Federal Register / Vol. 72, No. 232 / Tuesday, December 4, 2007 / Rules and Regulations 68077 

II. Waiver of Proposed Rulemaking and 

30-Day Delay in the Effective Date 

We ordinarily publish a notice of 

proposed rulemaking in the Federal 

Register to provide a period for public 

comment before the provisions of a rule 

take effect in accordance with section 

553(b) of the Administrative Procedure 

Act (APA) (5 U.S.C. 553(b)). However, 

we can waive this notice and comment 

procedure if the Secretary finds, for 

good cause, that the notice and 

comment process is impracticable, 

unnecessary, or contrary to the public 

interest, and incorporates a statement of 

the finding and the reasons therefore in 

the notice. 

Section 553(d) of the APA ordinarily 

requires a 30-day delay in effective date 

of final rules after the date of their 

publication in the Federal Register. 

This 30-day delay in effective date can 

be waived, however, if an agency finds 

for good cause that the delay is 

impracticable, unnecessary, or contrary 

to the public interest, and the agency 

incorporates a statement of the findings 

and its reasons in the rule issued. 

Therefore, for reasons noted below, 

we find good cause to waive proposed 

rulemaking and the 30-day delayed 

effective date for the corrections in this 

notice. This notice merely corrects 

typographical and technical errors in 

the preamble and regulations text of the 

September 5, 2007 final rule and does 

not make substantive changes to the 

policies that were adopted in the final 

rule. Therefore, we find that 

undertaking further notice and comment 

procedures to incorporate these 

corrections into the final rule and 

delaying the effective date of these 

changes is unnecessary and contrary to 

the public interest. 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance, and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: November 27, 2007. 

Ann C. Agnew, 

Executive Secretary to the Department. 

[FR Doc. 07–5905 Filed 11–30–07; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Parts 431, 440, and 441 

[CMS–2237–IFC] 

RIN 0938–AO50 

Medicaid Program; Optional State Plan 

Case Management Services 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Interim final rule with comment 

period. 

SUMMARY: This interim final rule with 

comment period revises current 

Medicaid regulations to incorporate 

changes made by section 6052 of the 

Deficit Reduction Act of 2005. In 

addition, it incorporates provisions of 

the Consolidated Omnibus Budget 

Reconciliation Act of 1985, the 

Omnibus Budget Reconciliation Act of 

1986, the Tax Reform Act of 1986, the 

Omnibus Budget Reconciliation Act of 

1987, and the Technical and 

Miscellaneous Revenue Act of 1988, 

concerning case management and 

targeted case management services. This 

interim final rule with comment period 

will provide for optional coverage of 

case management services or targeted 

case management services furnished 

according to section 1905(a)(19) and 

section 1915(g) of the Social Security 

Act. This interim final rule with 

comment period clarifies the situations 

in which Medicaid will pay for case 

management activities and also clarifies 

when payment will not be consistent 

with proper and efficient operation of 

the Medicaid program, and is not 

available. 

DATES: Effective Date: The effective date 

of this rule is March 3, 2008. 

Comment date: To be assured 

consideration, comments must be 

received at one of the addresses 

provided below, no later than 5 p.m. on 

February 4, 2008. 

ADDRESSES: In commenting, please refer 

to file code CMS–2237–IFC. Because of 

staff and resource limitations, we cannot 

accept comments by facsimile (FAX) 

transmission. 

You may submit comments in one of 

four ways (no duplicates, please): 

1. Electronically. You may submit 

electronic comments on specific issues 

in this regulation to http:// 

www.cms.hhs.gov/eRulemaking. Click 

on the link ‘‘Submit electronic 

comments on CMS regulations with an 

open comment period.’’ (Attachments 

should be in Microsoft Word, 

WordPerfect, or Excel; however, we 

prefer Microsoft Word.) 

2. By regular mail. You may mail 

written comments (one original and two 

copies) to the following address ONLY: 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, Attention: CMS–2237–

IFC, P.O. Box 8016, Baltimore, MD 

21244–8016. 

Please allow sufficient time for mailed 

comments to be received before the 

close of the comment period. 

3. By express or overnight mail. You 

may send written comments (one 

original and two copies) to the following 

address ONLY: Centers for Medicare & 

Medicaid Services, Department of 

Health and Human Services, Attention: 

CMS–2237–IFC, Mail Stop C4–26–05, 

7500 Security Boulevard, Baltimore, MD 

21244–1850. 

4. By hand or courier. If you prefer, 

you may deliver (by hand or courier) 

your written comments (one original 

and two copies) before the close of the 

comment period to one of the following 

addresses. If you intend to deliver your 

comments to the Baltimore address, 

please call telephone number (410) 786–

7195 in advance to schedule your 

arrival with one of our staff members. 

Room 445–G, Hubert H. Humphrey 

Building, 200 Independence Avenue, 

SW., Washington, DC 20201; or 7500 

Security Boulevard, Baltimore, MD 

21244–1850. 

(Because access to the interior of the 

HHH Building is not readily available to 

persons without Federal Government 

identification, commenters are 

encouraged to leave their comments in 

the CMS drop slots located in the main 

lobby of the building. A stamp-in clock 

is available for persons wishing to retain 

a proof of filing by stamping in and 

retaining an extra copy of the comments 

being filed.) 

Comments mailed to the addresses 

indicated as appropriate for hand or 

courier delivery may be delayed and 

received after the comment period. 

For information on viewing public 

comments, see the beginning of the 

SUPPLEMENTARY INFORMATION section. 

FOR FURTHER INFORMATION CONTACT: Jean 

Close, (410) 786–5831. 

SUPPLEMENTARY INFORMATION: 

Submitting Comments: We welcome 

comments from the public on all issues 

set forth in this rule to assist us in fully 

considering issues and developing 

policies. You can assist us by 

referencing the file code CMS–2237–IFC 

and the specific ‘‘issue identifier’’ that 

precedes the section on which you 

choose to comment. 


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68078 Federal Register / Vol. 72, No. 232 / Tuesday, December 4, 2007 / Rules and Regulations 

Inspection of Public Comments: All 

comments received before the close of 

the comment period are available for 

viewing by the public, including any 

personally identifiable or confidential 

business information that is included in 

a comment. We post all comments 

received before the close of the 

comment period on the following Web 

site as soon as possible after they have 

been received: http://www.cms.hhs.gov/ 

eRulemaking. Click on the link 

‘‘Electronic Comments on CMS 

Regulations’’ on that Web site to view 

public comments. 

Comments received timely also will 

be available for public inspection as 

they are received, generally beginning 

approximately 3 weeks after publication 

of a document, at the headquarters of 

the Centers for Medicare & Medicaid 

Services, 7500 Security Boulevard, 

Baltimore, Maryland 21244, Monday 

through Friday of each week from 8:30 

a.m. to 4 p.m. To schedule an 

appointment to view public comments, 

phone 1–800–743–3951. 

I. Background 

[If you choose to comment on issues 

in this section, please include the 

caption ‘‘Background’’ at the beginning 

of your comments.] 

Case management is commonly 

understood to be an activity that assists 

individuals in gaining access to 

necessary care and services appropriate 

to their needs. Many individuals, 

because of their age, condition, illness, 

living arrangement, or other factors, may 

benefit from receiving direct assistance 

in gaining access to services. In the 

context of this regulation, it is the 

individual’s access to care and services 

that is the subject of this management—

not the individual. Because case 

management has been subject to so 

many different interpretations over the 

years, many Medicaid agencies now 

refer to case management as ‘‘care 

management,’’ ‘‘service coordination,’’

‘‘care coordination’’ or some other term 

related to planning and coordinating 

access to health care and other services 

on behalf of an individual. Because 

section 1915 of the Social Security Act 

(the Act) uses the term ‘‘case 

management,’’ we will use this term 

throughout this document. 

In 1981, the Congress amended the 

Act to authorize Medicaid coverage of 

case management services under two 

provisions. Under section 1915(b) of the 

Act, States were authorized to develop 

primary care case management systems 

in order to direct individuals to 

appropriate Medicaid services. Under 

section 1915(c) of the Act, States were 

authorized to furnish case management 

as a distinct service under home and 

community-based services waivers. Case 

management is widely used under both 

authorities because of its value in 

ensuring that individuals receiving 

Medicaid benefits are assisted in making 

necessary decisions about the care they 

need and in locating service providers. 

The regulations set forth in this 

interim final regulation implement in 42 

CFR parts 431, 440, and 441 the case 

management services provisions 

authorized by sections 1905(a)(19) of the 

Act and 1915(g) of the Act. The 

definition of case management in the 

Deficit Reduction Act was effective on 

January 1, 2006. The provisions of this 

rule are effective 90 days after the date 

of publication of this rule. 

