42 C.F.R. §§ 440.10–440.165

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

42 C.F.R. § 440.10

(a)

Inpatient hospital services means services that—

(1)

Are ordinarily furnished in a hospital for the care and treatment of inpatients;

(2)

Are furnished under the direction of a physician or dentist; and

(3)

Are furnished in an institution that—

(i)

Is maintained primarily for the care and treatment of patients with disorders other than mental diseases;

(ii)

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

(iii)

Meets the requirements for participation in Medicare as a hospital; and

(iv)

Has in effect a utilization review plan, applicable to all Medicaid patients, that meets the requirements of § 482.30 of this chapter, unless a waiver has been granted by the Secretary.

(b)

Inpatient hospital services do not include SNF and ICF services furnished by a hospital with a swing-bed approval.

Notes, amendments, and revision history

Amendments

[47 FR 21050, May 17, 1982, as amended at 47 FR 31532, July 20, 1982; 51 FR 22041, June 17, 1986, 52 FR 47934, Dec. 17, 1987; 60 FR 61486, Nov. 30, 1995]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[47 FR 21050, May 17, 1982, as amended at 47 FR 31532, July 20, 1982; 51 FR 22041, June 17, 1986, 52 FR 47934, Dec. 17, 1987; 60 FR 61486, Nov. 30, 1995]

§440.20. Outpatient hospital services and rural health clinic services.

42 C.F.R. § 440.20

(a)

Outpatient hospital services means preventive, diagnostic, therapeutic, rehabilitative, or palliative services that—

(1)

Are furnished to outpatients;

(2)

Are furnished by or under the direction of a physician or dentist; and

(3)

Are furnished by an institution that—

(i)

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

(ii)

Meets the requirements for participation in Medicare as a hospital; and

(4)

May be limited by a Medicaid agency in the following manner— A Medicaid agency may exclude from the definition of “outpatient hospital services” those types of items and services that are not generally furnished by most hospitals in the State.

(b)

Rural health clinic services. If nurse practitioners or physician assistants (as defined in § 491.2 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 491 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 491.2 of this chapter) if the services are furnished in accordance with the requirements specified in § 405.2414(a) of this chapter.

(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 beneficiary. For purposes of visiting nurse care, a “homebound” beneficiary 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 § 491.8(b) of this chapter, unless required by State law or the State plan.

Notes, amendments, and revision history

Amendments

[43 FR 45224, Sept. 29, 1978, as amended at 47 FR 21050, May 17, 1982; 52 FR 47934, Dec. 17, 1987; 60 FR 61486, Nov. 30, 1995; 73 FR 66198, Nov. 7, 2008; 74 FR 31195, June 30, 2009; 85 FR 72909, Nov. 16, 2020]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[43 FR 45224, Sept. 29, 1978, as amended at 47 FR 21050, May 17, 1982; 52 FR 47934, Dec. 17, 1987; 60 FR 61486, Nov. 30, 1995; 73 FR 66198, Nov. 7, 2008; 74 FR 31195, June 30, 2009; 85 FR 72909, Nov. 16, 2020]

§440.30. Other laboratory and X-ray services.

42 C.F.R. § 440.30

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 practioner of the healing arts within the scope of his practice as defined by State law or ordered by a physician but provided by referral laboratory;

(b)

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

(c)

Furnished by a laboratory that meets the requirements of part 493 of this chapter.

