Sec. 202. Definitions relating to services
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In this title, the term community-based primary health services means ambulatory health services furnished— by a rural health clinic; by a federally qualified health center (as defined in section 1905(l)(2)(B) of the Social Security Act ), and which, for purposes of this Act, include services furnished by State and local health agencies; in a school-based setting; by public educational agencies and other providers of services to children entitled to assistance under the Individuals with Disabilities Education Act for services furnished pursuant to a written Individualized Family Services Plan or Individual Education Plan under such Act; and public and private nonprofit entities receiving Federal assistance under the Public Health Service Act .
In this title, the term preventive services means items and services— which— are specified in paragraph (2); or the Board determines to be effective in the maintenance and promotion of health or minimizing the effect of illness, disease, or medical condition; and which are provided consistent with the periodicity schedule established under paragraph (3). The services specified in this paragraph are as follows: Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.
Prenatal and well-baby care (for infants under 1 year of age). Well-child care (including periodic physical examinations, hearing and vision screening, and developmental screening and examinations) for individuals under 18 years of age, including evidence-informed preventive care and screenings included in the comprehensive guidelines of the Health Resources and Services Administration. Periodic screening mammography, Pap smears, and colorectal examinations and examinations for prostate cancer.
Physical examinations. Family planning services. Routine eye examinations, eyeglasses, and contact lenses. Hearing aids, but only upon a determination of a certified audiologist or physician that a hearing problem exists and is caused by a condition that can be corrected by use of a hearing aid. Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force. With respect to women, such additional preventive care and screenings not described in subparagraph
(I)that are included in the comprehensive guidelines of the Health Resources and Services Administration. The Board shall establish, in consultation with experts in preventive medicine and public health and taking into consideration those preventive services recommended by the Preventive Services Task Force and published as the Guide to Clinical Preventive Services, a periodicity schedule for the coverage of preventive services under paragraph (1). Such schedule shall take into consideration the cost-effectiveness of appropriate preventive care and shall be revised not less frequently than once every 5 years, in consultation with experts in preventive medicine and public health. In this title, the term home and community-based long-term care services means the following services provided to an individual to enable the individual to remain in such individual’s place of residence within the community: Home health aide services. Adult day health care, social day care or psychiatric day care. Medical social work services. Care coordination services, as defined in subsection (g)(1). Respite care, including training for informal caregivers. Personal assistance services, and homemaker services (including meals) incidental to the provision of personal assistance services. The term home health services means items and services described in section 1861(m) of the Social Security Act and includes home infusion services. The term home infusion services includes the nursing, pharmacy, and related services that are necessary to conduct the home infusion of a drug regimen safely and effectively under a plan established and periodically reviewed by a physician and that are provided in compliance with quality assurance requirements established by the Secretary. In this title, the term medical foods means foods which are formulated to be consumed or administered enterally under the supervision of a physician and which are intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. In this title, the term mental health and substance abuse treatment services means the following services related to the prevention, diagnosis, treatment, and rehabilitation of mental illness and promotion of mental health: Inpatient hospital services furnished primarily for the diagnosis or treatment of mental illness or substance abuse for up to 60 days during a year, reduced by a number of days determined by the Secretary so that the actuarial value of providing such number of days of services under this paragraph to the individual is equal to the actuarial value of the days of inpatient residential services furnished to the individual under subparagraph
(B)during the year after such services have been furnished to the individual for 120 days during the year (rounded to the nearest day), but only if (with respect to services furnished to an individual described in section 204(b)(1)) such services are furnished in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 204(b)(2). Intensive residential services (as defined in paragraph (2)) furnished to an individual for up to 120 days during any calendar year, except that— such services may be furnished to the individual for additional days during the year if necessary for the individual to complete a course of treatment to the extent that the number of days of inpatient hospital services described in subparagraph
(A)that may be furnished to the individual during the year (as reduced under such subparagraph) is not less than 15; and reduced by a number of days determined by the Secretary so that the actuarial value of providing such number of days of services under this paragraph to the individual is equal to the actuarial value of the days of intensive community-based services furnished to the individual under subparagraph
