February 8, 2018
What should States consider when including Specialized Services in State Plans?
In order to be eligible for federal financial participation (FFP), Specialized Services must be included in the State Plan. They are considered “specialized add-on services” that can be provided under the nursing facility benefit authorized the Section 1905(a) of the Social Security Act.
Although Specialized Services are intended for PASRR-eligible individuals, as specialized add-on services they must meet the three requirements for 1905(a) services:
1. Statewideness: Services must be available to the entire state and not be limited to a specific region or county unless it meets the exceptions identified at 42 CFR 431.50.
2. Comparability: Services must be available to all eligible Medicaid individuals who meet the criteria for a given service. The Medicaid comparability requirements can be found at 42 CFR 431.40, which elaborates on the requirements in the Social Security Act at Section 1902(a)(10)(B)(i).
3. Every willing provider: As specified at 42 CFR 431.5, a Medicaid-eligible individual must be able to choose from any provider who meets the conditions for enrollment. The Medicaid “free choice of providers” requirements can be found at 42 CFR 431.5.
Under comparability, services must be available to all eligible Medicaid individuals who meet the criteria for a given service (as found in the Social Security Act at 1902(a)(10)(B)(i) and in the CFR at 42 CFR 431.40). Services cannot be targeted exclusively to specific populations based on diagnosis. Importantly, however, service definitions can be tailored so they meet the needs of particular populations especially well. When individuals are identified as having a PASRR disability, this identification can serve as a type of “prior authorization” for access to specialized add-on services. Other individuals can access those services if they meet the needs-based criteria specified in the service definitions, and States can determine any additional evaluations that would be required for determining eligibility.