(d)

During the Public Health Emergency defined in 42 CFR 400.200 or any future Public Health Emergency resulting from an outbreak of communicable disease, and during any subsequent period of active surveillance (as defined in this paragraph), Medicaid coverage is available for laboratory tests and X-ray services that do not meet conditions specified in paragraph (a) or (b) of this section, if the purpose of such laboratory and X-ray services is to diagnose or detect SARS-CoV-2, antibodies to SARS-CoV-2, COVID-19, or the communicable disease named in the Public Health Emergency or its causes, and if the deviation from the conditions specified in paragraph (a) or (b) of this section is intended to avoid transmission of the communicable disease. For purposes of this paragraph, a period of active surveillance is defined as an outbreak of communicable disease during which no approved treatment or vaccine is widely available, and it ends on the date the Secretary terminates it, or the date that is two incubation periods after the last known case of the communicable disease, whichever is sooner. Additionally, during the Public Health Emergency defined in 42 CFR 400.200 or any future Public Health Emergency resulting from an outbreak of communicable disease, and during any subsequent period of active surveillance (as defined in this paragraph), Medicaid coverage is available for laboratory processing of self-collected laboratory test systems that are authorized by the FDA for home use, if available to diagnose or detect SARS-CoV-2, antibodies to SARS-CoV-2, COVID-19, or the communicable disease named in the Public Health Emergency or its causes, even if those self-collected tests would not otherwise meet the requirements of paragraph (a) or (b) of this section, provided that the self-collection of the test is intended to avoid transmission of the communicable disease. If, pursuant to this paragraph, a laboratory processes a self-collected test system that is authorized by the FDA for home use, and the test system does not meet the conditions in paragraph (a) of this section, the laboratory must notify the patient and the patient's physician or other licensed non-physician practitioner (if known by the laboratory), of the results.

Notes, amendments, and revision history

Amendments

[46 FR 42672, Aug. 24, 1981, as amended at 57 FR 7135, Feb. 28, 1992; 85 FR 27626, May 8, 2020]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[46 FR 42672, Aug. 24, 1981, as amended at 57 FR 7135, Feb. 28, 1992; 85 FR 27626, May 8, 2020]

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

42 C.F.R. § 440.40

(a)

Nursing facility services.

(1)

“Nursing facility services for individuals age 21 or older, other than services in an institution for mental diseases”, means services that are—

(i)

Needed on a daily basis and required to be provided on an inpatient basis under §§ 409.31 through 409.35 of this chapter.

(ii)

Provided by—

(A)

A facility or distinct part (as defined in § 483.5(b) of this chapter) that meets the requirements for participation under subpart B of part 483 of this chapter, as evidenced by a valid agreement between the Medicaid agency and the facility for providing nursing facility services and making payments for services under the plan; or

(B)

If specified in the State plan, a swing-bed hospital that has an approval from CMS to furnish skilled nursing facility services in the Medicare program; and

(iii)

Ordered by and provided under the direction of a physician.

(2)

Nursing facility services include services provided by any facility located on an Indian reservation and certified by the Secretary as meeting the requirements of subpart B of part 483 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 beneficiaries under age 21; and

(2)

Health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered. (See subpart B of part 441 of this chapter.)

(c)

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

Notes, amendments, and revision history

Amendments

[59 FR 56233, Nov. 10, 1994; 60 FR 50117, Sept. 28, 1995, as amended at 61 FR 59198, Nov. 21, 1996; 68 FR 46071, Aug. 4, 2003]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[59 FR 56233, Nov. 10, 1994; 60 FR 50117, Sept. 28, 1995, as amended at 61 FR 59198, Nov. 21, 1996; 68 FR 46071, Aug. 4, 2003]

§440.50. Physicians' services and medical and surgical services of a dentist.

42 C.F.R. § 440.50

(a)

“Physicians' services,” whether furnished in the office, the beneficiary's home, a hospital, a skilled nursing facility, or elsewhere, means services furnished by a physician—

(1)

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

(2)

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

(b)

“Medical and surgical services of a dentist” means medical and surgical services furnished, on or after January 1, 1988, by a doctor of dental medicine or dental surgery if the services are services that—

(1)

If furnished by a physician, would be considered physician's services.

(2)

Under the law of the State where they are furnished, may be furnished either by a physician or by a doctor of dental medicine or dental surgery; and

(3)

Are furnished by a doctor of dental medicine or dental surgery who is authorized to furnish those services in the State in which he or she furnished the services.

