plished efficiently and with consideration for the objective of providing necessary care within a homelike atmosphere. Staff are employed by the facility sufficient in number and competence, as determined by the appropriate State agency, to meet the requirements of the residents. [35 F.R. 8990, June 10, 1970] PART 237-FISCAL ADMINISTRATION OF FINANCIAL ASSISTANCE PROGRAMS Sec. 237.50 Recipient count, Federal financial participation. 237.60 Maintenance of State effort; Federal financial participation. AUTHORITY: The provisions of this Part 237 issued under sec. 1102, 49 Stat. 647; 42 U.S.C. 1302. § 237.50 Recipient count, Federal financial participation. Pursuant to the formulas in sections 3, 403, 1003, 1118, 1121, 1403, and 1603 of the Social Security Act, it is necessary to identify expenditures that may be included in claims for Federal financial participation. Except as stated in paragraphs (a), (b), (c), and (d) of this section, the quarterly statement of expenditures and recoveries which is required for OAA, AFDC, AB, APTD, and AABD must include, as a part of the basis for computing the amount of Federal participation in such expenditures, the number of eligible recipients each month. However, where the State is making claims under section 1118 of the Act or under optional provisions for Federal sharing specified in such paragraphs no recipient count is involved. Vendor payments for medical care may not be considered if the State has a plan approved under title XIX of the Act. The procedures for determining recipient count are set forth in such paragraphs. (a) Adult assistance categories. For each adult assistance category under title I, X, XIV, or XVI, of the Act, the recipient count for any month may include: (1) Eligible recipients who receive money payments or in whose behalf protective payments are made for that month, plus (2) Other eligible recipients in whose behalf vendor payments for medical care are made during that month, plus (3) Other eligible recipients in whose behalf payments are made for institutional services in intermediate care facilities for that month. However, if the State elects under section 1121 (c) of the Social Security Act to receive matching on the basis of the Federal medical assistance percentage for these payments, then they cannot be included for the purpose of the recipient count. (b) AFDC category. For the AFDC category under title IV, Part A, of the Act (1) The recipient count for any month may include: (i) Eligible recipients in families which receive a money payment (including payments for work performed under the work incentive program for that month), plus (ii) Other eligible recipients in families in whose behalf vendor payments for medical care are made during that month, plus (iii) Eligible children in foster care not otherwise counted in whose behalf a foster care payment or vendor payment for medical care is made in such month, plus (iv) Eligible recipients in families not otherwise counted in whose behalf protective or nonmedical vendor assistance payments are made for such month, not to exceed 10 percent of the total recipients counted under subdivisions (i), (ii), and (iii) of this subparagraph. The 10 percent limitation does not apply with respect to individuals for whom protective or nonmedical vendor payments are made pursuant to section 402(a) (19) (F) of the Act because there has been a refusal without good cause to accept employment, work or training. (2) The recipient count may include all eligible children, plus the eligible relative with whom the children are living (as specified in section 406(a)(1) of the Act). (3) (i) When at least one of the children in a family is eligible due to the incapacity of his parent in the home, the recipient count may include all eligible children, the parent, and the parent's spouse with whom the children are living, if the needs of such parent and spouse were included in computing the assistance payment. (ii) As used in subdivision (i) of this subparagraph, the term "parent" means the natural or adoptive parent, or the stepparent who was ceremonially married to the child's natural or adoptive parent and is legally obligated to support the child under State law of general ap plicability which requires stepparents to support stepchildren to the same extent that natural or adoptive parents are required to support their children; and the term "spouse" means an individual who is the husband or wife of the child's own parent, as defined above, by reason of a ceremonial or other legal marriage. (4) (1) For periods beginning on or after January 1, 1968, when at least one of the children in a family is eligible due to the unemployment of his father in the home, the recipient count may include all eligible children, the father, and his wife with whom the children are living, if the needs of such father and wife were included in computing the assistance payment. (ii) As used in subdivision (i) of this subparagraph, the term "father" means the natural or adoptive father, or the stepfather who was ceremonially married to the child's natural or adoptive mother and is legally obligated to support the child under State law of general applicability which requires stepparents to support stepchildren to the same extent that natural or adoptive parents are required to support their children; and the term "wife" means