II. Legislative History 

A. Changes Made by the Consolidated 

Omnibus Budget Reconciliation Act of 

1985 

Section 9508 of the Consolidated 

Omnibus Budget Reconciliation Act of 

1985 (COBRA) (Pub. L. 99–272), enacted 

on April 7, 1986, amended the Act 

concerning the provision of targeted 

case management services. Specifically, 

section 9508 of COBRA added a new 

section 1915(g) to the Act that—

• Provided that a State may elect to 

furnish case management, targeted to 

specified groups, as a service covered 

under the State plan; 

• Defined case management services 

as services that will assist individuals, 

eligible under the State plan, in gaining 

access to needed medical, social, 

educational, and other services; 

• Provided an exception to the 

statewideness requirement of section 

1902(a)(1) of the Act by allowing a State 

to limit its provision of case 

management services to individuals 

who reside in particular geographic 

areas or political subdivisions within 

the State; 

• Provided an exception to the 

comparability requirement of section 

1902(a)(10)(B) of the Act by allowing a 

State to furnish case management 

services to any specific group (targeted 

case management); and 

• Required that there be no restriction 

on free choice of providers of case 

management services that would violate 

section 1902(a)(23) of the Act. 

B. Changes Made by the Omnibus 

Budget Reconciliation Act of 1986 

Section 9411(b) of the Omnibus 

Budget Reconciliation Act of 1986 Pub. 

L. 99–509, enacted on October 21, 1986, 

amended section 1915(g) of the Act by 

clarifying that a State may limit the 

provision of case management services 

to individuals with acquired immune 

deficiency syndrome (AIDS), AIDSrelated conditions, or with either. 

Section 1915(g) of the Act also was 

amended to clarify that a State may 

limit case management services to 

individuals with chronic mental illness. 

C. Changes Made by the Tax Reform Act 

of 1986 

Section 1895(c)(3) of the Tax Reform 

Act of 1986 (Pub. L. 99–514), enacted on 

October 22, 1986, amended the statute 

to permit States to furnish non-targeted 

case management services under a State 

Medicaid plan. This law amended 

section 1905(a) of the Act by adding a 

new paragraph (19) that included case 

management services, as defined in 

section 1915(g)(2) of the Act, in the list 

of optional services a State may include 

in its Medicaid plan (the existing 

paragraph (19) was redesignated as 

paragraph (20)). 

D. Changes Made by the Omnibus 

Budget Reconciliation Act of 1987 

Section 4118(i) of the Omnibus 

Budget Reconciliation Act of 1987 

(OBRA ’87) Pub. L. 100–203, enacted on 

December 22, 1987, amended section 

1915(g)(1) of the Act to allow States to 

limit the providers of case management 

services available for individuals with 

developmental disabilities or chronic 

mental illness to ensure that the case 

managers for those individuals are 

capable of ensuring that those 

individuals receive needed services. 

E. Changes Made by the Technical and 

Miscellaneous Revenue Act of 1988 

Section 8435 of the Technical and 

Miscellaneous Revenue Act of 1988 

(Pub. L. 100–647), enacted on November 

10, 1988, prohibited the Secretary from 

denying approval of a State plan 

amendment to provide case 

management services on the basis that a 

State is required to provide those 

services under State law or on the basis 

that the State had paid or is paying for 

those services from other non-Federal 

revenue sources before or after April 7, 

1986. This provision also specified that 

the Secretary was not required to make 

payment under Medicaid for case 

management services that are furnished 

without charge to the users of such 

services. 

F. Changes Made by the Deficit 

Reduction Act of 2005 

Section 6052 of the Deficit Reduction 

Act (DRA) of 2005 (Pub. L. 109–171), 

enacted on February 8, 2006, addresses 

Reforms of Case Management and 

Targeted Case Management under 

Medicaid. This section redefined the 


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term ‘‘case management services’’ to 

mean services that will ‘‘assist 

individuals eligible under the State plan 

in gaining access to needed medical, 

social, educational, and other services’’

and to include the following 

components: 

• Assessment of an eligible 

individual to determine service needs, 

including activities that focus on needs 

identification, to determine the need for 

any medical, educational, social, or 

other services. These activities are 

defined to include the following: 

—Taking client history. 

—Identifying the needs of the 

individual, and completing related 

documentation. 

—Gathering information from other 

sources, such as family members, 

medical providers, social workers, 

and educators, if necessary, to form a 

complete assessment of the eligible 

individual. 

• Development of a specific care plan 

based on the information collected 

through the assessment described above. 

The care plan specifies the goals of 

providing case management to the 

eligible individual and actions to 

address the medical, social, educational, 

and other services needed by the 

eligible individual, including activities 

such as ensuring the active participation 

of the eligible individual and working 

with the individual (or the individual’s 

authorized health care decision maker) 

and others to develop such goals and 

identify a course of action to respond to 

the assessed needs of the eligible 

individual. 

• Referral and related activities to 

help an individual obtain needed 

services, including activities that help 

link the eligible individual with 

medical, social, educational providers, 

or other programs and services that are 

capable of providing needed services, 

such as making referrals to providers for 

needed services and scheduling 

appointments for the individual. 

• Monitoring and follow-up activities, 

including activities and contacts that are 

necessary to ensure that the care plan is 

effectively implemented and adequately 

addresses the needs of the eligible 

individual. Monitoring and follow-up 

activities may be with the individual, 

family members, providers, or other 

entities. These activities may be 

conducted as frequently as necessary to 

help determine such matters as: 

—Whether services are being furnished 

in accordance with the individual’s 

care plan. 

—Whether the services in the care plan 

are adequate to meet the needs of the 

individual. 

—Whether there are changes in the 

needs or status of the individual. 

If there are changes in the needs or 

status of the individual, monitoring and 

follow-up activities include making 

necessary adjustments in the care plan 

and service arrangements with 

providers. 

Section 6052 of the DRA also clarifies 

that the term ‘‘case management’’ does 

not include the ‘‘direct delivery of an 

underlying medical, educational, social, 

or other service to which an eligible 

individual has been referred’’ by adding 

clause section 1915(g)(2)(A)(iii) of the 

Act. In addition, with respect to foster 

care, the statute gives examples of some 

types of activities that are not covered. 

With respect to the direct delivery of 

foster care services, the following 

activities are not considered to qualify 

as components of Medicaid case 

management services: 

• Research gathering and completion 

of documentation required by the foster 

care program; 

• Assessing adoption placements; 

• Recruiting or interviewing potential 

foster care parents; 

• Serving legal papers; 

• Home investigations; 

• Providing transportation; 

• Administering foster care subsidies; 

or 

• Making placement arrangements. 

The DRA also added a new section 

1915(g)(2)(B) to the Act, defining the 

term ‘‘targeted case management 

services’’ as case management services 

that are furnished without regard to the 

requirements of section 1902(a)(1) of the 

Act, regarding statewide availability of 

services, and section 1902(a)(10)(B) of 

the Act, regarding comparability of 

services. Although the ability to provide 

these services without regard to section 

1902(a)(1) of the Act and section 

1902(a)(10)(B) of the Act is not new, this 

paragraph clarifies that the State can 

‘‘target’’ case management services to 

specific classes of individuals, or to 

individuals who reside in specified 

areas of the State (or both). 

Section 6052 of the DRA also added 

a new section 1915(g)(3) to the Act, to 

clarify that when a case manager 

contacts individuals who are not 

eligible for Medicaid, or who are 

Medicaid eligible but not included in 

the eligible target population in the 

State, that contact may qualify as 

Medicaid case management services. 

The contact is considered an allowable 

case management activity when the 

purpose of the contact is directly related 

to the management of the eligible 

individual’s care. It is not considered an 

allowable case management activity if 

those contacts relate directly to the 

identification and management of the 

non-eligible or non-targeted individual’s 

needs and care. 

Section 6052 of the DRA added a new 

section 1915(g)(4) to the Act to discuss 

the circumstances under which Federal 

financial participation (FFP) is available 

for case management or targeted case 

management services. With a few 

exceptions described in the following 

paragraph, in accordance with section 

1902(a)(25) of the Act, FFP only is 

available for the cost of case 

management or targeted case 

management services if there are no 

other third parties liable to pay for those 

services, including as reimbursement 

under a medical, social, educational, or 

other program. When the costs of any 

part of case management or targeted 

case management services are 

reimbursable under another federally 

funded program, a State is directed to 

allocate the costs between the other 

program(s) and Medicaid in accordance 

with OMB Circular (No. A–87) (or any 

related or successor guidance or 

regulations regarding allocation of costs 

among Federally funded programs) 

under an approved cost allocation 

program. 