Notes, amendments, and revision history

Amendments

[56 FR 8851, Mar. 1, 1991]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[56 FR 8851, Mar. 1, 1991]

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

42 C.F.R. § 440.60

(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 § 405.232(b) 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.

Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

§440.70. Home health services.

42 C.F.R. § 440.70

(a)

“Home health services” means the services in paragraph (b) of this section that are provided to a beneficiary—

(1)

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

(2)

On orders written by a physician, nurse practitioner, clinical nurse specialist or physician assistant, working in accordance with State law, as part of a written plan of care that the ordering practitioner reviews every 60 days for services described in (b)(1), (2), and (4) of this section; and

(3)

On his or her physician's orders or orders written by a licensed practitioner of the healing arts acting within the scope of practice authorized under State law, as part of a written plan of care for services described in paragraph (b)(3) of this section. The plan of care must be reviewed by the ordering practitioner as specified in paragraph (b)(3)(iii) of this section.

(b)

Home health services include the following services and items. Paragraphs (b)(1), (2) and (3) of this section are required services and items that must be covered according to the home health coverage parameters. Services in paragraph (b)(4) of this section are optional. Coverage of home health services cannot be contingent upon the beneficiary needing nursing or therapy services.

(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 practitioner as defined in (a)(2) of this section;

(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 any setting in which normal life activities take place, as defined at § 440.70(c)(1).

(i)

Supplies are health care related items that are consumable or disposable, or cannot withstand repeated use by more than one individual, that are required to address an individual medical disability, illness or injury.

(ii)

Equipment and appliances are items that are primarily and customarily used to serve a medical purpose, generally are not useful to an individual in the absence of a disability, illness or injury, can withstand repeated use, and can be reusable or removable. State Medicaid coverage of equipment and appliances is not restricted to the items covered as durable medical equipment in the Medicare program.

(iii)

A beneficiary's need for medical supplies, equipment, and appliances must be reviewed by a physician or, as defined in § 400.200 of this chapter, an other licensed practitioner of the healing arts acting within the scope of practice authorized under State law, annually.

(iv)

Frequency of further physician or, as defined in § 400.200 of this chapter, an other licensed practitioner review of a beneficiary's continuing need for the items is determined on a case-by-case basis based on the nature of the item prescribed.

(v)

States can have a list of preapproved medical equipment supplies and appliances for administrative ease but States are prohibited from having absolute exclusions of coverage on medical equipment, supplies, or appliances. States must have processes and criteria for requesting medical equipment that is made available to individuals to request items not on the State's list. The procedure must use reasonable and specific criteria to assess items for coverage. When denying a request, a State must inform the beneficiary of the right to a fair hearing.

(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 beneficiary's place of residence, for home health services, does not include a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities, except for home health services in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483. For example, a registered nurse may provide short-term care for a beneficiary in an intermediate care facility for Individuals with Intellectual Disabilities during an acute illness to avoid the beneficiary's transfer to a nursing facility.

(1)

Nothing in this section should be read to prohibit a beneficiary from receiving home health services in any setting in which normal life activities take place, other than a hospital, nursing facility; intermediate care facility for individuals with intellectual disabilities; or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to beneficiaries who are homebound.

(2)

Additional services or service hours may, at the State's option, be authorized to account for medical needs that arise in the settings home health services are provided.

(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, including the capitalization requirements under § 489.28 of this chapter.

(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

(2)

Is operated under competent medical supervision either—

(i)

In connection with a hospital; or

(ii)

As a facility in which all medical and related health services are prescribed by or under the direction of individuals licensed to practice medicine or surgery in the State.

(f)

No payment may be made for services referenced in paragraphs (b)(1) through (4) of this section, unless a practitioner referenced in paragraph (a)(2) of this section or for medical equipment, a practitioner described in paragraph (a)(3) of this section documents that there was a face-to-face encounter with the beneficiary that meets the following requirements.

