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42 CFR Ch. IV (10–1–09 Edition)§441.17

from the new Surety for a term speci-fied by the Medicaid agency.(j)

Effect of failure to obtain, maintain,and timely file a surety bond.

(1) TheMedicaid agency must terminate theHHA’s provider agreement if the HHAfails to obtain, file timely, and main-tain a surety bond in accordance withthis section and the Medicaid agency’sinstructions.(2) The Medicaid agency must refuseto enter into a provider agreementwith an HHA if an HHA seeking to be-come a participating HHA fails to ob-tain and file timely a surety bond inaccordance with this section and in-structions issued by the State Medicaidagency.(k)

Evidence of compliance.

(1) TheMedicaid agency may at any time re-quire an HHA to make a specific show-ing of being in compliance with the re-quirements of this section and may re-quire the HHA to submit such addi-tional evidence as the Medicaid agencyconsiders sufficient to demonstrate theHHA’s compliance.(2) The Medicaid agency may termi-nate the HHA’s provider agreement orrefuse to enter into a provider agree-ment if an HHA fails to timely furnishsufficient evidence at the Medicaidagency’s request to demonstrate com-pliance with the requirements of thissection.(l)

Surety’s standing to appeal Medicaiddeterminations.

The Medicaid agencymust establish procedures for grantingappeal rights to Sureties.(m)

Effect of conditions of payment.

If a Surety has paid the Medicaid agencyan amount on the basis of liability in-curred under a bond obtained by anHHA under this section, and the Med-icaid agency subsequently collectsfrom the HHA, in whole or in part, onsuch overpayment that was the basisfor the Surety’s liability, the Medicaidagency must reimburse the Suretysuch amount as the Medicaid agencycollected from the HHA, up to theamount paid by the Surety to the Med-icaid agency, provided the Surety hasno other liability under the bond.

[63 FR 310, Jan. 5, 1998, as amended at 63 FR10731, Mar. 4, 1998; 63 FR 29654, June 1, 1998;63 FR 41170, July 31, 1998]

§441.17Laboratory services.

(a) The plan must provide for pay-ment of laboratory services as definedin §440.30 of this subchapter if providedby—(1) An independent laboratory thatmeets the requirements for participa-tion in the Medicare program found in§405.1316 of this chapter;(2) A hospital-based laboratory thatmeets the requirements for participa-tion in the Medicare program found in§482.27 of this chapter;(3) A rural health clinic, as defined in§491.9 of this chapter; or(4) A skilled nursing facility—basedclinical laboratory, as defined in§405.1128(a) of this chapter.(b) Except as provided under para-graph (c), if a laboratory or other enti-ty is requesting payment under Med-icaid for testing for the presence of thehuman immunodeficiency virus (HIV)antibody or for the isolation and iden-tification of the HIV causative agent asdescribed in §405.1316(f) (2) and (3) of this chapter, the laboratory recordsmust contain the name and other iden-tification of the person from whom thespecimen was taken.(c) An agency may choose to approvethe use of alternative identifiers, inplace of the requirement for patient’sname, in paragraph (b) of this sectionfor HIV antibody or causative agenttesting of Medicaid recipients.

[54 FR 48647, Dec. 2, 1988. Redesignated at 63FR 310, Jan. 5, 1998.]

§441.18Case management services.

(a) If a State plan provides for casemanagement services (including tar-geted case management services), asdefined in §440.169 of this chapter, theState must meet the following require-ments:(1) Allow individuals the free choiceof any qualified Medicaid providerwithin the specified geographic areaidentified in the plan when obtainingcase management services, in accord-ance with §431.51 of this chapter, ex-cept as specified in paragraph (b) of this section.(2) Not use case management (includ-ing targeted case management) serv-ices to restrict an individual’s accessto other services under the plan.

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Centers for Medicare & Medicaid Services, HHS §441.18

(3) Not compel an individual to re-ceive case management services, condi-tion receipt of case management (ortargeted case management) services onthe receipt of other Medicaid services,or condition receipt of other Medicaidservices on receipt of case management(or targeted case management) serv-ices.(4) Indicate in the plan that casemanagement services provided in ac-cordance with section 1915(g) of the Actwill not duplicate payments made topublic agencies or private entitiesunder the State plan and other pro-gram authorities;(5) [Reserved](6) Prohibit providers of case man-agement services from exercising theagency’s authority to authorize ordeny the provision of other servicesunder the plan.(7) Require providers to maintaincase records that document for all indi-viduals receiving case management asfollows:(i) The name of the individual.(ii) The dates of the case manage-ment services.(iii) The name of the provider agency(if relevant) and the person providingthe case management service.(iv) The nature, content, units of thecase management services received andwhether goals specified in the care planhave been achieved.(v) Whether the individual has de-clined services in the care plan.(vi) The need for, and occurrences of,coordination with other case managers.(vii) A timeline for obtaining neededservices.(viii) A timeline for reevaluation of the plan.(8) Include a separate plan amend-ment for each group receiving casemanagement services that includes thefollowing:(i) Defines the group (and any sub-groups within the group) eligible to re-ceive the case management services.(ii) Identifies the geographic area tobe served.(iii) Describes the case managementservices furnished, including the typesof monitoring.(iv) Specifies the frequency of assess-ments and monitoring and provides ajustification for those frequencies.(v) Specifies provider qualificationsthat are reasonably related to the pop-ulation being served and the case man-agement services furnished.(vi) [Reserved](vii) Specifies if case managementservices are being provided to Med-icaid-eligible individuals who are in in-stitutions (except individuals betweenages 22 and 64 who are served in IMDsor individuals who are inmates of pub-lic institutions).(9) Include a separate plan amend-ment for each subgroup within a groupif any of the following differs amongthe subgroups:(i) The case management services tobe furnished;(ii) The qualifications of case man-agement providers; or(iii) The methodology under whichcase management providers will bepaid.(b) If the State limits qualified pro-viders of case management services fortarget groups of individuals with devel-opmental disability or chronic mentalillness, in accordance with §431.51(a)(4)of this chapter, the plan must identifyany limitations to be imposed on theproviders and specify how these limita-tions enable providers to ensure thatindividuals within the target groups re-ceive needed services.(c) Case management does not in-clude, and FFP is not available in ex-penditures for, services defined in§441.169 of this chapter when the casemanagement activities constitute thedirect delivery of underlying medical,educational, social, or other services towhich an eligible individual has beenreferred, including for foster care pro-grams, services such as, but not lim-ited to, the following:(1) Research gathering and comple-tion of documentation required by thefoster care program.(2) Assessing adoption placements.(3) Recruiting or interviewing poten-tial foster care parents.(4) Serving legal papers.(5) Home investigations.(6) Providing transportation.(7) Administering foster care sub-sidies.(8) Making placement arrangements.(d) After the State assesses whetherthe activities are within the scope of