It should be noted that per section 

1903(c) of the Act, nothing in this rule 

would prohibit or restrict payment for 

medical assistance for covered Medicaid 

services furnished to a child with a 

disability because such services are 

included in the child’s Individualized 

Education Program (IEP) or Individual 

Family Service Plan (IFSP). Likewise, 

payment for those services that are 

included in the IEP or IFSP would not 

be available when those services are not 

covered Medicaid services. 

Section 6052 of the DRA also 

clarified, in a new section 1915(g)(5) of 

the Act, that nothing in section 1915(g) 

of the Act shall be construed as affecting 

the application of rules with respect to 

third party liability under programs or 

activities carried out under title XXVI of 

the Public Health Service Act (the HIV 

Health Care Services Program) or the 

Indian Health Service. 

This rule implements in Federal 

regulations the statutory provisions 

permitting coverage of case management 

and targeted case management as 

optional services under a State 

Medicaid plan, in accordance with 

sections 1905(a)(19) and 1915(g) of the 

Act, as amended by the DRA, and all 

other relevant statutory provisions. 

III. Provisions of the Interim Final Rule 

[If you choose to comment on issues 

in this section, please indicate the 

caption ‘‘Provisions of the Interim Final 


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68080 Federal Register / Vol. 72, No. 232 / Tuesday, December 4, 2007 / Rules and Regulations 

Rule’’ at the beginning of your 

comments.] 

To incorporate the policies and 

implement the statutory provisions 

described above, we are making the 

following revisions to 42 CFR chapter 

IV, subchapter C, Medical Assistance 

Programs. 

A. Freedom of Choice Exception To 

Permit Limitation of Case Management 

Providers for Certain Target Groups—

§ 431.51(c) 

While the freedom of choice 

requirement is beneficial to the 

Medicaid population as a whole, in 

OBRA ’87, the Congress recognized that 

this requirement might not adequately 

protect the interests of persons with a 

developmental disability or chronic 

mental illness. In several States (or 

political subdivision), a particular 

agency may be designated under State 

law or regulation to serve as the 

exclusive source of case management 

services with respect to these 

populations. Therefore, section 4118(i) 

of OBRA ’87 amended section 1915(g)(1) 

of the Act to provide States with some 

latitude to restrict the availability of 

case management providers to these 

targeted groups to assure that case 

management providers are capable of 

ensuring that Medicaid eligible 

individuals will receive needed 

services. 

Consistent with section 1915(g) of the 

Act, as amended by section 4118(i) of 

OBRA ’87, when a target group consists 

solely of individuals with 

developmental disabilities or chronic 

mental illness, including a subgroup of 

those individuals (for example, children 

with mental illness), States may limit 

provider participation to specific 

persons or entities by setting forth 

qualifying criteria that assure the ability 

of the case managers to connect 

individuals with needed services. We 

note, however, that a State’s decision to 

restrict case managers for these 

populations does not impinge on 

targeted individuals’ rights to choose 

freely among those individuals or 

entities that the State has found 

qualified and eligible to provide 

targeted case management services. 

Absent a waiver to the contrary, those 

individuals also maintain their right to 

choose qualified providers of all other 

Medicaid services they receive. 

We are amending § 431.51 by revising 

paragraphs (c)(2) and (c)(3) and adding 

a new paragraph (c)(4) to afford States 

the option of limiting providers of case 

management services available to 

furnish services defined in § 440.169 for 

targeted groups that consist solely of 

individuals with developmental 

disabilities or chronic mental illness. 

This implements the statutory 

provisions at section 1915(g)(1) of the 

Act. 

B. Statewideness and Comparability 

Exception to Permitting Targeting—

§ 431.54 

While a State can provide case 

management services under its State 

plan to all Medicaid eligible 

individuals, it is not required to do so. 

Under section 1915(g)(1) of the Act, a 

State is not bound by the 

‘‘statewideness’’ requirement of section 

1902(a)(1) of the Act. (The 

‘‘statewideness’’ requirement of section 

1902(a)(1) of the Act provides, in part, 

that the provisions of a State plan be in 

effect in all political subdivisions of the 

State.) Thus, States may limit the 

provision of case management services 

to any defined location of the State (that 

is, city, county, community, etc.). 

Section 1915(g)(1) of the Act also 

permits States to target case 

management services to individuals 

with particular diseases or conditions, 

without regard to the ‘‘comparability’’

provision in section 1902(a)(10)(B) of 

the Act. (The ‘‘comparability’’ provision 

generally requires States to make 

Medicaid services available in the same 

amount, duration, and scope to all 

individuals within the categorically 

needy group or covered medically 

needy group. The comparability 

provision also requires that the 

Medicaid services available to any 

individual in a categorically needy 

group are not less in amount, duration, 

and scope than those Medicaid services 

available to an individual in a medically 

needy group.) Thus, a State may limit 

case management services to any 

specific identifiable group, such as 

individuals with human 

immunodeficiency virus (HIV), acquired 

immune deficiency syndrome (AIDS), 

AIDS-related conditions, or chronic 

mental illness. A State’s flexibility to 

target case management services to a 

specific group sets these services apart 

from most other services available under 

the Medicaid program. 

In identifying the groups eligible to 

receive targeted case management 

services, States are not required to 

distinguish eligible individuals by 

traditional Medicaid concepts of 

eligibility groups (that is, mandatory 

categorically needy, optional 

categorically needy, medically needy), 

although this avenue continues to be 

available to States, should they choose 

it. Instead, States may target case 

management services by age, type or 

degree of disability, illness or condition, 

or any other identifiable characteristic 

or combination of characteristics. There 

is no limit on the number of groups to 

whom case management services may 

be targeted. 

We note that the exception to the 

comparability requirement applies only 

to the provision of targeted case 

management services under section 

1915(g) of the Act. The comparability 

requirements of section 1902(a)(10)(B) 

of the Act continue to apply to all other 

Medicaid services for which an 

individual may be eligible, unless these 

services are subject to comparability 

exceptions in their own right. In other 

words, receipt of case management 

services does not in any way alter an 

individual’s eligibility to receive other 

services under the State plan. 

In § 431.54, we are revising paragraph 

(a) and adding a new paragraph (g) that 

includes targeted case management 

services as an exception to the 

comparability requirements in § 440.250 

and to the statewide operation 

requirement in § 431.50(b). This 

implements the targeting provisions at 

section 1915(g)(1) of the Act. 

C. Definition of Case Management 

Services—§ 440.169 

Consistent with the provisions of 

section 1915(g)(2) of the Act, as added 

by the DRA, we will define case 

management services in § 440.169(a) 

generally as services that assist 

individuals eligible under the plan in 

gaining access to needed medical, 

social, educational, and other services. 

The intent of case management is to 

assist the individual in gaining access to 

needed services, consistent with the 

requirements of the law and these 

regulations. ‘‘Other services’’ to which 

an individual eligible under the plan 

may gain access may include services 

such as housing and transportation. 

In § 440.169(b), we define targeted 

case management services as case 

management services furnished to 

particular defined target groups or in 

any defined locations without regard to 

requirements related to statewide 

provision of services or comparability. 

The integrated medical direction and 

management of services furnished to 

inpatients in a medical institution 

already includes case management 

activities. Therefore, including separate 

coverage for institutionalized 

individuals will in general, result in 

duplicative coverage and payment. 

Individuals with complex and chronic 

medical needs and individuals 

transitioning to a community setting 

after a significant period of time in a 

hospital, nursing facility, or 

intermediate care facility for individuals 

with mental retardation, however, 


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require case management that is beyond 

the scope of work of institutional 

discharge planners. These case 

management services facilitate the 

process of transitioning individuals 

from institutional care to community 

services. For example, individuals may 

require assistance locating community 

services. Thus, services we define as 

case management services for 

transitioning individuals from medical 

institutions to the community will be 

included as a separately covered case 

management service. 

In § 440.169(c), we define case 

management services for the 

transitioning of individuals from 

institutions to the community. 

Individuals (except individuals ages 22 

to 64 who reside in an institution for 

mental diseases (IMD) or individuals 

who are inmates of public institutions) 

may be considered to be transitioning to 

the community during the last 60 

consecutive days (or a shorter period 

specified by the State) of a covered, 

long-term, institutional stay that is 180 

consecutive days or longer in duration. 