an idividual who is the wife of the child's own father, as defined above, by reason of a ceremonial or other legal marriage. (5) The recipient count for a month in which only a vendor payment is made for medical services furnished to any eligible child in the family, to any eligible relative with whom the child is living, or to any of the "essential persons," may include all eligible recipients in the family in the month that the medical service was received. (6) Where there are two or more dependent children living in a place of residence with two other persons who are not married to each other and each of such other persons is a relative who has responsibility for the care and control of one or more of the dependent children, there may be two separate AFDC families for purposes of aid and recipient count, if neither of such persons is the parent of all the dependent children. (c) Recipient count involving two categories. Where a vendor payment is made for medical services rendered to an individual in a month in which he was eligible only under one Federally-aided program, the payment may be included as assistance and the recipient may be counted under such program in the month of payment, even though at the time of such vendor payment the individual may be receiving assistance and included in the recipient count under another Federally-aided program. (d) Essential person: An "essential person" or other ineligible person who is living with the eligible person may not be counted as a recipient. [34 F.R. 751, Jan. 17, 1969] § 237.60 Maintenance of State effort; Federal financial participation. For the programs administered under titles I, IV-Part A, X, XIV, XVI, and XIX of the Social Security Act: (a) For fiscal years ending June 30, 1967, and June 30, 1968, a State may, at its option, apply the "maintenance of State effort" provisions under section 1117 of the Social Security Act on a fiscal year basis rather than on a quarterly basis. If a State exercises this option, it must choose, as the base period against which its effort is to be measured, either the fiscal year ending June 30, 1965, or the fiscal year ending June 30, 1964. Subsections (b) and (c) of section 1117 of the Act (relating to the manner of determining expenditures and reductions) would also be applied on a fiscal year basis if the State exercises this option. (b) A State may, at its option, apply the “maintenance of State effort” provisions under section 1117 of the Act on the basis of several additional alternatives as to the expenditures (total and Federal share) that will be taken into account in determining whether a reduction is necessary under section 1117 of the Act. (1) The State may take into account, as previously provided, all expenditures under titles I, IV-Part A, X, XIV, XVI, and XIX (including money payments, vendor medical payments, and costs of administration); or (2) The State may make the determination (i) On the basis of these expenditures plus the expenditures under section 523 of the Act (or section 422 of the Social Security Act, as amended by section 240 (c) of Public Law 90-248), relating to child welfare services, (ii) On the basis of money payments alone (under titles I, IV-Part A, X, XIV, and XVI), or (iii) On the basis of money payments alone plus the expenditures under section 523 or 422 of the Act. (c) These additional options both as to making the determination on a fiscal year rather than quarterly basis, and as to the expenditures included, may be applied retroactively to July 1, 1966, by any State subject to a reduction under the provisions of section 1117 of the Act as in effect prior to the enactment of section 221 of Public Law 90-248. (d) The “maintenance of State effort” provisions have been made inapplicable to periods prior to July 1, 1966. (e) Section 1117 of the Act was repealed, effective July 1, 1968, by section 221(d) of Public Law 90-248. [34 F.R. 11, Jan. 1, 1969] § 248.11 Title XIX; optional inclusion of certain "essential persons" under plan approved under title I, X, XIV, or XVI; Federal financial participation. Effective with respect to payments made on or after January 2, 1968, under a State plan approved under title XIX of the Social Security Act, Federal financial participation is available in the costs of medical care and services provided under such a plan to a spouse of a recipient of financial assistance under another plan of the State approved under title I, X, XIV, or XVI of the Act, who is living with and has been determined, in accordance with such other plan, to be essential to the well-being of such recipient, and whose needs are taken into account in determining the amount of financial assistance provided to such recipient. [34 FR. 1320, Jan. 28, 1969] § 248.21 Financial eligibility; medical assistance program; medically needy. (a) Requirements for State plans. A State plan for medical assistance, if it includes the medically needy, must: 50-100-71- 6 (1) Provide levels of income and resources for maintenance, in total dollar amounts, as a basis for establishing financial eligibility for medical assistance, in accordance with the following: (1) Such income levels must be comparable as among individuals and families of varying sizes. (ii) The income levels for maintenance must be, as a minimum, at the level of the most liberal money payment standard used by the