(1)

For the initiation of home health services, the face-to-face encounter must be related to the primary reason the beneficiary requires home health services and must occur within the 90 days before or within the 30 days after the start of the services.

(2)

For the initiation of medical equipment, the face-to-face encounter must be related to the primary reason the beneficiary requires medical equipment and must occur no more than 6 months prior to the start of services.

(3)

The face-to-face encounter may be conducted by one of the following practitioners:

(i)

A physician;

(ii)

A nurse practitioner or clinical nurse specialist, as those terms are defined in section 1861(aa)(5) of the Act, in accordance with State law;

(iii)

A certified nurse midwife, as defined in section 1861(gg) of the Act, as authorized by State law;

(iv)

A physician assistant, as defined in section 1861(aa)(5) of the Act, in accordance with State law; or

(v)

For beneficiaries admitted to home health immediately after an acute or post-acute stay, the attending acute or post-acute physician.

(vi)

For medical equipment, supplies, or appliances, a licensed practitioner of the healing arts acting within the scope of practice authorized under state law.

(4)

If State law does not allow the non-physician practitioner, as described in paragraphs (f)(3)(ii) through (vi) of this section, to perform the face-to-face encounter independently, the non-physician practitioner must communicate the clinical findings of that face-to-face encounter to the ordering physician. Those clinical findings must be incorporated into a written or electronic document included in the beneficiary's medical record.

(5)

To assure clinical correlation between the face-to-face encounter and the associated home health services, the practitioner responsible for ordering the services must:

(i)

Document the face-to-face encounter which is related to the primary reason the patient requires home health services, occurred within the required timeframes prior to the start of home health services.

(ii)

Must indicate the practitioner who conducted the encounter, and the date of the encounter.

(6)

The face-to-face encounter may occur through telehealth, as implemented by the State.

(g)

(1)

No payment may be made for medical equipment, supplies, or appliances referenced in paragraph (b)(3) of this section to the extent that a face-to-face encounter requirement would apply as durable medical equipment (DME) under the Medicare program, unless a practitioner referenced in paragraph (a)(3) of this section documents a face-to-face encounter with the beneficiary consistent with the requirements of paragraph (f) of this section except as indicated in paragraph (g)(2) of this section.

(2)

The face-to-face encounter may be performed by any of the practitioners described in paragraph (f)(3) of this section, with the exception of certified nurse-midwives, as described in paragraph (f)(3)(iii) of this section.

Notes, amendments, and revision history

Amendments

[43 FR 45224, Sept. 29, 1978, as amended at 45 FR 24888, Apr. 11, 1980; 62 FR 47902, Sept. 11, 1997; 63 FR 310, Jan. 5, 1998; 81 FR 5566, Feb. 2, 2016; 85 FR 19291, Apr. 6, 2020; 85 FR 27626, May 8, 2020]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[43 FR 45224, Sept. 29, 1978, as amended at 45 FR 24888, Apr. 11, 1980; 62 FR 47902, Sept. 11, 1997; 63 FR 310, Jan. 5, 1998; 81 FR 5566, Feb. 2, 2016; 85 FR 19291, Apr. 6, 2020; 85 FR 27626, May 8, 2020]

§440.80. Private duty nursing services.

42 C.F.R. § 440.80

Private duty nursing services means nursing services for beneficiaries who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of the hospital or skilled nursing facility. These services are provided—

(a)

By a registered nurse or a licensed practical nurse;

(b)

Under the direction of the beneficiary's physician; and

(c)

To a beneficiary in one or more of the following locations at the option of the State—

(1)

His or her own home;

(2)

A hospital; or

(3)

A skilled nursing facility.

Notes, amendments, and revision history

Amendments

[52 FR 47934, Dec. 17, 1987]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[52 FR 47934, Dec. 17, 1987]

§440.90. Clinic services.

42 C.F.R. § 440.90

Clinic services means preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are furnished by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients. The term includes the following services furnished to outpatients (services in paragraphs (a) through (c) of this section are a mandatory part of clinic services, while services in paragraphs (d) and (e) of this section are optional):

(a)

Services furnished at the clinic by or under the direction of a physician or dentist.