For a covered, short-term, institutional 

stay of less than 180 consecutive days, 

individuals may be considered to be 

transitioning to the community during 

the last 14 days before discharge. We 

use these time requirements to 

distinguish case management services 

that are not within the scope of 

discharge planning activities from case 

management required for transitioning 

individuals with complex, chronic, 

medical needs to the community. As 

specified in § 441.18(a)(8)(vii)(D) and 

(E), FFP would not be payable until the 

date that an individual leaves the 

institution, is enrolled with the 

community case management provider, 

and receiving medically necessary 

services in a community setting. 

In sum, we are defining the case 

management benefit to include only 

services to individuals who are residing 

in a community setting or transitioning 

to a community setting following an 

institutional stay. 

Our proposed exclusion of FFP for 

case management services or targeted 

case management services provided to 

individuals under age 65 who reside in 

an IMD or to individuals involuntarily 

living in the secure custody of law 

enforcement, judicial, or penal systems 

is consistent with the statutory 

requirements in paragraphs (A) and (B) 

following paragraph section 1905(a)(28) 

of the Act. The statute indicates that 

‘‘except as otherwise provided in 

paragraph (16), such term [medical 

assistance] does not include (A) any 

such payments with respect to care or 

services for any individual who is an 

inmate of a public institution. An 

individual is considered to be living in 

secure custody if serving time for a 

criminal offense in, or confined 

involuntarily to, State or Federal 

prisons, local jails, detention facilities, 

or other penal facilities. A facility is a 

public institution when it is under the 

responsibility of a governmental unit or 

over which a governmental unit 

exercises administrative control. Case 

management services could be 

reimbursed on behalf of Medicaideligible individuals paroled, on 

probation, on home release, in foster 

care, in a group home, or other 

community placement, that are not part 

of the public institution system, when 

the services are identified due to a 

medical condition targeted under the 

State’s Plan, and are not used in the 

administration of other non-medical 

programs. 

At paragraph (B), following paragraph 

section 1905(a)(28) of the Act, the 

statute indicates that medical assistance 

does not include ‘‘any such payments 

with respect to care or services for any 

individual who has not attained 65 

years of age and who is a patient in an 

institution for mental diseases.’’

Paragraph (16) includes in the definition 

of ‘‘medical assistance’’ ‘‘* * * 

inpatient psychiatric hospital services 

for individuals under age 21 * * *’’. 

Section 1905(h) of the Act defines 

‘‘inpatient psychiatric hospital services’’

to include inpatient services in 

inpatient settings other than psychiatric 

hospitals, as specified by the Secretary 

in regulations. The Secretary has 

specified in regulations at § 440.160 that 

such settings include ‘‘a psychiatric 

facility which is accredited by the Joint 

Commission on Accreditation of 

Healthcare Organizations, the Council 

on Accreditation of Services for 

Families and Children, the Commission 

on Accreditation of Rehabilitation 

Facilities, or by any other accrediting 

organization with comparable 

standards, that is recognized by the 

State.’’ Thus, the term ‘‘inpatient 

hospital services for individuals under 

age 21’’ includes services furnished in 

accredited psychiatric residential 

treatment facilities, currently known as 

‘‘PRTFs,’’ providing inpatient 

psychiatric services for individuals 

under age 21 that are not hospitals. 

However, the statutory wording of the 

exception to the IMD exclusion makes it 

clear that medical assistance includes 

payment only for inpatient hospital 

services furnished to residents under 

age 21 in an inpatient psychiatric 

hospital or, by regulation, to residents 

under age 21 in an accredited PRTF. 

FFP does not extend to other services 

furnished to individuals under age 21 

residing in these settings. However, we 

are clarifying in this rule that FFP is 

available for community case 

management services to transition an 

individual receiving inpatient 

psychological services for individuals 

under age 21 (authorized under section 

1905(a)(16) of the Act), after discharge 

from a medical institution to the 

community. FFP would not be payable 

until the date that an individual leaves 

the institution, is enrolled with the 

community case management provider, 

and receiving medically necessary 

services in a community setting. 

At § 440.169(d), we specify that case 

management includes the following 

elements specified in section 

1915(g)(2)(A)(ii) of the Act: 

1. Assessment and periodic 

reassessment of an eligible individual to 

determine service needs, including 

activities that focus on needs 

identification, to determine the need for 

any medical, educational, social, or 

other services. Such assessment 

activities include: 

• Taking client history. 

• Identifying the needs of the 

individual and completing related 

documentation. 

• Gathering information from other 

sources such as family members, 

medical providers, social workers, and 

educators, if necessary, to form a 

complete assessment of the eligible 

individual. 

Because the statute defines case 

management services as those services 

that will assist individuals eligible 

under the plan in gaining access to 

needed medical, social, educational, 

and other services, we believe that an 

assessment of an individual’s needs 

should be comprehensive and address 

all needs of the individual. Thus, we are 

requiring in § 440.169(d)(1) that the 

assessment be comprehensive in order 

to address all areas of need, the 

individual’s strengths and preferences, 

and consider the individual’s physical 

and social environment. Performance of 

a comprehensive assessment can 

minimize the need for an individual to 

be covered under multiple case 

management plans and have multiple 

case managers, and can reduce the 

likelihood of service duplication and 

inefficiencies. 

Assessment includes periodic 

reassessment to determine whether an 

individual’s needs and/or preferences 

have changed. At this time, we will not 

put forth Federal standards for the 

frequency of reassessment, but 

recommend that face-to-face 

reassessments be conducted at least 


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annually or more frequently if changes 

occur in an individual’s condition. 

2. Development and periodic revision 

of a specific care plan based on the 

information collected through an 

assessment or reassessment, that 

specifies the goals and actions to 

address the medical, social, educational, 

and other services needed by the 

eligible individual, including activities 

such as ensuring the active participation 

of the eligible individual and working 

with the individual (or the individual’s 

authorized health care decision maker) 

and others to develop those goals and 

identify a course of action to respond to 

the assessed needs of the eligible 

individual. 

Because the assessment of an 

individual’s needs must be 

comprehensive, the care plan also must 

be comprehensive to address these 

needs. However, while the assessment 

and care plan must be comprehensive 

and address all of the individual’s 

needs, an individual may decline to 

receive services in the care plan to 

address these needs. Section 1902(a)(23) 

of the Act requires that recipients have 

free choice of qualified providers. This 

means that the individual cannot be 

required to receive services from a 

particular provider—or from any 

provider—if the individual chooses. If 

an individual declines services listed in 

the care plan, this must be documented 

in the individual’s case records. 

• Referral and related activities (such 

as scheduling appointments for the 

individual) to help an individual obtain 

needed services, including activities 

that help link eligible individuals with 

medical, social, educational providers, 

or other programs and services that are 

capable of providing needed services to 

address identified needs and achieve 

goals specified in the care plan. 

• Referral and related activities do 

not include providing transportation to 

the service to which the individual is 

referred, escorting the individual to the 

service, or providing child care so that 

an individual may access the service. 

The case management referral activity is 

completed once the referral and linkage 

has been made. It does not include the 

direct services, program, or activity to 

which the individual is linked. 

• Monitoring and follow-up activities, 

including activities and contacts that are 

necessary to ensure that the care plan is 

effectively implemented and adequately 

addresses the needs of the eligible 

individual. Monitoring and follow-up 

activities may be with the individual, 

family members, providers, or other 

entities or individuals. These activities 

may be conducted as frequently as 

necessary to help determine whether: 

—The services are being furnished in 

accordance with the individual’s care 

plan. 

—The services in the care plan are 

adequate to meet the needs of the 

individual. 

—There are changes in the needs or 

status of the individual. If there are 

changes in the needs or status of the 

individual, monitoring and follow-up 

activities include making necessary 

adjustments in the care plan and 

service arrangements with providers. 

Monitoring may involve either faceto-face or telephone contact. We are 

requiring that monitoring occur at a 

frequency established by the State, but 

no less frequently than annually. 

In the course of providing case 

management services, case managers 

can use a person-centered approach. A 

person-centered approach is a process 

used to develop, implement, and 

manage a care plan that attempts to 

fulfill the objectives and personal 

preferences of the individual or the legal 

representative of that individual. The 

process focuses on the person rather 

than the system; directly involves the 

person (or the legal representative of 

that individual) in the plan 

development, all aspects of 

implementation and management; and 

is tailored to meet individualized needs. 

Varying levels of person-centered 

planning, including choice not to 

participate, may be selected by the 

individual (or by the individual’s legal 

representative). The individual or legal 

representative can participate 

throughout all components of case 

management and direct who may 

participate in the care plan development 

process along with the case manager 

and the individual or the individual’s 

legal representative. 

