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.

[43 FR 45224, Sept. 29, 1978, as amended at 45 FR 24889, Apr. 11, 1980]

§ 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.

PART 441-SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES

Sec.

441.1 Purpose.

Subpart A-General Provisions

441.10 Basis.

thority to prescribe regulations relating to services:

(a) Sections 1902(a)(13)(A)(ii) 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).

(e) Section 1905(a) (following (a)(17)), which prohibits FFP in expenditures for certain services

(§ 441.13).

[43 FR 45229, Sept. 29, 1978, as amended at 45 FR. 24889, Apr. 11, 1980]

§ 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 § 44.40(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 or mental diseases, as defined in § 440.140 of this subchapter.

(7) Inpatient psychiatric services for individuals under age 21, as defined in § 440.160 of this subchapter.

8441.13 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 related 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.

8441.15 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]

§ 441.20 Family planning services.

For recipients eligible under the plan for family planning services, the plan must provide that each recipient is free from coercion or mental pressure and free to choose the method of family planning to be used.

§ 441.30 Optometric services.

The plan must provide for payment of optometric services as physician services, whether furnished by an optometrist or a physician, if—

(a) The plan does not provide for payment for services provided by an optometrist, except for eligibility determinations under §§ 435.531 and 436.531 of this subchapter, but did provide for those services at an earlier period; and

(b) The plan specifically provides that physicians' services include services an optometrist is legally authorized to perform.

§ 441.40 End-stage renal disease.

FFP in expenditures for services described in Subpart A of Part 440 is available for facility treatment of endstage renal disease only if the facility has been approved by the Secretary to furnish those services under Medicare. This requirement for approval of the facility does not apply under emergency conditions permitted under Medicare (see § 405.1011 of this chapter).

60-131 0-81--38

§ 441.50 Basis and purpose.

This subpart implements—

(a) Section 1905(a)(4)(B) of the Social Security Act, by prescribing State plan requirements for providing early and periodic screening and diagnosis of eligible Medicaid recipients under age 21 to ascertain physical and mental defects, and providing treatment to correct or ameliorate defects and chronic conditions found; and

(b) Section 403(g) of the Act, by specifying the conditions under which HHS will impose a penalty on States by reducing Federal financial participation under title IV-A of the Act (Aid to Families with Dependent Children), for failure to provide EPSDT services to eligible AFDC recipients under age 21. (See 45 CFR 205.146(c) for penalty reduction in AFDC.)

(1) Health and developmental history.

(2) Unclothed physical examination. (3) Effective January 1, 1981, developmental assessment.

(4) Immunizations which are appropriate for age and health history.

(5) Assessment of nutritional status. (6) Vision testing.

(7) Hearing testing.

(8) Laboratory procedures appropriate for age and population groups.

(9) For children 3 years of age and over, dental services furnished by direct referral to a dentist for diagnosis and treatment.

(b) Treatment. In addition to any treatment services included in the plan, the agency must provide the following services, even if they are not included in the plan

(1) Treatment for defects in vision and hearing, including eyeglasses and hearing aids; and

(2) Dental care needed for relief of pain and infections, restoration of teeth and maintenance of dental health.

EFFECTIVE DATE NOTE: At 44 FR 29420, May 18, 1979, § 441.56 was revised. The provisions of paragraph (a)(3), regarding the screening requirement for developmental assessments, were made effective on January 1, 1981.

§ 441.57 Discretionary services.

Under the EPSDT program, the agency may provide for any other medical or remedial care specified in Part 440 of this subchapter, even if the agency does not otherwise provide for these services to other recipients or provides for them in a lesser amount, duration, or scope.

§ 441.58 Periodicity schedule.

The agency must implement a periodicity schedule that—

(a) Is developed after consultation with representatives of recognized medical and dental professional

groups;

(b) Specifies screening services applicable at each stage of the recipient's life, up to age 21, including a neonatal examination; and

(c) Identifies the time period, based on the recipient's age in years and

months, that defines when screening services will be delivered.

§ 441.59 Administration.

The agency must

(a) Identify available screening and diagnostic facilities; and

(b) Ensure that the services offered by these facilities are available for recipients under age 21.

§ 441.60 Identifying, informing, and referring eligible recipients to title V services.

The agency must

(a) Identify all recipients eligible for EPSDT services, including those who are in need of medical or remedial services furnished through title V grantees; and

(b) Ensure that recipients eligible for title V services are informed of available services, and referred if they desire to title V grantees that offer services appropriate to the recipients' needs.

[45 FR 24889, Apr. 11, 1980]

§ 441.61 Maximum utilization of existing services.

The agency must make maximum use of existing screening, diagnostic, and treatment services provided by public and voluntary agencies such as well-baby clinics, neighborhood health centers, rural health centers, rural health clinics, and similar agencies.

§ 441.62 Transportation and scheduling assistance.

The agency must offer to the family or recipient, and provide if requested— (a) Assistance with transportation as required under § 431.53 of this chapter; and

(b) Assistance with scheduling appointments for services.

PENALTY FOR FAILURE TO PROVIDE
EPSDT SERVICES

§ 441.70 Imposition of penalty.

For each quarter that a State fails to comply with the requirements to provide EPSDT services to AFDC recipients, as specified in §§ 441.71-441.90, HHS will reduce by one percent Federal financial participation in State payments for AFDC.

§ 441.71 Application of the penalty.

(a) HHS will impose penalties under this subpart if a State fails to maintain accurately the documentation required in § 441.90 or if a State fails to meet the following measures of compliance with the requirements of this subpart:

(1) In at least 95 percent of the sample cases reviewed by HCFA, the State has met all informing requirements as specified in § 441.75.

(2) For families or recipients that request EPSDT services, in at least 75 percent of the sample cases reviewed by HCFA, either

(i) Screening must have been completed and treatment initiated, as specified in §§ 441.80 and 441.85, within 120 days after the initial request for screening or the date rescreening was due under the State's periodicity schedule; or

(ii) The State can show, with supportive evidence, that within the 120day time periods, either

(A) The family or recipient lost eligibility;

(B) The State was not able to locate the family or recipient despite a good faith effort to do so; or

(C) The recipient's failure to receive necessary services was due to an action or decision by the family or recipient, rather than a failure by the State to meet requirements of this subpart, including the requirement to offer and provide the support services specified in § 441.62.

(3) For families or recipients that request EPSDT services, in at least 95 percent of the sample cases reviewed by HCFA, either

(i) Screening must have been completed and treatment initiated, as specified in §§ 441.80 and 441.85, within 180 days after the initial request for screening or the date rescreening was due under the State's periodicity schedules; or

(ii) The State can show, with supportive evidence, that, within the 180day time periods, either

(A) The family or recipient lost eligibility;

(B) The State was not able to locate the family or recipient despite a good faith effort to do so; or