individuals when they are patients in a hospital or skilled nursing home, even though physicians' services as defined in paragraph (b) (5) of this section are not otherwise included for the medically needy.

(3) Effective July 1, 1970, provide for the inclusion of home health services for any eligible individual who, under the plan, is entitled to skilled nursing home services.

(4) Specify the amount and/or duration of each item of medical and remedial care and services that will be provided to the categorically needy and to the medically needy, if the plan includes this latter group. Such items must be sufficient in amount, duration, and scope to reasonably achieve their purpose. Effective July 1, 1970, specify that there will be provision for assuring necessary transportation of recipients to and from providers of services and describe the methods that will be used.

(5) Provide that the medical and remedial care and services made available to any categorically needy individual included under the plan will not be less in amount, duration, or scope than those made available to other individuals included under the program, except that:

(i) Skilled nursing home services may be limited to persons 21 years of age or older;

(ii) Services to persons in institutions for tuberculosis or mental diseases may be limited to persons 65 years of age or over;

(iii) Benefits under part B of title XVIII of the Social Security Act made available to individuals 65 years of age or over through a "buy-in" agreement or payment of the premiums, or the payment of part or all of the deductibles, cost sharing or similar charges under part B, may be limited to such individuals; and

(iv) Early and periodic screening and diagnosis for individuals, and treatment of conditions found, as provided in section 1905 (a) (4) (B) of the Act, may be limited to individuals under 21 years of age.

(6) Provide that the medical and remedial care and services made available to a group (i.e., either the categorically needy or the medically needy) will be equal in amount, duration, and scope for all individuals within the group, with the permissible exceptions specified in subparagraph (5) of this paragraph.

(7) Include a description of the

methods that will be used to assure that the medical and remedial care and services are of high quality, and a description of the standards established by the State to assure high quality care.

(8) Provide for broadening the scope of the medical and remedial care and services made available under the plan, to the end that, by July 1, 1975, comprehensive medical and remedial care and services will be furnished to all eligible individuals.

(9) If the State plan includes medical and remedial care and services in relation to family planning, as defined in paragraph (b) (15) (ii) of this section, provide that there shall be freedom from coercion or pressure of mind and conscience, and freedom of choice of method, so that individuals can choose in accordance with the dictates of their consciences.

(b) Federal financial participation. Subject to the limitations in paragraph (c) of this section, Federal financial participation is available in expenditures for medical or remedial care and services under the State plan which meet the following definitions:

(1) Inpatient hospital services (other than services in an institution for tuberculosis or mental diseases). "Inpatient hospital services" are those items and services ordinarily furnished by the hospital for the care and treatment of inpatients provided under the direction of a physician or dentist in an institution maintained primarily for treatment and care of patients with disorders other than tuberculosis or mental diseases and which is licensed or formally approved as a hospital by an officially designated State standard-setting authority and is qualified to participate under title XVIII of the Social Security Act, or is determined currently to meet the requirements for such participation; and which has in effect a hospital utilization review plan applicable to all patients who receive medical assistance under title XIX of the Act.

(2) Outpatient hospital services. "Outpatient hospital services" are those preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services furnished by or under the direction of a physician or dentist to an outpatient by an institution which is licensed or formally approved as a hospital by an officially designated State standardsetting authority and is qualified to participate under title XVIII of the Social

Security Act, or is determined currently to meet the requirements for such participation.

(3) Other laboratory and X-ray services. The term "other laboratory and X-ray services" means professional and technical laboratory and radiological services ordered by a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by State law, and provided to a patient by, or under the direction, of a physician or licensed practitioner, in an office or similar facility other than a hospital outpatient department or a clinic, and provided to a patient by a laboratory that is qualified to participate under title XVIII of the Social Security Act, or is determined currently to meet the requirements for such participation.