Case management services must be 

provided by a single Medicaid case 

management provider. This provision is 

consistent with the requirement that the 

case management includes a 

comprehensive assessment and care 

plan. Thus, when an individual could 

be served under more than one targeted 

case management plan amendment 

because he falls within the scope of 

more than one target group (for example 

when the individual has both mental 

retardation and a mental illness and the 

State has target groups for both 

conditions), a decision must be made 

concerning the appropriate target group 

so that the individual will have one case 

management provider. That provider 

will be responsible for ensuring that the 

comprehensive assessment and care 

plan address the individual’s needs 

stemming from mental retardation and 

from the mental illness. In doing so, the 

case management provider must 

coordinate with service providers in 

both systems of care to ensure that the 

individual’s needs are met. We intend to 

provide for a delayed compliance date 

so that States will have a transition 

period of the lesser of 2 years or 1 year 

after the close of the first regular session 

of the State Legislature that begins after 

this regulation becomes final before we 

will take enforcement action on the 

requirement for one case manager to 

provide comprehensive services to 

individuals. We will be available to 

States as needed for technical assistance 

during this transition period. 

We note that section 1915(g)(2) of the 

Act specifically defines case 

management services in terms of 

services furnished to individuals who 

are eligible under the State plan. This 

provision reinforces basic program 

requirements found in section 1905(a) of 

the Act that require medical assistance 

to be furnished only to eligible 

individuals. An ‘‘eligible individual’’ is 

a person who is eligible for Medicaid 

and eligible for case management 

services (including targeted case 

management services) as defined in the 

Medicaid State plan, at the time the 

services are furnished. Case 

management as medical assistance 

under the State plan cannot be used to 

assist an individual, who has not yet 

been determined eligible for Medicaid, 

to apply for or obtain this eligibility. 

(Those activities may be an 

administrative expense of the State’s 

operation of its Medicaid program, 

rather than a medical assistance 

service.) 

While the provision of case 

management services to non-Medicaid 

eligible individuals cannot be covered, 

we are including a regulatory provision 

at § 440.169(e) to make clear that the 

effective case management of eligible 

individuals may require some contact 

with non-eligible individuals. For 

instance, in completing the assessment 

for a Medicaid eligible child for whom 

targeted case management is available, it 

may be appropriate for a case manager 

to interview the child’s parents and/or 

other family members who are not 

eligible for Medicaid, or who are not, 

themselves, part of a target population 

specified in the State plan. Contacts 

with family members that are for the 

purpose of helping the Medicaideligible individual access services can 

be covered by Medicaid. It also may be 

appropriate to have non-eligible family 

members involved in all components of 

case management because they may be 

able to help identify needs and supports 

to assist the eligible individual in 


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obtaining services, provide case 

managers with useful feedback, and 

alert case managers to changes in the 

individual’s needs. 

A case manager’s contacts with 

individuals who are not eligible for 

Medicaid, or who are not included in 

the group who receives targeted case 

management services, can be considered 

allowable activities, eligible for FFP, 

when the purpose of the contact is 

directly related to the management of 

the eligible individual’s care. However, 

these activities will not be considered 

allowable if they relate directly to the 

identification and management of the 

non-eligible, or non-targeted 

individual’s needs and care. Contacts 

that relate to the case management of 

non-eligible individuals, that is, 

assessment of their needs, referring 

them to service providers, and 

monitoring their progress, cannot be 

covered by Medicaid due to the fact 

they are not Medicaid eligible or not 

covered under the case management 

target population. If these other family 

members or other individuals also are 

Medicaid eligible and covered under a 

target group included in the State plan, 

Medicaid could pay for case 

management services furnished to them. 

In addition, these individuals could 

receive other medically necessary 

services for which they may qualify. 

D. Comparability Exception To Permit 

Targeting—§ 440.250 

We will revise § 440.250 by adding a 

new paragraph (r) to provide for an 

exception to the comparability 

requirements under § 440.240 for 

targeted case management services. 

E. Technical Change to Statement of 

Statutory Basis—§ 441.10 

In part 441, subpart A, we will revise 

§ 441.10 to add a new paragraph (m), 

which provides a statutory basis for the 

provision of case management and 

targeted case management services. 

F. Limitations on Case Management 

Services—§ 441.18 

At § 441.18(a)(1), we are specifying 

that, with the exception discussed above 

at § 431.51, individuals must have the 

free choice of any qualified provider. 

Section 9508 of COBRA amended 

section 1915(g) of the Act to require that 

there be no restriction on a recipient’s 

free choice of providers, in violation of 

section 1902(a)(23) of the Act. Based on 

COBRA’s legislative history, we believe 

the Congress intended that individuals 

receiving case management services 

under section 1915(g) of the Act not be 

locked into designated providers, 

whether for case management services, 

or for other services. (See H. Rept. No. 

453, 99th Cong., 1st Sess. 546 (1985).) 

Therefore, except as described in 

§ 441.18(b), individuals eligible to 

receive case management (or targeted 

case management) services must be free 

to choose their case management 

provider from among those that have 

qualified to participate in Medicaid and 

are willing to provide the services. 

States must establish qualifications 

for providers of case management 

services in the State plan. These 

qualifications relate to minimum age 

requirements, education, work 

experience, training, and other 

requirements, such as licensure or 

certification, which the State may 

establish. The Act does not set any 

minimum educational or professional 

qualifications for the provision of case 

management services. Therefore, States 

have flexibility to establish 

qualifications that are reasonably related 

to the demands of the Medicaid case 

management services to be furnished 

and the population being served. For 

example, it is reasonable to expect that 

the qualifications for case managers 

serving children who are ventilatordependent to be different than those 

qualifications for case managers serving 

persons with intellectual disabilities. 

While the case manager must possess 

the knowledge and skills to conduct a 

comprehensive assessment and to assist 

the individual or the individual’s legal 

representative with the development of 

a comprehensive care plan, this does 

not mean that the case manager must 

have experience with the program 

requirements of every medical, social, 

educational, or other program to which 

an individual may be referred; it means 

that the case manager must be familiar 

with the general needs of the population 

being served and must be able to 

connect and coordinate with medical, 

social, educational, and other programs 

that serve the population. If the case 

manager also provides other services 

under the plan, the State must ensure 

that a conflict of interest does not exist 

that will result in the case manager 

making self-referrals. 

We are also including at § 441.18(a)(2) 

and § 441.18(a)(3) provisions to ensure 

that the provision of case management 

is neither coerced nor a method to 

restrict access to care or free choice of 

qualified providers. The receipt of case 

management services must be at the 

option of individuals included in a 

specific target group. This requirement 

is also consistent with section 

1902(a)(19) of the Act. A recipient 

cannot be compelled to receive case 

management services for which he or 

she might be eligible. Requiring an 

individual to receive case management 

services against his or her will would 

not be in the best interest of the 

individual and, thus, will violate 

sections 1902(a)(19) and 1902(a)(23) of 

the Act. A State also cannot condition 

receipt of case management services on 

the receipt of other services since this 

also serves as a restriction on the 

individual’s access to case management 

services. 

Section 1915(g)(1) of the Act prohibits 

the use of case management services in 

any fashion that will restrict an 

individual’s access to other care and 

services furnished under the State plan, 

which will violate section 1902(a)(23) of 

the Act. The purpose of case 

management services authorized by 

section 1915(g) of the Act is to help an 

individual gain access to services, not 

hinder this access. Permitting case 

managers to function as gatekeepers 

under this optional State plan service 

will allow case managers to restrict 

access to services—that is, to the extent 

to which authorization may be denied, 

access also may be denied. Because this 

concept is contrary to the statutory 

definition of case management services, 

providers of case management services 

(including targeted case management 

services) furnished under this section 

are prohibited from serving as 

gatekeepers under Medicaid. (States 

may use a section 1915(b) waiver or 

primary care case management (PCCM) 

services under section 1905(a)(25) for 

this purpose.) Similarly, a State cannot 

require that an individual receive case 

management services as a prerequisite 

for receiving other Medicaid services. 

In § 441.18(a)(4), we require that the 

State’s plan provide that case 

management services will not duplicate 

payments made to public agencies or 

private entities under the State plan and 

other program authorities. In 

authorizing States to offer case 

management services, the Congress 

recognized that there was some 

potential for duplicate payments. This 

recognition led to an explicit statement 

in the legislative history of COBRA that 

prohibited the duplication of payments. 

(See H. Rept. No. 453, 99th Cong., 1st 

Sess. 546 (1985).) The Congress clarified 

its prohibition on the duplication of 

funding in section 8435 of the Technical 

and Miscellaneous Revenue Act of 1988. 