State, at any time on or after January 1, 1966, as a measure of financial eligibility in any categorical money payment program in the State, or at the level for which Federal financial participation is available pursuant to paragraph (b) of this section, whichever is less. Where a State imposes any deduction cost sharing, enrollment fee, premium, or similar charge under the plan with respect to any medical assistance furnished to an individual thereunder, such charge may not be imposed to the extent that it would reduce the individual's income below the most liberal money payment standard referred to in the preceding sentence. (iii) A lower income level for maintenance must be used for individuals not living in their own homes but receiving care in nursing homes, institutions for tuberculosis, or mental diseases or other medical facilities providing long-term care. This lower income level must be reasonable in amount for clothing and personal needs for such individuals. When such an individual's home is maintained for a spouse or other dependents, the appropriate income level for such dependents, plus the individual's income level for maintenance in a long-term care facility, is applicable. (iv) Resources which may be held must, as a minimum, be at the most liberal level used in any money payment program in the State on or after January 1, 1966, and the amount of liquid assets which may be held must increase with an increase in the number of individuals in the family. There must be separate levels established for resources. (2) Provide that there will be a flexible measurement of available income which will be applied in the following order of priority: (i) First, for maintenance, so that any income in an amount at or below the established level will be protected for maintenance. (ii) Next, income in excess of that needed for maintenance will be applied to costs incurred for medical insurance premiums and for necessary medical or remedial care recognized under State law and not encompassed within the State plan for medical assistance. States may set reasonable limits on such medical services for which excess income may be applied. (iii) All of the remaining excess income will be applied to costs of medical assistance included in the State plan. (3) Provide that all income and resources (after all State policies governing the disregard, or setting aside for future needs, of income and resources in the State's approved plans under titles I, IV-Parts A, X, XIV, and XVI have been applied) will be considered in establishing eligibility, and in the flexible application of income to medical costs not in the State plan, and payment toward the medical assistance costs. (4) Provide that only such income and resources as are actually available will be considered; that income and resources will be reasonably evaluated; and that only such income and resources will be considered as will be "in hand" within a period, preferably of not more than 3 months, but not in excess of 6 months, ahead, including the month in which medical services were rendered for which payment would be made under the plan. (5) Provide that financial responsibility of any individual for any applicant or recipient of medical assistance will be limited to the responsibility of spouse for spouse and of parents for children under age 21, or blind, or permanently and totally disabled; and specify the extent to which the financial responsibility of any such relatives is taken into account. (b) Federal financial participation. Payments in behalf of medically needy individuals are subject to Federal financial participation only to the extent that they are made for a member of a family the annual income of which is within the income levels established in the following: (1) In the case of any State with an approved plan under which medical assistance was furnished to medically needy individuals prior to July 26, 1967, the applicable income levels with respect to the third and fourth calendar quarters of 1968 are 150 percent of the amounts specified in subparagraph (2) of this paragraph. With respect to all calendar quarters during 1969, the income levels are 140 percent of such amounts and, thereafter, 1333 percent of such amounts. In the case of any other State, the income levels with respect to any calendar quarter beginning after March 31, 1968, are 1331⁄2 percent of the amounts specified in subparagraph (2) of this paragraph. Any total yearly income levels established by applying the above percentages which are not multiples of $100 shall be rounded to the next higher multiple of $100. Federal financial participation is available for a person whose annual income exceeds this level to the extent that medical expenses exceed the income excess (see subparagraph (iii) of this paragraph). (2) (2) The amounts to be applied in calculating the income levels referred to in subparagraph (1) of this paragraph are the highest amounts which would ordinarily be paid to a family of the same size without any income or resources, in the form of money payments, under the plan of the State approved under part A of title IV of the Act, subject to the following modifications: (i) In the case of a single individual the amount of the income level shall be reasonaby related to the amounts payable under such plan to families consisting of two or more individuals