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. 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. Federal financial participation is available for any item of medical or remedial care and services included under this section for individuals under the age of 21. Such care and services may be provided under the plan to individuals under the age of 21, even if such care and services are not provided,

or are provided in lesser amount, duration or scope to individuals 21 years of age or older.

NOTE: Subdivision (b)(4) (ii), revised at 36 F.R. 21409, Nov. 9, 1971, is effective 90 days after publication. For the convenience of the user, the superseded text appears below.

(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.

whether

(5) Physicians' services, 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 recommendation 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 neces

sary 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.

(11) "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 cost of an attendant may include transportation, meals, lodging, and salary of the attendant, except that no salary may be paid a member of the patient's family.

(ii) Family planning services, including drugs, supplies, and devices, when such services are under the supervision of a physician.

(iii) Services of Christian Science nurses who are listed and certified by the First Church of Christ Scientist, Boston, Mass., when these services have been requested by the patient and are provided (a) by, or under the supervision of, a Christian Science visiting nurse organization listed and certified by the First Church of Christ Scientist, Boston, Mass.; or (b) as private duty services to an individual in his own home or in a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ Scientist, Boston, Mass., 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 sanatorium.

(iv) Care and services provided in Christian Science sanatoria operated by, or listed and certified by, the First Church of Christ Scientist, Boston, Mass.

(v) Skilled nursing home services, as defined in subparagraph (4) (i) of this paragraph, provided to patients under 21 years of age.

(vi) Emergency hospital services which are necessary to prevent the death or serious impairment of the health of the individual and which, because of the threat to the life or health of the individual, necessitate the use of the most accessible hospital available which is equipped to furnish such services, even though the hospital does not currently meet the conditions for participation under title XVIII of the Social Security Act, or definitions of inpatient or outpatient hospital services set forth in subparagraphs (1) and (2) of this paragraph.

(vii) Personal care services in a recipient's home rendered by an individual, not a member of the family, who is qualified to provide such services, where the services are prescribed by a physician in accordance with a plan of treatment and are supervised by a registered nurse.

(c) Limitations. Federal financial participation in expenditures for medical

and remedial care and services listed in paragraph (b) of this section is not available with respect to any individual who is an inmate of a public institution (except as a patient in a medical institution), or any individual who has not attained 65 years of age and who is a patient in an institution for tuberculosis or mental diseases.

(d) General provisions. (1) In all the items listed in paragraph (b) of this section, the following definitions apply, except to the extent the context otherwise requires:

(i) "Patient" is an individual who is in need of and receiving professional services directed by a licensed practitioner of the healing arts toward maintenance, improvement, or protection of health or alleviation of disability or pain.

(ii) "Inpatient" is a patient who has been admitted to a hospital, skilled nursing home, or other medical institution on recommendation of a physician or dentist and is receiving room, board, and professional services in the institution on a continuous 24-hour a day basis.

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

(2) Nothing in the Social Security Act or Federal policies thereunder will be construed to require any State to compel any person to undergo any medical screening, examination, diagnosis, or treatment or to accept any other health care or services provided under its approved State plan if such person objects, or in the case of a child, his parent or guardian objects, to such care on religious grounds. An individual may not be found eligible unless he undergoes such physical examination as is necessary to establish his eligibility, e.g., an examination must be made of an individual applying for medical assistance on the basis of his disability (as disabled under the AFDC, AB, APTD, or AABD program). [34 F.R. 9784, June 24, 1969, as amended at 35 F.R. 3072, Feb. 17, 1970; 35 F.R. 6792, Apr. 29, 1970; 36 F.R. 21409, Nov. 9, 1971; 36 F.R. 24004, Dec. 17, 1971]

EDITORIAL NOTE: The amendment appearing at 36 F.R. 21409, Nov. 9, 1971, renumbering subparagraphs (a) (3) through (a) (9), is effective 90 days after publication in the FEDERAL REGISTER.

§ 249.11 Free choice of providers of medical services: State plan require

ment.

A State plan for medical assistance under title XIX of the Social Security Act must provide that any individual eligible for medical assistance under the plan may obtain the services available under the plan from any institution, agency, pharmacy, or practitioner, including an organization which provides such services or arranges for their availability on a prepayment basis, which is qualified to perform such services. This provision does not prohibit the State agency from establishing the fees which will be paid to providers for furnishing medical and remedial care available under the plan or from setting reasonable standards relating to the qualifications of providers of such care. In the case of Guam, Puerto Rico, and the Virgin Islands this provision applies only with respect to calendar quarters beginning after June 30, 1972. [35 F.R. 8732, June 5, 1970] [Reserved]

§ 249.31

§ 249.32

Direct payment to certain recipients for physicians' or dentists' services.

(a) State plan requirements. If a State, under its program of medical assistance under title XIX of the Social Security Act, elects to make direct payments to individuals who are not receiving assistance under the State's plan approved under titles I, X, XIV, XVI, or part A of title IV of the Act for physicians' or dentists' services, the State plan for medical assistance must so provide and must specify the conditions under which payments will be made. Such payments to individuals are in all respect viewed as an alternative to payments made by the State agency directly to the physicians or dentists, and are subject to the same conditions. For example, the payments may not exceed the reasonable charge for such services established by the single State agency.

(b) Federal financial participation. Effective January 2, 1968, Federal financial participation is available for direct payments to individuals who are not receiving assistance under the State's plan approved under titles I, X, XIV, XVI, or part A of title IV of the Act, for physicians' or dentists' services in those States which elect to make such direct payments. Direct payments must be sup