This provision prohibits the Secretary 

from denying approval of a case 

management State plan amendment on 

the basis that the State is required to 

provide those services under State law, 

or on the basis that the State had paid 

for those services from other nonFederal funds. In other words, the 

duplication of payment prohibition does 


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not preclude States from using Medicaid 

to pay for case management services 

that previously had been funded solely 

with State and/or local dollars. The 

amendment also specifies, however, that 

the Secretary is not required to make 

payment under Medicaid for case 

management services that are furnished 

without charge to users of the services. 

When an individual could be served 

under more than one targeted case 

management plan amendment because 

he falls within the scope of more than 

one target group, a decision must be 

made concerning the appropriate target 

group so that the individual will have 

one case manager responsible for his 

services and duplicate payment for the 

same purpose will not be made. 

While FFP would not be available for 

case management services that 

duplicates payments made under other 

program authorities, section 1903(c) of 

the Act provides an exception for 

medical assistance for covered Medicaid 

services, including case management 

services, furnished to a child with a 

disability because such services are 

included in an individualized education 

program or individualized family 

service plan. 

In section 441.18(a)(5), we would 

require case management services to be 

provided on a one-to-one basis to 

eligible individuals by one case 

manager. We are including this 

requirement to implement the 

provisions of section 1915(g)(2)(A)(ii) 

that sets forth a unified care planning 

process for case management to respond 

to the needs of eligible individuals 

based on a comprehensive assessment. 

The statute describes a step-by-step 

process, each component built upon the 

previous one, to ensure that the care 

plan is effectively implemented and 

adequately addresses all of the assessed 

needs of the eligible individual. Having 

one case manager is necessary to ensure 

accountability and coordination in 

assisting individuals in gaining access 

to services to address all components of 

assessed need. Fragmenting the service 

would reduce the quality of case 

management; the point of case 

management is to address the 

complexities of coordinated service 

delivery for individuals with medical 

needs. The case manager should be the 

focus for coordinating and overseeing 

the effectiveness of all providers and 

programs in responding to the assessed 

need. 

We are including § 441.18(a)(6) to 

prohibit providers of case management 

services from exercising the State 

Medicaid agency’s authority to 

authorize or deny the provision of other 

services under the plan. Although a 

State Medicaid agency may place great 

weight on the informed 

recommendation of a case manager, it 

must not rely solely on case 

management recommendations in 

making decisions about the medical 

necessity of other Medicaid services that 

the individual may receive. The 

decision to authorize the provision of a 

service must remain with the State 

Medicaid agency as required by 

§ 431.10(e). Costs related to these 

activities, such as prior authorization or 

determination of medical necessity, 

which are necessary for the proper and 

efficient administration of the Medicaid 

State plan, must be claimed as a direct 

administrative expense by the Medicaid 

agency and may not be included in the 

development of a case management rate. 

If a State plan provides for case 

management services (including 

targeted case management services), the 

State must require providers to maintain 

case records that document the 

information required by § 441.18(a)(7). 

These case records must document, for 

each individual receiving case 

management, the name of the 

individual; the dates of case 

management services; the name of the 

provider agency (if relevant) and person 

chosen by the individual to provide the 

case management services; the nature, 

content, units of case management 

services received and whether the goals 

specified in the care plan have been 

achieved; whether the individual has 

declined services in the care plan; 

timelines for providing services and 

reassessment; and the need for, and 

occurrences of, coordination with case 

managers of other programs. 

States that opt to furnish case 

management services must do so by 

amending their State plans in 

accordance with § 441.18(a)(8) and 

§ 441.18(a)(9). FFP is not available for 

case management as a medical 

assistance service under sections 

1905(a)(19) and 1915(g) of the Act in the 

absence of an approved amendment to 

the State’s Medicaid plan. A State’s 

amendment to its State plan must 

contain all information necessary for 

CMS to determine whether the plan can 

be approved to serve as a basis for FFP. 

Each amendment must—

• Specify whether case management 

will be targeted, and if so, define the 

targeted group (and/or subgroup); 

• Identify the geographic area to be 

served; 

• Describe the services to be 

furnished including types of 

monitoring; 

• Specify the frequency of 

assessments and monitoring and 

provide a justification for the 

frequencies (given that targeted groups 

may vary in their need for case 

management services); 

• Specify the qualifications of the 

service providers; 

• Specify the methodology under 

which case management providers will 

be paid and rates are calculated; 

• Specifies if case management 

services are being provided to Medicaideligible individuals who are in 

institutions to facilitate transitioning to 

the community. In this case, the 

amendment must specify if case 

management services are being provided 

to individuals with long-term stays of 

180 consecutive days or longer or to 

individuals with short-term stays of less 

than 180 consecutive days. 

Furthermore, when States choose to 

provide case management services to 

individuals in institutions to facilitate 

transitioning to the community, the 

State plan must specify the time period 

or other conditions under which case 

management may be provided in this 

manner. The time period that case 

management is provided in an 

institution must not exceed an 

individual’s length of stay. In addition, 

the State plan must specify the case 

management activities and include an 

assurance that these activities are 

coordinated with and do not duplicate 

institutional discharge planning; 

include an assurance that the amount, 

duration, and scope of the case 

management activities would be 

documented in an individual’s plan of 

care which includes case management 

activities prior to and post-discharge, to 

facilitate a successful transition to 

community living; specify that case 

management is only provided by and 

reimbursed to community case 

management providers; specify that FFP 

is only available to community 

providers and will not be claimed on 

behalf of an individual until the 

individual is discharged from the 

institution and enrolled in community 

services; and describe the system and 

process the State will use to monitor 

providers’ compliance with these 

provisions. 

• In addition, if the State plan 

provides for targeted case management, 

the State must submit a State plan 

amendment for each target group that 

will receive case management services. 

A separate amendment also must be 

submitted for each subgroup within a 

group if any of these elements differ for 

that subgroup. 

While a State has some flexibility to 

establish the methodology and rates it 

will use to reimburse providers of case 

management or targeted case 


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management services, a State cannot 

employ a methodology or rate that 

results in payment for a bundle of 

services. Per diem rates, weekly rates, 

and monthly rates represent a bundled 

payment methodology that is not 

consistent with section 1902(a)(30)(A) of 

the Act, which requires that States have 

methods and procedures to assure that 

payments are consistent with efficiency, 

economy, and quality of care. A 

bundled payment methodology exists 

when a State pays a single rate for more 

than one service furnished to an eligible 

individual during a fixed period of time. 

The payment is the same regardless of 

the number of services furnished or the 

specific costs, or otherwise available 

rates. Since these bundled (daily, 

weekly, or monthly) rates are not 

reflective of the actual types or numbers 

of services provided or the actual costs 

of providing the services, they are not 

accurate or reasonable payments and 

may result in higher payments than 

would be made on a fee-for-service basis 

for each individual service. A bundled 

rate is inconsistent with economy, since 

the rate is not designed to accurately 

reflect true costs or reasonable fee-forservice rates, and with efficiency, since 

it requires substantially more Federal 

oversight resources to establish the 

accuracy and reasonableness of State 

expenditures. We therefore expect that 

case management and targeted case 

management services reimbursed on a 

fee-for-service basis, as opposed to a 

capitated basis, will be reimbursed 

based on units of time. Because of the 

nature of case management, which can 

include contacts of brief duration, we 

believe that the most efficient and 

economical unit of service is a unit of 

15 minutes or less. Accordingly, we are 

requiring in § 441.18(a)(8)(vi) that the 

unit of service for case management and 

targeted case management services be 15 

minutes or less. 

In § 441.18(b) we require that, if a 

State limits qualified providers of case 

management services for target groups 

with developmental disability or 

chronic mental illness, in accordance 

with § 431.51(a)(4), the plan must 

identify the limitations being imposed 

on the providers and specify how these 

limitations enable providers to ensure 

that individuals within the target groups 

receive needed services. 

At § 441.18(c)(1), we specify that the 

case management benefit does not 

include, and FFP is not available for, 

activities that are an integral component 

of another covered Medicaid service. To 

include those activities as a separate 

benefit will result in duplicate coverage 

and payment. This activity would not be 

consistent with proper and efficient 

operation of the program. For example, 

when an individual receives services 

from a physician and the physician 

refers the individual to a home health 

agency for services, that referral is 

integral to the physician’s service and 

FFP will not be available for that 

activity as a case management service. 

Individuals participating in a 

managed care plan receive case 

management services as an integral part 

of the managed care services. This case 

management is for the purpose of 

managing the medical services provided 

by or through the plan and does not 

extend to helping an individual gain 

access to social, educational, and other 

services the individual may need. Thus, 

an individual receiving services through 

a managed care plan may also receive 

case management or targeted case 

management services when the 

individual is eligible for those services. 

