Martha A. Churchill Attorney at Law
108 E. Main St., Milan, MI 48160     Phone:  (734) 439-4055.  Fax: 439-4056

Home    About Martha   Bankruptcy Law         
Developmental Disabilities
               Social Security
Milan, Michigan       Send E-Mail

 

Federal law 1396d:
What must the state provide to
Medicaid recipients?

According to 42 U.S.C.A. § 1396a, the list of services which must be provided to Medicaid recipients is found in (1) through (5), as well as (17) and (21) of 42 USC §1396d.

So, what is in the list at 42 USC §1396d? Here is the complete list. Items which are required are marked with * meaning the state must provide these services.

*(1) inpatient hospital services (other than services in an institution for mental diseases);

*(2)
(A) outpatient hospital services,
(B) consistent with State law permitting such services, rural health clinic services (as defined in subsection (l)(1) of this section) and any other ambulatory services which are offered by a rural health clinic (as defined in subsection (l)(1) of this section) and which are otherwise included in the plan, and
(C) Federally- qualified health center services (as defined in subsection (l)(2) of this section) and any other ambulatory services offered by a Federally-qualified health center and which are otherwise included in the plan;

*(3) other laboratory and X-ray services;

*(4)
(A) nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older;
(B) early and periodic screening, diagnostic, and treatment services (as defined in subsection (r) of this section) for individuals who are eligible under the plan and are under the age of 21; and
(C) family planning services and supplies furnished (directly or under arrangements with others) to individuals of child-bearing age (including minors who can be considered to be sexually active) who are eligible under the State plan and who desire such services and supplies;

*(5)
(A) physicians' services furnished by a physician (as defined in section 1395x(r)(1) of this title), whether furnished in the office, the patient's home, a hospital, or a nursing facility, or elsewhere, and
(B) medical and surgical services furnished by a dentist (described in section 1395x(r)(2) of this title) to the extent such services may be performed under State law either by a doctor of medicine or by a doctor of dental surgery or dental medicine and would be described in clause (A) if furnished by a physician (as defined in section 1395x(r)(1) of this title);

(6) medical care, or 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;

(7) home health care services;

(8) private duty nursing services;

(9) clinic services furnished by or under the direction of a physician, without regard to whether the clinic itself is administered by a physician, including such services furnished outside the clinic by clinic personnel to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address;

(10) dental services;

(11) physical therapy and related services;

(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;

(13) other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level;

(14) inpatient hospital services and nursing facility services for individuals 65 years of age or over in an institution for mental diseases;

(15) services in an intermediate care facility for the mentally retarded (other than in an institution for mental diseases) for individuals who are determined, in accordance with section 1396a(a)(31) of this title, to be in need of such care;

(16) effective January 1, 1973, inpatient psychiatric hospital services for individuals under age 21, as defined in subsection (h) of this section;

*(17) services furnished by a nurse-midwife (as defined in section 1395x(gg) of this title) which the nurse-midwife is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), whether or not the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider, and without regard to whether or not the services are performed in the area of management of the care of mothers and babies throughout the maternity cycle;

(18) hospice care (as defined in subsection (o) of this section);

(19) case-management services (as defined in section 1396n(g)(2) of this title) and TB-related services described in section 1396a(z)(2)(F) of this title;

(20) respiratory care services (as defined in section 1396a(e)(9)(C) of this title);

*(21) services furnished by a certified pediatric nurse practitioner or certified family nurse practitioner (as defined by the Secretary) which the certified pediatric nurse practitioner or certified family nurse practitioner is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), whether or not the certified pediatric nurse practitioner or certified family nurse practitioner is under the supervision of, or associated with, a physician or other health care provider;

(22) home and community care (to the extent allowed and as defined in section 1396t of this title) for functionally disabled elderly individuals; and

(23) community supported living arrangements services (to the extent allowed and as defined in section 1396u of this title);

(24) personal care services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, or institution for mental disease that are
(A) authorized for the individual by a physician in accordance with a plan of treatment or (at the option of the State) otherwise authorized for the individual in accordance with a service plan approved by the State,
(B) provided by an individual who is qualified to provide such services and who is not a member of the individual's family, and
(C) furnished in a home or other location;

(25) primary care case management services (as defined in subsection (t) of this section);

(26) services furnished under a PACE program under section 1396u-4 of this title to PACE program eligible individuals enrolled under the program under such section; and

(27) any other medical care, and any other type of remedial care recognized under State law, specified by the Secretary, except as otherwise provided in paragraph (16), such term does not include--
(A) any such payments with respect to care or services for any individual who is an inmate of a public institution (except as a patient in a medical institution); or
(B) any such payments with respect to care or services for any individual who has not attained 65 years of age and who is a patient in an institution for mental diseases.

[NOTE: paragraphs marked with * are required; that is, the state must provide those services. The other paragraphs are optional, depending on the state’s contract with HCFA.]


For information on how to make a Request for Medicaid Fair Hearing, click on FAIR HEARING. For a sample request letter, click on SAMPLE REQUEST.  

Perhaps you would like to read the "Medicaid Manual" and find out what Community Mental Health is legally required to offer for people with mental illness, developmental disabilities, and substance abuse.  If so, click on CHAPTER III.

 

 

Home       About Martha     Bankruptcy Law
  Developmental Disabilities            Social Security  
Milan, Michigan
         
  

Martha A. Churchill, Attorney
108 E. Main St., Milan, MI 48160
Phone:  (734) 439-4055.  Fax: 439-4056 Send e-mail

website consultation by Kinetic Visuals    Sanskrit alphabet