CMS-10190 Non-Emergency Medical Transportation preprint

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Attachment 3.1-B
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
SECTION 3 – SERVICES: GENERAL PROVISIONS

3.1

Amount, Duration, and Scope of Services
Medicaid is provided in accordance with the requirements of sections 1902(a), 1902(e), 1903(i), 1905(a),
1905(p), 1905(r), 1905(s), 1906, 1915, 1916, 1920, 1925, 1929, and 1933 of the Act; section 245A(h) of the
Immigration and Nationality Act; and 42 CFR Parts 431, 440, 441, 442,
and 483.

B. Medically Needy
The following identifies the medical and remedial service covered for medically needy groups, specifies all
limitations on the amount, durations and scope of those services.


Medically Needy not covered.


The same amount, duration and scope of services covered for the Medically Needy as the
Categorically Needy.


The amount, duration and scope of services covered for the Medically Needy are
different than the services covered for the Categorically Needy.*

(If the State attests “The amount, duration and scope of services covered for the Medically Needy are
different than the services covered for the Categorically Needy” then a text box, with header, appears for
the State to supply information.)
Instructions:
The State must provide a description of the service(s) it plans to cover for the Medically
Needy. The description will include the specific differences in service(s) between the
Categorically Needy group(s), as identified in 3.1(A)(1-32), and the
Medically Needy group(s).

TN #
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Approval Date______
Effective Date______

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TN #
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Attachment 3.1-B
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Approval Date______
Effective Date______