For example, an individual with AIDS 

served by a managed care plan may also 

be served under a case management 

plan targeted to persons with AIDS/HIV. 

However, FFP is not available for case 

management of medical services that are 

also managed by the individual’s 

managed care plan. In this situation, it 

is expected that the Medicaid case 

manager would coordinate with the 

managed care plan as appropriate. At 

§ 441.18(c)(2) through § 441.18(c)(5), we 

set forth limitations authorized by the 

DRA on the case management benefit. 

The regulation text at § 441.18(c) 

includes the statutory principle set forth 

at section 1915(g)(2)(A)(iii) of the Act 

providing that the case management 

benefit does not include services that 

involve the direct delivery of underlying 

medical, educational, social, or other 

services to which an eligible individual 

has been referred. 

The statutory definition of case 

management established by the DRA 

draws a distinction between services 

that assist an individual in accessing 

needed services and the actual services 

to which access is gained. Case 

management services include only those 

activities that help an individual gain 

access to needed medical, social, 

educational, and other services. Case 

managers can assist individuals in 

gaining access to needed services, 

regardless of the funding source of the 

service to which the individual is 

referred. By including more than 

medical care, States can implement a 

holistic approach to the delivery of 

services by using case management to 

identify all of an individual’s care needs 

and coordinate access to services that 

address these needs. 

Case management does not include 

the actual direct services the individual 

obtains. For this reason, if a case 

manager provides a direct service, such 

as counseling, during the course of a 

case management visit, the direct 

service cannot be reimbursed as part of 

the case management service. This 

service may be covered under another 

Medicaid service category, such as 

rehabilitation services, if the service is 

covered under the State’s Medicaid 

program, the case management provider 

also is a qualified provider of that 

service, and the individual chooses to 

receive the service from the case 

manager. The performance of diagnostic 

tests also is a direct service. While 

diagnostic tests may provide 

information that inform the assessment 

and care development process, they do 

not constitute an assessment activity 

under section 1915(g)(2) of the Act that 

is covered under the case management 

benefit. These services, however, may 

be covered under another medical 

assistance category if provided in the 

State plan. Similarly, referral and 

related activities do not include the 

provision of transportation or escort 

services, nor do they include the 

provision of day care services so that an 

eligible individual with children can 

access needed services. These are direct 

services rather than coverable case 

management activities. 

The nature of the case management 

benefit to ‘‘assist eligible individuals to 

gain access to needed services’’ and the 

similarity of its 1985 definition to the 

purpose of other programs also has led 

many to confuse the Medicaid benefit 

with the actual administration of nonMedicaid programs. This is particularly 

true when a large number or percentage 

of the participants in these nonMedicaid programs also are eligible for 

Medicaid (and thus, potentially 

included in a target group eligible to 

receive targeted case management 

services). Concerns in this area have 

been raised through audits, the review 

of State plan amendments and by the 

Government Accountability Office 

(Report GAO–05–748, entitled ‘‘States 

Use of Contingency Fee Consultants to 

Maximize Federal Reimbursements 

Highlights Need for Improved Federal 

Oversight,’’ June 2005). The following 

are examples of targeted case 

management State plans that were 

inconsistent with Federal policy, 

resulting in excessive Federal Medicaid 

outlays. These examples illustrate the 

need for the specific definitions and 

guidance contained in this rule. 

• In one State, in fiscal year 2003, the 

State received an estimated $17 million 

in Federal reimbursement for targeted 

case management claims from juvenile 

justice and child welfare agencies of 


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which about $12 million was for 

services that were integral to nonMedicaid programs. 

• A State agency claimed $86.6 

million Federal share in fiscal years 

2002 and 2003 for unallowable targeted 

case management services furnished by 

a social services agency. Contrary to 

Federal requirements, the rates charged 

to Medicaid included social workers’

salary costs for child protection and 

welfare services. 

• In a CMS audit of a State’s counties 

that provided targeted case management 

services, 72 percent of encounters in 

one county were incorrectly claimed 

during a 1-year period. These 

encounters either did not meet the 

definition of targeted case management 

at section 1915(g)(2) of the Act or were 

claimed for clients that were ineligible 

for Medicaid. 

These past abuses and other 

occurrences of cost shifting from State 

foster care programs led to the reforms 

in case management and targeted case 

management made by section 6052 of 

the DRA. In the DRA, the Congress 

specifically precluded the use of the 

Medicaid case management benefit for 

the direct delivery of an underlying 

medical, social, educational, or other 

service funded by other programs. In 

addition, the Congress provided 

examples with respect to foster care of 

services that are excluded from case 

management services. The inclusion of 

examples for foster care does not limit 

the general prohibition on including the 

direct services of other programs from 

case management services under 

Medicaid as well. For example, the 

exclusion extends to—

• Child Welfare/Child Protective 

Services. States provide child protective 

services to children at risk of abuse or 

neglect. These services include 

investigation of allegations of abuse or 

neglect, identification of risk factors, 

provision of services to children and 

families in their own homes, monitoring 

of at-risk children, placement of 

children into foster care or adoptive 

homes, and evaluation of interventions. 

Child protective services includes 

development and oversight of a service 

plan for the child and family with the 

goal of moving the child toward 

permanency either through family 

reunification, adoption, or other 

permanent living arrangement. Because 

these services have their own 

goals’protecting vulnerable children and 

moving them toward a safe and stable 

living situation—we believe child 

protective services are the direct 

services of State child welfare programs 

and are not Medicaid case management. 

These activities of child welfare/child 

protective services are separate and 

apart from the Medicaid program. Thus, 

Medicaid case management services 

must not be used to fund the services of 

State child welfare/child protective 

services workers. Further, Medicaid 

may not pay for case management 

services furnished by contractors to the 

State child welfare/child protective 

services agency, even if they would 

otherwise be qualified Medicaid 

providers, because they are furnishing 

direct services of the programs of that 

agency. However, children receiving 

child welfare/child protective services 

may still qualify to receive Medicaid 

targeted case management services, 

when these services are provided 

according to the Medicaid State plan 

program by a qualified Medicaid 

provider who is not furnishing direct 

services of other programs. For example, 

a Medicaid eligible child with a mental 

disorder receiving child protective 

services may also qualify to receive case 

management services targeted to 

children with mental disorders. 

• Parole and Probation. States often 

use parole and probation as methods by 

which offenders can be eased back into 

the mainstream society. The 

supervision, counseling, and oversight 

required by these programs assist 

individuals in learning—or relearning—how to live within the legal 

bounds that society places on the 

behavior of its members. Both parole 

and probation are, however, functions of 

the administration of the justice system, 

and exist independent of the Medicaid 

program. These functions have their 

own goals (for example, conformance to 

law, adherence to conditions imposed 

by a court) which may coincide with 

goals of the Medicaid program, but exist 

separate and independent from it. 

Because probation and parole functions 

are necessary and integral components 

of the administration of another system, 

we believe that parole and probation 

functions are the direct services of 

corrections programs and are not 

Medicaid case management. Thus, we 

are prohibiting the use of parole or 

probation officers (or other employees 

or contractors of the justice system or 

court) as case management providers 

under Medicaid. Individuals who are on 

parole or probation may still qualify to 

receive Medicaid case management or 

targeted case management services for 

which they otherwise qualify (for 

example, a Medicaid-eligible individual 

with a traumatic brain injury could 

qualify to receive case management 

targeted to a group of persons with brain 

injuries). However, claims for Medicaid 

case management must not include the 

administration of the State’s parole or 

probation system. 

• Public Guardianship. Persons who 

have been determined to need 

guardians, because they are found 

incapable of handling their own affairs, 

may qualify for Medicaid case 

management when they are also part of 

a group to whom this service is 

provided (for example, persons with 

developmental disabilities). The public 

guardianship function, however, is also 

a State or locally administered activity 

that is independent of the Medicaid 

program. There is a fundamental 

difference between guardians (or 

conservators, or other similarly 

appointed individuals) and case 

managers. Case managers may assist 

decision-makers in reaching 

conclusions about the needs of an 

individual and the services that may 

best meet those needs, but they do not 

make these decisions on behalf of that 

individual. That is the function of a 

guardian (or conservator, or other 

similarly appointed individual). Case 

managers may, therefore, assist 

guardians and others, in enabling an 

individual to gain access to needed 

services, but they may not be used to 

replace or fund the function of this 

fundamentally non-Medicaid activity. 