(b)

Services furnished outside the clinic, by clinic personnel under the direction of a physician, to an individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address.

(c)

Services furnished outside a clinic that is a facility of the Indian Health Service, whether operated by the Indian Health Service or by a Tribe or Tribal organization (as authorized by the Indian Self-Determination and Education Assistance Act (ISDEAA), Pub. L. 93-638), by clinic personnel under the direction of a physician.

(d)

Services furnished outside of a clinic that is primarily organized for the care and treatment of outpatients with behavioral health disorders, including mental health and substance use disorders, by clinic personnel under the direction of a physician.

(e)

Services furnished outside of a clinic that is located in a rural area and is not a rural health clinic (as referenced in section 1905(a)(2)(B) of the Social Security Act and § 440.20(b)) by clinic personnel under the direction of a physician. States must include a definition of rural area in their State plans. This definition must be either a definition adopted and used by a Federal governmental agency for programmatic purposes, or a definition adopted by a State governmental agency with a role in setting State rural health policy.

Notes, amendments, and revision history

Amendments

[56 FR 8851, Mar. 1, 1991, as amended at 60 FR 61486, Nov. 30, 1995; 89 FR 94591, Nov. 27, 2024]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[56 FR 8851, Mar. 1, 1991, as amended at 60 FR 61486, Nov. 30, 1995; 89 FR 94591, Nov. 27, 2024]

§440.100. Dental services.

42 C.F.R. § 440.100

(a)

“Dental services” means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his profession, including treatment of—

(1)

The teeth and associated structures of the oral cavity; and

(2)

Disease, injury, or impairment that may affect the oral or general health of the beneficiary.

(b)

“Dentist” means an individual licensed to practice dentistry or dental surgery.

Notes, amendments, and revision history

Amendments

[43 FR 45224, Sept. 29, 1978, as amended at 45 FR 24888, Apr. 11, 1980]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[43 FR 45224, Sept. 29, 1978, as amended at 45 FR 24888, Apr. 11, 1980]

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

42 C.F.R. § 440.110

(a)

Physical therapy—

(1)

Physical therapy means services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a beneficiary by or under the direction of a qualified physical therapist. It includes any necessary supplies and equipment.

(2)

A “qualified physical therapist” is an individual who meets personnel qualifications for a physical therapist at § 484.115.

(b)

Occupational therapy—

(1)

Occupational therapy means services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a beneficiary by or under the direction of a qualified occupational therapist. It includes any necessary supplies and equipment.

(2)

A “qualified occupational therapist” is an individual who meets personnel qualifications for an occupational therapist at § 484.115.

(c)

Services for individuals with speech, hearing, and language disorders—

(1)

Services for individuals with speech, hearing, and language disorders means diagnostic, screening, preventive, or corrective services provided by or under the direction of a speech pathologist or audiologist, for which a patient is referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law. It includes any necessary supplies and equipment.

(2)

A “speech pathologist” is an individual who meets one of the following conditions—

(i)

Has a certificate of clinical competence from the American Speech and Hearing Association.

(ii)

Has completed the equivalent educational requirements and work experience necessary for the certificate.

(iii)

Has completed the academic program and is acquiring supervised work experience to qualify for the certificate.

(3)

A “qualified audiologist” means an individual with a master's or doctoral degree in audiology that maintains documentation to demonstrate that he or she meets one of the following conditions:

(i)

The State in which the individual furnishes audiology services meets or exceeds State licensure requirements in paragraph (c)(3)(ii)(A) or (c)(3)(ii)(B) of this section, and the individual is licensed by the State as an audiologist to furnish audiology services.

(ii)

In the case of an individual who furnishes audiology services in a State that does not license audiologists, or an individual exempted from State licensure based on practice in a specific institution or setting, the individual must meet one of the following conditions:

(A)

Have a Certificate of Clinical Competence in Audiology granted by the American Speech-Language-Hearing Association.