(4) (i) Skilled nursing home services (other than services in an institution for tuberculosis or mental diseases) for individuals 21 years of age or older. "Skilled nursing home services" means those items and services furnished by a skilled nursing home maintained primarily for the care and treatment of inpatients with disorders other than tuberculosis or mental diseases which are provided 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. A "skilled nursing home" is a facility, or a distinct part of a facility, which meets the following conditions:

(a) The facility is constructed, equipped, maintained, and operated in compliance with all applicable State and local laws and regulations affecting the health and safety of the patients and their protection against the hazards of fire and other disaster, and there is a written, rehearsed disaster plan.

(b) The administrator is qualified by training and experience for successful operation of a nursing home and has the necessary authority and responsibility for management of the facility.

(c) The facility employs staff sufficient in number and qualifications to meet the requirements of the patients accepted for care or remaining in the facility for care.

(d) Food is prepared and served under competent direction, at regular and appropriate times. Professional consultation is available to assure good nutritional standards and that the dietary needs of the patients are met.

(e) Patient care is provided in accordance with written policies formulated

with the advice of one or more professional registered nurses.

(f) Constructive care directed toward restoring and maintaining each patient at his best possible functional level is provided, including activities designed to encourage self-care and independence provided as a part of the patient's treatment program.

(g) Patients in need of nursing care are admitted to a facility only upon recommendation by a physician of the need for the level of care provided by that facility. The care of such patients is continuously under the supervision of a physician; and the facility maintains arrangements that assure that the services of a physician who can act in case of emergency are continuously available.

(h) Effective July 1, 1969, the facility has been determined by the single State agency to meet all of the standards established under section 1902 (a) (28) of the Act, as evidenced by an agreement between the single State agency and the facility for the provision of skilled nursing home care and the making of payments under the plan. The predecessor condition relating to nursing service staff as stated in Interim Policy Statement No. 19, paragraph B. (4) (a) (viii), published in the FEDERAL REGISTER on November 5, 1968 (33 F.R. 16165), and in the Handbook of Public Assistance, Supplement D, section D-5141.4.1 (h), is revoked as of July 1, 1968.

(i) All drugs and medications are prescribed, handled, stored, and administered in accordance with accepted professional practices.

(j) An individual record is maintained for each patient covering his medical, nursing, and related care in accordance with accepted professional standards.

(k) Effective arrangements are maintained through which services required by the patients but not regularly provided within the facility can be obtained promptly when needed. This includes laboratory, X-ray, and other diagnostic services, and regular and emergency dental care. It includes, also, provisions for recognition of need for social services and for prompt reporting of such need to the local welfare department or other appropriate source.

(1) Effective July 1, 1968, the facility is licensed or formally approved as a nursing home by an officially designated State standard-setting authority and has not been determined by such authority not to meet fully all requirements of the

State for licensure as a nursing home except as provided in the next sentence. Payments to a nursing home which formerly met fully all requirements of the State for licensure as a nursing home, but is currently determined not to meet fully all such requirements, may be recognized for a period specified by the State standard-setting authority, if during such period such home promptly takes all necessary steps to again meet such requirements.

(m) The facility (including a facility operated by a governmental agency) meets all requirements which are applied for licensure or formal approval as a nursing home to the same type of facility in any other ownership category (i.e. governmental, non-profit or proprietary) within the State.

(ii) Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found. Effective July 1, 1969 (or earlier at the option of the State), early and periodic screening and diagnosis of individuals under the age of 21 who are eligible under the plan to ascertain their physical or mental defects, and health care, treatment, and other measures to correct or ameliorate defects and chronic conditions discovered thereby.

(5) Physicians' services, whether furnished in the office, the patient's home, a hospital, a skilled nursing home or elsewhere. "Physicians' services" are those services provided, within the scope of practice of his profession as defined by State law, by or under the personal supervision of an individual licensed under State law to practice medicine or osteopathy.

(6) Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law. This term means any medical or remedial care or services other than physicians' services, provided within the scope of practice as defined by State law, by an individual licensed as a practitioner under State law.

