinic services, as defined in paragraph (b) of this section, that are otherwise included in the plan and meet specific State plan requirements for furnishing those services. Other ambulatory services furnishd by a rural health clinic are not subject to the physician supervision requirements specified in § 481.8(b) of this chapter, unless required by State law or the State plan.

§ 440.30 Other laboratory and X-ray services.

"Other laboratory and X-ray services" means professional and technical laboratory and radiological services

(a) Ordered and provided by or under the direction of a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by State law;

(b) Provided in an office or similar facility other than a hospital outpatient department or clinic; and

(c) Provided by a laboratory that meets the requirements for participation in Medicare.

§ 440.40 Skilled nursing facility services for individuals age 21 or older (other than services in an institution for tuberculosis or mental diseases). EPSDT, and family planning services and supplies.

(a) Skilled nursing facility services. (1) “Skilled nursing facility services for individuals age 21 or older, other than services in an institution for tuberculosis or mental diseases," means services that are

(i) Needed on a daily basis and required to be provided on an inpatient basis under §§ 405.127, 405.128, and 405.128a of this chapter;

(ii) Provided by a facility or distinct part of a facility that is certified to meet the requirements for participation under Subpart C of Part 442 of this subchapter, as evidenced by a valid agreement between the Medicaid agency and the facility for providing skilled nursing facility services and making payments for services under the plan; and

(iii) Ordered by and under the direction of a physician.

(2) Skilled nursing facility services includes services provided by any facility located on an Indian reservation and certified by the Secretary as meeting the requirements of Subpart K of Part 405 of this chapter.

(b) EPSDT. "Early and periodic screening and diagnosis and treatment" means

(1) Screening and diagnostic services to determine physical or mental defects in recipients under age 21; and

(2) Health care, treatment, and other measures to correct or amelio

rate any defects and chronic conditions discovered. (See Subpart B of Part 441 of this subchapter.)

(c) Family planning services and supplies for individuals of child-bearing age. [Reserved]

§ 440.50 Physicians' services.

"Physicians' services," whether furnished in the office, the recipient's home, a hospital, a skilled nursing facility, or elsewhere, means services provided

(a) Within the scope of practice of medicine or osteopathy as defined by State law; and

(b) By or under the personal supervision of an individual licensed under State law to practice medicine or osteopathy.

§ 440.60 Medical or other remedial care provided by licensed practitioners.

(a) "Medical care or any other type remedial care provided by licensed practitioners" means any medical or remedial care or services, other than physicians' services, provided by licensed practitioners within the scope of practice as defined under State law. (b) Chiropractors' services include only services that

(1) Are provided by a chiropractor who is licensed by the State and meets standards issued by the Secretary under § 405.232b of this chapter; and

(2) Consists of treatment by means of manual manipulation of the spine that the chiropractor is legally authorized by the State to perform.

§ 440.70 Home health services.

(a) "Home health services" means the services in paragraph (b) of this section that are provided to a recipient

(1) At his place of residence, as specified in paragraph (c) of this section; and

(2) On his physician's orders as part of a written plan of care that the physician reviews every 60 days.

(b) Home health services include the following services and items. Those listed in paragraphs (b) (1), (2) and (3) of this section are required services; those in paragraph (b)(4) of this section are optional.

(1) Nursing service, as defined in the State Nurse Practice Act, that is provided on a part-time or intermittent basis by a home health agency as defined in paragraph (d) of this section, or if there is no agency in the area, a registered nurse who

(i) Is currently licensed to practice in the State;

(ii) Receives written orders from the patient's physician;

(iii) Documents the care and services provided; and

(iv) Has had orientation to acceptable clinical and administrative recordkeeping from a health department

nurse.

(2) Home health aide service provided by a home health agency,

(3) Medical supplies, equipment, and appliances suitable for use in the home, and

(4) Physical therapy, occupational therapy, or speech pathology and audiology services, provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services. (See § 441.15 of this subchapter.)

(c) A recipient's place of residence, for home health services, does not include a hospital, skilled nursing facility, or intermediate care facility except for home health services in an intermediate care facility that are not required to be provided by the facility under Subparts F and G of Part 442 of this subchapter. For example, a registered nurse may provide short-term care for a recipient in an intermediate care facility during an acute illness to avoid the recipient's transfer to a skilled nursing facility.

(d) "Home health agency" means a public or private agency or organization, or part of an agency or organization, that meets requirements for participation in Medicare.

(e) A "facility licensed by the State to provide medical rehabilitation services" means a facility that—

(1) Provides therapy services for the primary purpose of assisting in the rehabilitation of disabled individuals through an integrated program of—

(i) Medical evaluation and services; and

(ii) Psychological, social, or vocational evaluation and services; and