(B)

Have successfully completed a minimum of 350 clock-hours of supervised clinical practicum (or is in the process of accumulating that supervised clinical experience under the supervision of a qualified master or doctoral-level audiologist); performed at least 9 months of full-time audiology services under the supervision of a qualified master or doctoral-level audiologist after obtaining a master's or doctoral degree in audiology, or a related field; and successfully completed a national examination in audiology approved by the Secretary.

Notes, amendments, and revision history

Amendments

[43 FR 45224, Sept. 29, 1978, as amended at 45 FR 24888, Apr. 11, 1980; 56 FR 8854, Mar. 1, 1991; 60 FR 19861, Apr. 21, 1995; 69 FR 30587, May 28, 2004; 77 FR 29031, May 16, 2012; 82 FR 4578, Jan. 13, 2017]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[43 FR 45224, Sept. 29, 1978, as amended at 45 FR 24888, Apr. 11, 1980; 56 FR 8854, Mar. 1, 1991; 60 FR 19861, Apr. 21, 1995; 69 FR 30587, May 28, 2004; 77 FR 29031, May 16, 2012; 82 FR 4578, Jan. 13, 2017]

§440.120. Prescribed drugs, dentures, prosthetic devices, and eyeglasses.

42 C.F.R. § 440.120

(a)

“Prescribed drugs” means simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are—

(1)

Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by Federal and State law;

(2)

Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and

(3)

Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

(b)

“Dentures” are artificial structures made by or under the direction of a dentist to replace a full or partial set of teeth.

(c)

“Prosthetic devices” means replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by State law to—

(1)

Artificially replace a missing portion of the body;

(2)

Prevent or correct physical deformity or malfunction; or

(3)

Support a weak or deformed portion of the body.

(d)

“Eyeglasses” means lenses, including frames, and other aids to vision prescribed by a physician skilled in diseases of the eye or an optometrist.

Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

§440.130. Diagnostic, screening, preventive, and rehabilitative services.

42 C.F.R. § 440.130

(a)

“Diagnostic services,” except as otherwise provided under this subpart, includes any medical procedures or supplies recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under State law, to enable him to identify the existence, nature, or extent of illness, injury, or other health deviation in a beneficiary.

(b)

“Screening services” means the use of standardized tests given under medical direction in the mass examination of a designated population to detect the existence of one or more particular diseases or health deviations or to identify for more definitive studies individuals suspected of having certain diseases.

(c)

“Preventive services” means services recommended by a physician or other licensed practitioner of the healing arts acting within the scope of authorized practice under State law to—

(1)

Prevent disease, disability, and other health conditions or their progression;

(2)

Prolong life; and

(3)

Promote physical and mental health and efficiency.

(d)

“Rehabilitative services,” except as otherwise provided under this subpart, includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under State law, for maximum reduction of physical or mental disability and restoration of a beneficiary to his best possible functional level.

Notes, amendments, and revision history

Amendments

[43 FR 45224, Sept. 29, 1978, as amended at 78 FR 42306, July 15, 2013]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[43 FR 45224, Sept. 29, 1978, as amended at 78 FR 42306, July 15, 2013]

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

42 C.F.R. § 440.140

(a)

Inpatient hospital services. “Inpatient hospital services for individuals age 65 or older in institutions for mental diseases” means services provided under the direction of a physician for the care and treatment of beneficiaries in an institution for mental diseases that meets the requirements specified in § 482.60(b), (c), and (e) of this chapter and—

(1)

Meets the requirements for utilization review in § 482.30(a), (b), (d), and (e) of this chapter; or

(2)

Has been granted a waiver of those utilization review requirements under section 1903(i)(4) of the Act and subpart H of part 456 of this chapter.

(b)

Nursing facility services. “Nursing facility services for individuals age 65 or older in institutions for mental diseases” means nursing facility services as defined in § 440.40 and in subpart B of part 483 of this chapter that are provided in institutions for mental diseases, as defined in § 435.1010 of this chapter.