(D)during the year after such services have been furnished to the individual for 90 days (or, in the case of services described in subparagraph (D)(ii), for 180 days) during the year (rounded to the nearest day). Outpatient treatment services of mental illness or substance abuse (other than intensive community-based services under subparagraph (D)) for an unlimited number of days during any calendar year furnished in accordance with standards established by the Secretary for the management of such services, and, in the case of services furnished to an individual described in section 204(b)(1) who is not an inpatient of a hospital, in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 204(b)(2). Intensive community-based services (as described in paragraph (3))— for an unlimited number of days during any calendar year, in the case of services described in section 1861(ff)(2)(E) of the Social Security Act (42 U.S.C. 1395x(ff)(2)(E)) that are furnished to an individual who is a seriously mentally ill adult, a seriously emotionally disturbed child, or an adult or child with serious substance abuse disorder (as determined in accordance with criteria established by the Secretary); in the case of services described in section 1861(ff)(2)(C) of the Social Security Act ( 42 U.S.C. 1395x(ff)(2)(C) ), for up to 180 days during any calendar year, except that such services may be furnished to the individual for a number of additional days during the year equal to the difference between the total number of days of intensive residential services which the individual may receive during the year under part A (as determined under subparagraph (B)) and the number of days of such services which the individual has received during the year; or in the case of any other such services, for up to 90 days during any calendar year, except that such services may be furnished to the individual for the number of additional days during the year described in clause (ii). Subject to subparagraphs
(B)and (C), the term intensive residential services means inpatient services provided in any of the following facilities: Residential detoxification centers. Crisis residential programs or mental illness residential treatment programs. Therapeutic family or group treatment homes. Residential centers for substance abuse treatment. No service may be treated as an intensive residential service under subparagraph
(A)unless the facility at which the service is provided— is legally authorized to provide such service under the law of the State (or under a State regulatory mechanism provided by State law) in which the facility is located or is certified to provide such service by an appropriate accreditation entity approved by the State in consultation with the Secretary; and meets such other requirements as the Secretary may impose to ensure the quality of the intensive residential services provided. In the case of services furnished to an individual described in section 204(b)(1), no service may be treated as an intensive residential service under this subsection unless the service is furnished in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 204(b)(2). No service may be treated as an intensive residential service under subparagraph
(A)unless the service is furnished in accordance with standards established by the Secretary for the management of such services. The term intensive community-based services means the items and services described in subparagraph
(B)prescribed by a physician (or, in the case of services furnished to an individual described in section 204(b)(1), by an organized system of care for mental health and substance abuse services in accordance with such section) and provided under a program described in subparagraph
(D)under the supervision of a physician (or, to the extent permitted under the law of the State in which the services are furnished, a non-physician mental health professional) pursuant to an individualized, written plan of treatment established and periodically reviewed by a physician (in consultation with appropriate staff participating in such program) which sets forth the physician’s diagnosis, the type, amount, frequency, and duration of the items and services provided under the plan, and the goals for treatment under the plan, but does not include any item or service that is not furnished in accordance with standards established by the Secretary for the management of such services. The items and services described in this subparagraph are— partial hospitalization services consisting of the items and services described in subparagraph (C); psychiatric rehabilitation services; day treatment services for individuals under 19 years of age; in-home services; case management services, including collateral services designated as such case management services by the Secretary; ambulatory detoxification services; and such other items and services as the Secretary may provide (but in no event to include meals and transportation), that are reasonable and necessary for the diagnosis or active treatment of the individual’s condition, reasonably expected to improve or maintain the individual’s condition and functional level and to prevent relapse or hospitalization, and furnished pursuant to such guidelines relating to frequency and duration of services as the Secretary shall by regulation establish (taking into account accepted norms of medical practice and the reasonable expectation of patient improvement). For purposes of subparagraph (B)(i), partial hospitalization services consist of the following: Individual and group therapy with physicians or psychologists (or other mental health professionals to the extent authorized under State law). Occupational therapy requiring the skills of a qualified occupational therapist. Services of social workers, trained psychiatric nurses, behavioral aides, and other staff trained to work with psychiatric patients (to the extent authorized under State law). Drugs and biologicals furnished for therapeutic purposes (which cannot, as determined in accordance with regulations, be self-administered). Individualized activity therapies that are not primarily recreational or diversionary. Family counseling (the primary purpose of which is treatment of the individual’s condition). Patient training and education (to the extent that training and educational activities are closely and clearly related to the individual’s care and treatment). Diagnostic services. A program described in this subparagraph is a program (whether facility-based or freestanding) which is furnished by an entity— legally authorized to furnish such a program under State law (or the State regulatory mechanism provided by State law) or certified to furnish such a program by an appropriate accreditation entity approved by the State in consultation with the Secretary; and meeting such other requirements as the Secretary may impose to ensure the quality of the intensive community-based services provided. In this title, the term care coordination services means services provided by care coordinators (as defined in paragraph (2)) to individuals described in paragraph
