DCIS att 4 39A

Attachment 4.39B

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

State/Territory:

PASRR Definition of Specialized Services

1. Specialized services are those services for MI or MR provided or arranged for by the State that are determined by Level II process according to 42 CFR 483.130, to be required by an individual. Level II determinations and evaluation reports indicate the full range of services required by the individual, distinguishing between specialized services provided by the State and services of a lesser intensity to be provided by the NF or other providers according to 42 CFR 483.128(i) and (j).

2. Specialized Services for Mental Illness, developed by the State mental health authority, are determined to be needed by an individual according to the evaluation criteria at 42 CFR 483.134.

(Check each that applies. Specify a definition of the service(s), the entity(s) that provide them, including provider qualifications, and the locations(s) at which these services are offered.)

a. □ SS for MI that require placement other than NF. (Define)

b. □ SS for MI that are provided to NF residents, whether provided in the facility or elsewhere. (Define)

3. Specialized Services for Mental Retardation or a Related Condition, developed by the State mental retardation authority, are determined to be needed by an individual according to the evaluation criteria at 42 CFR 483.136.

(Check each that applies. Specify a definition of the service(s), the entity(s) that provide them, including provider qualifications, and the locations(s) at which these services are offered.)

a. □ SS for MR that require placement other than NF. (Define)

b. □ SS for MR that are provided to NF residents, whether provided in the facility or elsewhere. (Define)

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TN# 94-03 Approval Date Effective Date

Supersedes

TN#