Notes, amendments, and revision history

Amendments

[59 FR 56234, Nov. 10, 1994, as amended at 71 FR 39229, July 12, 2006]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[59 FR 56234, Nov. 10, 1994, as amended at 71 FR 39229, July 12, 2006]

§440.150. Intermediate care facility (ICF/IID) services.

42 C.F.R. § 440.150

(a)

“ICF/IID services” means those items and services furnished in an intermediate care facility for Individuals with Intellectual Disabilities if the following conditions are met:

(1)

The facility fully meets the requirements for a State license to provide services that are above the level of room and board;

(2)

The primary purpose of the ICF/IID is to furnish health or rehabilitative services to persons with Intellectual Disability or persons with related conditions;

(3)

The ICF/IID meets the standards specified in subpart I of part 483 of this chapter.

(4)

The beneficiary with Intellectual Disability for whom payment is requested is receiving active treatment, as specified in § 483.440 of this chapter.

(5)

The ICF/IID has been certified to meet the requirements of subpart C of part 442 of this chapter, as evidenced by a valid agreement between the Medicaid agency and the facility for furnishing ICF/IID services and making payments for these services under the plan.

(b)

ICF/IID services may be furnished in a distinct part of a facility other than an ICF/IID if the distinct part—

(1)

Meets all requirements for an ICF/IID, as specified in subpart I of part 483 of this chapter;

(2)

Is clearly an identifiable living unit, such as an entire ward, wing, floor or building;

(3)

Consists of all beds and related services in the unit;

(4)

Houses all beneficiaries for whom payment is being made for ICF/IID services; and

(5)

Is approved in writing by the survey agency.

Notes, amendments, and revision history

Amendments

[59 FR 56234, Nov. 10, 1994]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[59 FR 56234, Nov. 10, 1994]

§440.155. Nursing facility services, other than in institutions for mental diseases.

42 C.F.R. § 440.155

(a)

“Nursing facility services, other than in an institution for mental diseases” means services provided in a facility that—

(1)

Fully meets the requirements for a State license to provide, on a regular basis, health-related services to individuals who do not require hospital care, but whose mental or physical condition requires services that—

(i)

Are above the level of room and board; and

(ii)

Can be made available only through institutional facilities;

(2)

Has been certified to meet the requirements of subpart C of part 442 of this chapter as evidenced by a valid agreement between the Medicaid agency and the facility for providing nursing facility services and making payments for services under the plan; and

(b)

“Nursing facility services” include services—

(1)

Considered appropriate by the State and provided by a religious nonmedical institution as defined in § 440.170(b); or

(2)

Provided by a facility located on an Indian reservation that—

(i)

Furnishes, on a regular basis, health-related services; and

(ii)

Is certified by the Secretary to meet the standards in subpart E of part 442 of this chapter.

(c)

“Nursing facility services” may include services provided in a distinct part (as defined in § 483.5(b) of this chapter) of a facility other than a nursing facility if the distinct part (as defined in § 483.5(b) of this chapter)—

(1)

Meets all requirements for a nursing facility;

(2)

Is an identifiable unit, such as an entire ward or contiguous ward, a wing, floor, or building;

(3)

Consists of all beds and related facilities in the unit;

(4)

Houses all beneficiaries for whom payment is being made for nursing facility services, except as provided in paragraph (d) of this section;

(5)

Is clearly identified; and

(6)

Is approved in writing by the survey agency.

(d)

If a State includes as nursing facility services those services provided by a distinct part of a facility other than a nursing facility, it may not require transfer of a beneficiary within or between facilities if, in the opinion of the attending physician, it might be harmful to the physical or mental health of the beneficiary.

(e)

Nursing facility services may include services provided in a swing-bed hospital that has an approval to furnish nursing facility services.