(7) Home health care services. "Home health care services" in addition to the services of physicians, dentists, physical therapists, and other services and items available to patients in their homes and described elsewhere in these definitions, are any of the following items and services when they are provided on recom

mendation of a licensed physician to a patient in his place of residence, but not including as a residence a hospital or a skilled nursing home:

(i) Intermittent or part-time nursing services furnished by a home health agency;

(ii) Intermittent or part-time nursing services of a professional registered nurse or a licensed practical nurse under the direction of the patient's physician, when no home health agency is available to provide nursing services;

(iii) Medical supplies, equipment, and appliances recommended by the physician as required in the care of the patient and suitable for use in the home;

(iv) Services of a home health aide, who is an individual assigned to give personal care services to a patient in accordance with the plan of treatment outlined for the patient by the attending physician and the home health agency which assigns a professional registered nurse to provide continuing supervision of the aide on her assignment. The term "home health agency" means a public or private agency or organization, or a subdivision of such an agency or organization, which is qualified to participate as a home health agency under title XVIII of the Social Security Act, or is determined currently to meet the requirements for such participation.

(8) Private duty nursing services. "Private duty nursing services" are nursing services provided by a professional registered nurse or a licensed practical nurse, under the general direction of the patient's physician, to a patient in his own home or in a hospital, skilled nursing home, or extended care facility when the patient requires individual and continuous care beyond that available from a visiting nurse or that routinely provided by the nursing staff of the hospital, nursing home, or extended care facility.

(9) Clinic services. "Clinic services" are preventive diagnostic, therapeutic, rehabilitative, or palliative items or services furnished to an outpatient by or under the direction of a physician or dentist in a facility which is not part of a hospital but which is organized and operated to provide medical care to outpatients.

(10) Dental services. "Dental services" are any diagnostic, preventive, or corrective procedures administered by or under the supervision of a dentist in the

practice of his professon. Such services include treatment of the teeth and associated structures of the oral cavity, and of disease, injury, or impairment which may affect the oral or general health of the individual. The term "dentist" means a person licensed to practice dentistry or dental surgery.

(11) Physical therapy and related services. "Physical therapy and related services" means physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders, and the use of such supplies and equipment as are necessary.

(i) "Physical therapy" means those services prescribed by a physician and provided to a patient by or under the supervision of a qualified physical therapist. A "qualified physical therapist" is a graduate of a program of physical therapy approved by the Council on Medical Education of the American Medical Association in collaboration with the American Physical Therapy Association, or its equivalent, and where applicable, is licensed by the State.

(ii) "Occupational therapy" means those services prescribed by a physician and provided to a patient and given by or under the supervision of a qualified occupational therapist. A "qualified occupational therapist” is registered by the American Occupational Therapy Association or is a graduate of a program in occupational therapy approved by the Council on Medical Education of the American Medical Association and is engaged in the required supplemental clinical experience prerequisite to registration by the American Occupational Therapy Association.

(iii) "Services for individuals with speech, hearing, and language disorders" are those diagnostic, screening, preventive or corrective services provided by or under the supervision of a speech pathologist or audiologist in the practice of his profession for which a patient is referred by a physician. A speech pathologist or audiologist is one who has been granted the Certificate of Clinical Competence in the American Speech and Hearing Association, or who has completed the equivalent educational requirements and work experience necessary for such a certificate, or who has completed the academic program and is in the process of accumulating the necessary supervised work experience required to qualify for such a certificate.

(12) Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist, whichever the individual may select. (i) “Prescribed drugs" are any simple or compounded substance or mixture of substances prescribed as such or in other acceptable dosage forms for the cure, mitigation, or prevention of disease, or for health maintenance, by a physician or other licensed practitioner of the healing arts within the scope of his professional practice as defined and limited by Federal and State law. With respect to "prescribed drugs", Federal financial participation is available in expenditures for drugs dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act. When dispensing, the practitioner must do so on his written prescription and maintain records thereof.

(ii) "Dentures" are artificial structures prescribed by a dentist to replace a full or partial set of teeth and made by, or according to the directions of, a dentist.

(iii) "Prosthetic devices" means replacement, corrective, or supportive devices prescribed for a patient by a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by State law for the purpose of artificially replacing a missing portion of the body, or to prevent or correct physical deformity or malfunction, or to support a weak or deformed portion of the body.