who are without income or resources. (ii) If the amounts established under such plan are subject to a maximum family limit, the income level for families which exceed such limit will be determined by adding an amount for each member of the family to such limit. The amounts to be added shall be reasonably related to those established under the plan for families which are within the maximum family limit. (iii) In computing a family's or individual's income for purposes of subparagraphs (1) and (2) of this paragraph, there shall be excluded any costs (whether in the form of insurance premiums or otherwise) incurred by such family or individual for medical care or for any other type of remedial care recognized under State law. (3) If a State furnishes medical assistance on the basis of income levels which are higher than those specified in this section, the State agency must submit to the Department of Health, Education, and Welfare for its approval income levels which are calculated on the basis provided in this section, and must establish procedures to assure that claims for Federal financial participation are limited accordingly. [34 F.R. 1320, Jan. 28, 1969] (a) State plan requirements. A State plan under title XIX of the Social Security Act must provide that: (1) Medical assistance will be furnished to eligible individuals who are residents of the State but are absent therefrom to the same extent that such assistance is furnished under the plan to meet the cost of medical care and services rendered to eligible individuals in such State, at least to the extent that medical care and services are needed in any other State (as defined in section 1101(a)(1) of the Social Security Act, as amended, 42 U.S.C. 1301(a)(1)), under any of the following circumstances: (i) Where an emergency arises from accident or illness; (ii) Where the health of the individual would be endangered if the care and services are postponed until he returns to the State in which he resides; or (iii) Where his health would be endangered if he undertook travel to return to such State. (2) Medical care and services will be provided outside the State to eligible residents of the State, at least in the following situations: (i) When it is general practice for residents of a particular locality to use medical resources outside the State; or (ii) When the medical care and services available, or the availability of needed supplementary resources, make it desirable for the individual to use medical facilities outside the State for short or long periods, in accordance with plans developed jointly by the agency and the individual, consistent with medical advice. (3) The State agency will facilitate the meeting of medical needs within the State for residents from other States. (b) Condition for plan approval. A State plan under title XIX of the Act may not impose any resident requirement which excludes any individual who is a resident of the State. For purposes of this section: (1) A resident of a State is one who is living in the State voluntarily with the intention of making his home there and not for a temporary purpose. A child is a resident of the State in which he is living other than on a temporary basis. Residence may not depend upon the reason for which the individual entered the State, except insofar as it may bear upon whether he is there voluntarily or for a "temporary purpose." (2) Residence is retained until abandoned. Temporary absence from the State, with subsequent returns to the State, or intent to return when the purposes of the absence have been accomplished, does not interrupt continuity of residence. (Sec. 2, 49 Stat. 620, 74 Stat. 987, sec. 402, 49 Stat. 627, sec. 1002, 49 Stat. 645, sec. 1402, 64 Stat. 555, sec. 1602, 76 Stat. 198, sec. 1902, 79 Stat. 344; 42 U.S.C. 302, 602, 1202, 1352, 1382, 1396a) [35 F.R. 17719, Nov. 18, 1970] PART 249-SERVICES AND PAYMENT IN MEDICAL ASSISTANCE PROGRAMS Sec. 249.10 Amount, duration, and scope of medical assistance. 249.11 Free choice of providers of medical services: State plan requirement. 249.31 Supplementation of payments made to skilled nursing homes; State plan requirements. 249.32 Direct payment to certain recipients for physicians' or dentists' services. 249.33 Standards for payment for skilled nursing home care. 249.40 249.41 Cost sharing and similar charges; AUTHORITY: The provisions of this Part 249 issued under sec. 1102, 49 Stat. 647; 42 U.S.C. 1302. NOTE: For interim policies published under this part, see 34 F.R. 9788, June 24, 1969. § 249.10 Amount, duration, and scope of medical assistance. (a) State plan requirements. A State plan for medical assistance under title XIX of the Social Security Act must: (1) Specify that at least the first five items of medical and remedial care and services, set forth in paragraph (b) (1) through (5) of this section, will be provided to the categorically needy. (2) Specify that, if the plan includes the medically needy, at least the following items of medical and remedial care and services will be provided to the medically needy: (i) The first five items set forth in paragraph (b) (1) through (5) of this section; or (ii) (a) Any seven of the items set forth in paragraph (b) (1) through (14) of this section; and (b) If the plan includes inpatient hospital services or skilled nursing home services, physicians' services to eligible |