Notes, amendments, and revision history

Amendments

[59 FR 56234, Nov. 10, 1994, as amended at 64 FR 67052, Nov. 30, 1999; 68 FR 46071, Aug. 4, 2003]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[59 FR 56234, Nov. 10, 1994, as amended at 64 FR 67052, Nov. 30, 1999; 68 FR 46071, Aug. 4, 2003]

§440.160. Inpatient psychiatric services for individuals under age 21.

42 C.F.R. § 440.160

“Inpatient psychiatric services for individuals under age 21” means services that—

(a)

Are provided under the direction of a physician;

(b)

Are provided by—

(1)

A psychiatric hospital that undergoes a State survey to determine whether the hospital meets the requirements for participation in Medicare as a psychiatric hospital as specified in § 482.60 of this chapter, or is accredited by a national organization whose psychiatric hospital accrediting program has been approved by CMS; or a hospital with an inpatient psychiatric program that undergoes a State survey to determine whether the hospital meets the requirements for participation in Medicare as a hospital, as specified in part 482 of this chapter, or is accredited by a national accrediting organization whose hospital accrediting program has been approved by CMS.

(2)

A psychiatric facility which is accredited by the Joint Commission on Accreditation of Healthcare Organizations, the Council on Accreditation of Services for Families and Children, the Commission on Accreditation of Rehabilitation Facilities, or by any other accrediting organization, with comparable standards, that is recognized by the State.

(c)

Meet the requirements in § 441.151 of this subchapter.

Notes, amendments, and revision history

Amendments

[63 FR 64198, Nov. 19, 1998, as amended at 75 FR 50418, Aug. 16, 2010]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[63 FR 64198, Nov. 19, 1998, as amended at 75 FR 50418, Aug. 16, 2010]

§440.165. Nurse-midwife service.

42 C.F.R. § 440.165

(a)

“Nurse-midwife services” means services that—

(1)

Are furnished by a nurse-midwife within the scope of practice authorized by State law or regulation and, in the case of inpatient or outpatient hospital services or clinic services, are furnished by or under the direction of a nurse-midwife to the extent permitted by the facility; and

(2)

Unless required by State law or regulations or a facility, are reimbursed without regard to whether the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider. (See § 441.21 of this chapter for provisions on independent provider agreements for nurse-midwives.)

(b)

“Nurse-midwife” means a registered professional nurse who meets the following requirements:

(1)

Is currently licensed to practice in the State as a registered professional nurse.

(2)

Is legally authorized under State law or regulations to practice as a nurse-midwife.

(3)

Except as provided in paragraph (b)(4) of this section, has completed a program of study and clinical experience for nurse-midwives, as specified by the State.

(4)

If the State does not specify a program of study and clinical experience that nurse-midwives must complete to practice in that State, meets one of the following conditions:

(i)

Is currently certified as a nurse-midwife by the American College of Nurse-Midwives (ACNM or by the ACNM Certification Council, Inc. (ACC).

(ii)

Has satisfactorily completed a formal education program (of at least one academic year) that, upon completion qualifies the nurse to take the certification examination offered by the American College of Nurse-Midwives (ACNM) or by the ACNM Certification Council, Inc. (ACC).

(iii)

Has successfully completed a formal educational program for preparing registered nurses to furnish gynecological and obstetrical care to women during pregnancy, delivery, and the postpartum period, and care to normal newborns, and was practicing as a nurse-midwife for a total of 12 months during any 18-month period from August 8, 1976 to July 16, 1982.

Notes, amendments, and revision history

Amendments

[47 FR 21050, May 17, 1982; 47 FR 23448, May 28, 1982, as amended at 55 FR 48611, Nov. 21, 1990; 61 FR 61486, Nov. 30, 1996]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45224, Sept. 29, 1978, unless otherwise noted.

Amendments

[47 FR 21050, May 17, 1982; 47 FR 23448, May 28, 1982, as amended at 55 FR 48611, Nov. 21, 1990; 61 FR 61486, Nov. 30, 1996]