(3)for the coordination and monitoring of home and community-based long-term care services to ensure appropriate, cost-effective utilization of such services in a comprehensive and continuous manner, and includes— transition management between inpatient facilities and community-based services, including assisting patients in identifying and gaining access to appropriate ancillary services; and evaluating and recommending appropriate treatment services, in cooperation with patients and other providers and in conjunction with any quality review program or plan of care under section 205. In this title, the term care coordinator means an individual or nonprofit or public agency or organization which the State health security program determines— is capable of performing directly, efficiently, and effectively the duties of a care coordinator described in paragraph (1); and demonstrates capability in establishing and periodically reviewing and revising plans of care, and in arranging for and monitoring the provision and quality of services under any plan. State health security programs shall establish safeguards to ensure that care coordinators have no financial interest in treatment decisions or placements. Care coordination may not be provided through any structure or mechanism through which quality review is performed. An individual described in this paragraph is an individual described in section 203 (relating to individuals qualifying for long-term and chronic care services). In this title, subject to subsection (b), the term dental services means the following: Emergency dental treatment, including extractions, for bleeding, pain, acute infections, and injuries to the maxillofacial region. Prevention and diagnosis of dental disease, including examinations of the hard and soft tissues of the oral cavity and related structures, radiographs, dental sealants, fluorides, and dental prophylaxis. Treatment of dental disease, including non-cast fillings, periodontal maintenance services, and endodontic services. Space maintenance procedures to prevent orthodontic complications. Orthodontic treatment to prevent severe malocclusions. Full dentures. Medically necessary oral health care. Any items and services for special needs patients that are not described in subparagraphs
(A)through
(G)and that— are required to provide such patients the items and services described in subparagraphs
(A)through (G); are required to establish oral function (including general anesthesia for individuals with physical or emotional limitations that prevent the provision of dental care without such anesthesia); consist of orthodontic care for severe dentofacial abnormalities; or consist of prosthetic dental devices for genetic or birth defects or fitting for such devices. Any dental care for individuals with a seizure disorder that is not described in subparagraphs
(A)through
(H)and that is required because of an illness, injury, disorder, or other health condition that results from such seizure disorder. Dental services are subject to the following limitations: The examinations and prophylaxis described in paragraph (1)(B) are covered only consistent with a periodicity schedule established by the Board, which schedule may provide for special treatment of individuals less than 18 years of age and of special needs patients. The dental sealants described in such paragraph are not covered for individuals 18 years of age or older. Such sealants are covered for individuals less than 10 years of age for protection of the 1st permanent molars. Such sealants are covered for individuals 10 years of age or older for protection of the 2d permanent molars. Prior to January 1, 2020, the items and services described in paragraph (1)(C) are covered only for individuals less than 18 years of age and special needs patients. On or after such date, such items and services are covered for all individuals enrolled for benefits under this Act, except that endodontic services are not covered for individuals 18 years of age or older. The items and services described in paragraph (1)(D) are covered only for individuals at least 3 years of age, but less than 13 years of age and— are limited to posterior teeth; involve maintenance of a space or spaces for permanent posterior teeth that would otherwise be prevented from normal eruption if the space were not maintained; and do not include a space maintainer that is placed within 6 months of the expected eruption of the permanent posterior tooth concerned. For purposes of this title: The term medically necessary oral health care means oral health care that is required as a direct result of, or would have a direct impact on, an underlying medical condition. Such term includes oral health care directed toward control or elimination of pain, infection, or reestablishment of oral function. The term special needs patient includes an individual with a genetic or birth defect, a developmental disability, or an acquired medical disability. Except as may be provided by the Board, the terms nursing facility and nursing facility services have the meanings given such terms in sections 1919(a) and 1905(f), respectively, of the Social Security Act . Except as may be provided by the Board— the term intermediate care facility for individuals with an intellectual disability has the meaning given the term intermediate care facility for individuals with mental retardation in section 1905(d) of the Social Security Act (as in effect before the enactment of this Act); and the term services in intermediate care facilities for individuals with an intellectual disability means services described in section 1905(a)(15) of such Act (as so in effect) in an intermediate care facility for individuals with an intellectual disability to an individual determined to require such services in accordance with standards specified by the Board and comparable to the standards described in section 1902(a)(31)(A) of such Act (as so in effect). Except as may be provided by the Board, the definitions contained in section 1861 of the Social Security Act shall apply.
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Sec. 202
Definitions relating to services
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