(iv) "Eyeglasses" are lenses, including frames when necessary, and other aids to vision prescribed by a physician skilled in diseases of the eye, or by an optometrist, whichever the patient may select, to aid or improve vision.

(13) Other diagnostic, screening, preventive, and rehabilitative services. (i) "Diagnostic services", other than those for which provision is made elsewhere in these definitions, include any medical procedures or supplies recommended for a patient by his physician or other licensed practitioner of the healing arts within the scope of his practice as defined by State law, as necessary to enable him to identify the existence, nature, or extent of illness, injury, or other health deviation in the patient.

(ii) "Screening services" consist of the use of standardized tests performed 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 suspects for more definitive studies.

(iii) "Preventive services" are those provided by a physician or other licensed practitioner of the healing arts, within the scope of his practice as defined by State law, to prevent illness, disease, disability and other health deviations or their progression, prolong life and promote physical and mental health and efficiency.

(iv) "Rehabilitative services”, in addition to those for which provision is made elsewhere in these definitions, include any medical remedial items or services prescribed for a patient by his physician or other licensed practitioner of the healing arts, within the scope of his practice as defined by State law, for the purpose of maximum reduction of physical or mental disability and restoration of the patient to his best possible functional level.

(14) Inpatient hospital services and skilled nursing home services for individuals 65 years of age or over in an institution for tuberculosis or mental diseases. For purposes of this subparagraph:

(i) "Inpatient hospital services" are those items and services ordinarily furnished by the hospital to inpatients, which are provided to an inpatient in the institution or to a patient who is receiving care in the institution under a day-care or a night-care plan, and which are furnished under the direction of a physician to a patient in an institution for tuberculosis or an institution for mental diseases.

(ii) "Skilled nursing home services" are those items and services given in a skilled nursing home, as defined in subparagraph (4) (i) of this paragraph, when these items and services are furnished to patients who would not have been discharged from, or would be admitted to, an institution for tuberculosis or mental diseases if skilled nursing home services were not available to them.

(iii) An "institution for tuberculosis", qualified to carry out the provisions of the Act in respect to the care and treatment of individuals 65 years of age or over is one that (a) meets the requirements for a tuberculosis hospital under title XVIII, section 1861 (g), of the Social Security Act; or (b) effective only until

July 1, 1969, is licensed, or formally approved, by an officially designated State standard-setting authority as a hospital or medical institution operated primarily to provide diagnosis, treatment and rehabilitation to inpatients with tuberculosis.

(iv) An "institution for mental diseases", qualified to carry out the provisions of the Act in respect to the care and treatment of individuals 65 years of age or over is one that (a) meets requirements for a psychiatric hospital under title XVIII, section 1861 (f), of the Social Security Act; or (b) effective only until July 1, 1970, is approved by appropriate State standard-setting authorities as a hospital established for the care of the mentally ill and as being physically safe and as having staff adequate in number and qualifications to carry out an active program of diagnostic, treatment and rehabilitative services for its patients; and specifically provides psychiatric supervision, medical services, including 24hour nursing services under the supervision of a registered nurse, and the social services necessary to assure a continuous plan of treatment and care for all of its patients. Effective October 1, 1969, in the case of any institution for mental diseases which qualifies for Federal Financial Participation through subdivision (b) the single State agency must have on file a written plan which describes the steps which the institution will take for meeting the requirements of title XVIII, section 1861 (f) of the Act by July 1, 1970.

(15) Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary. This term includes the following items in those States in which they are recognized under State law and under the circumstances, and to the extent to which, they are so recognized:

(i) Transportation, including expenses for transportation and other related travel expenses, necessary to securing medical examinations and/or treatment when determined by the agency to be necessary in the individual case. "Travel expenses" are defined to include the cost of transportation for the individual by ambulance, taxicab, common carrier or other appropriate means; the cost of outside meals and lodging en route to, while receiving medical care, and returning from a medical resource; and the cost of an attendant to accompany him, if medically or otherwise necessary. The