• Special Education. The Individuals 

with Disabilities Education Act (IDEA) 

ensures every child with a disability has 

available a free appropriate public 

education (FAPE) that includes special 

education and related services. Part B of 

the IDEA requires the development and 

implementation of an individualized 

education program (IEP) that addresses 

the unique needs of each child aged 3 

through 21 with a disability. Part C of 

the IDEA requires the development and 

implementation of an individualized 

family service plan (IFSP) to address the 

unique developmental needs of an 

infant or toddler under 3 years of age 

with a disability. The IEP identifies the 

special education and related services 

needed for the child with a disability. 

An IFSP identifies the early intervention 

services and other services needed for 

an infant or toddler with a disability 

and his or her family. 

While some of the services identified 

on a child’s IEP (e.g., a related service 

such as physical therapy) may be 

covered under Medicaid, the 

development, review, and 

implementation of the IEP is part of a 

process that is required by Part B of the 

IDEA. This process should not be 

confused with Medicaid case 

management (or targeted case 

management) services, which also may 

be needed by the child. Similarly, under 

Part C, the IFSP may identify a need for 


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case management as well as other 

services and activities some of which 

may be covered under Medicaid and 

others that, while a necessary 

component of the Part C program, are 

not covered under Medicaid. One 

distinction between the IEP and IFSP is 

that the IFSP process for an infant or 

toddler with a disability under the age 

of three requires a service coordinator 

from the outset, some of whose 

activities may be Medicaid-funded case 

management (or targeted case 

management) services. Case 

management activities in this context 

could include taking the infant or 

toddler’s history, identifying service 

needs, and gathering information from 

other sources to form a comprehensive 

assessment. Case management would 

not include administrative functions 

that are purely IDEA functions such as 

scheduling IFSP team meetings, and 

providing the requisite prior written 

notice. 

An IEP or IFSP may identify the need 

for case management to coordinate 

access to a broad range of medical 

service providers from several 

disciplines, and also may identify needs 

for case management to gain access to 

non-medical services. As with other 

Medicaid covered services (such as 

physical, occupational, or speech 

therapy) identified on the IEP or IFSP, 

such case management services may be 

covered under Medicaid when 

furnished to a Medicaid-eligible child 

by a Medicaid qualified provider who 

assists in gaining access to and 

coordinating all needed services. To 

facilitate coordinated care, case 

management is a covered Medicaid 

service only when a single case manager 

comprehensively addresses all of the 

individual’s service needs. 

• While Medicaid funding could be 

available for the costs of a Medicaidqualified case manager who may be 

operating in a school or early 

intervention program in assisting IDEAeligible children in gaining access to 

needed services, including those 

identified in their IEP or IFSP, 

coordinating the provision of those 

services, and facilitating the timely 

delivery of services, Medicaid case 

management services must remain 

separate and apart from the 

administration of the IDEA programs. 

Medicaid may pay for those case 

management services where IDEA and 

Medicaid overlap, but not for 

administrative activities that are 

required by IDEA but not needed to 

assist individuals in gaining access to 

needed services. These would include 

activities such as writing an IEP or IFSP, 

providing required notices to parents, 

preparing for or conducting IEP or IFSP 

meetings, or scheduling or attending IEP 

or IFSP meetings. Section 504 of the 

Rehabilitation Act (RA) of 1973 requires 

school districts to provide to students 

with disabilities, appropriate 

educational services designed to meet 

the individual needs of such students to 

the same extent as the needs of students 

without disabilities are met; that is, to 

provide an equal opportunity for 

students with disabilities to participate 

in or benefit from educational aids, 

benefits, or services. We are clarifying in 

this regulation that FFP is not available 

for any case management activities not 

included in an IEP or IFSP but 

performed solely based on obligations 

under section 504 of the RA to ensure 

equal access to the educational program 

or activity. 

In accordance with section 1903(c) of 

the Act, nothing in this rule would 

prohibit or restrict payment for medical 

assistance for covered Medicaid services 

furnished to a child with a disability 

because such services are included in 

the child’s Individualized Education 

Program (IEP) or Individual Family 

Service Plan (IFSP). Likewise, payment 

for those services that are included in 

the IEP or IFSP would not be available 

when those services are not covered 

Medicaid services. In addition, 

Medicaid funds must not be used to 

replace or otherwise supplant funds 

used for activities related to the 

administration of the IDEA for infants 

and young children such as Child Find. 

Therefore, at § 441.18(c)(2), we state 

the general prohibition established by 

the DRA in section 1915(g)(2)(A)(iii) of 

the Act on including as Medicaid case 

management the direct delivery of 

services, as well as include a list of 

programs to which we are applying this 

prohibition in this regulation (parole 

and probation, public guardianship, 

special education, child welfare/child 

protective services, and foster care). We 

also include in § 441.18(c)(3) the 

specific statutory examples with respect 

to foster care—

• Research gathering and completion 

of documentation required by the foster 

care program; 

• Assessing adoption placements; 

• Recruiting or interviewing potential 

foster care parents; 

• Serving legal papers; 

• Home investigations; 

• Providing transportation; 

• Administering foster care subsidies; 

or 

• Making placement arrangements. 

These examples of direct delivery of 

foster care activities are all 

administrative activities that are integral 

to the delivery of services through the 

foster care program. For the reasons 

discussed above, since the statute cites 

these administrative activities as 

examples, rather than as an all-inclusive 

list, at § 441.18(c)(3), we are interpreting 

the exclusion of administrative 

activities to extend to all administrative 

activities integral to the administration 

of the foster care program. Other foster 

care activities subject to this payment 

exclusion include case management; 

referral to services; overseeing foster 

care placements; the training, 

supervision, and compensation of foster 

care parents; and attendance at court 

appearances related to foster care. Since 

the activities of foster care programs are 

separate and apart from the Medicaid 

program, Medicaid case management 

services must not be used to fund the 

services of foster care workers. The 

following is an example of how this 

payment exclusion will be applied: 

When a title IV–E eligible child in foster 

care is referred by a caseworker to the 

Medicaid program for medical services 

or mental health services covered by the 

Medicaid program, that administrative 

activity neither can be allocated and 

claimed to the Medicaid program as an 

administrative expense of the Medicaid 

program nor can those costs be claimed 

as a case management medical 

assistance service. The State may, 

instead, claim these costs under the title 

IV–E program to the extent allowable 

(see 45 CFR 1356.60(c)(2) and ACF 

Child Welfare Policy Manual Section 

8.1B). FFP for the medical services to 

which a Medicaid-eligible child who 

resides in foster care was referred would 

be available under the Medicaid 

program. 

Furthermore, case management 

activities included under therapeutic 

foster care programs will be subject to 

this payment exclusion since these 

activities are inherent to the foster care 

program. FFP for medical services to a 

Medicaid eligible child with medical 

care needs who resides in therapeutic 

foster care would still be available, 

provided all Medicaid requirements 

were met. 

At § 441.18(c)(4), we also apply this 

exclusion from the definition of case 

management the administrative 

activities integral to other non-medical 

programs, based on the general 

exclusion from case management of 

services delivered under other programs 

in section 1915(g)(2)(A)(iii) of the Act. 

At § 441.18(c)(4), we, thus, will 

exclude from the case management 

benefit the administrative activities of 

any other non-medical program, 

specifically including activities that 

constitute the administration of special 

education programs under IDEA, the 


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parole and probation functions 

conducted by or under the authority of 

State or local courts or other justice 

entities, legal services provided by any 

entity, child welfare/child protective 

services and activities concerning 

guardianship of a person or the person’s 

assets performed by or under the 

auspices of offices of public 

guardianship, or activities by any 

individual who has been appointed to 

perform guardianship, conservatorship 

(or other similar duties) on behalf of a 

Medicaid recipient by a court. 

It is important to note that the 

exclusion of Medicaid funding for case 

management activities that are used in 

the administration of other non-medical 

programs does not, in any way, 

compromise Medicaid recipients’

eligibility for medically necessary 

services under the plan, including 

medically necessary case management 

(and targeted case management) services 

that are not used to administer other 

programs. Thus, a Medicaid eligible 

child with a developmental disability, 

who receives foster care services, will 

qualify for Medicaid case management 

services targeted towards individuals 

with intellectual or other developmental 

disabilities that are not furnished 

through the foster care program. 

Similarly, a Medicaid-eligible child 

with chronic asthma receiving foster 

care services will receive medically 

necessary treatment services for that 

condition funded by Medicaid. Both of 

these children, who also receive foster 

care services, will continue to qualify 

for Medicaid-funded services. Thus, 

FFP will be available under the 

Medicaid program for medically 

necessary services. Similarly, an adult 

who tests positive for the human 

immunodeficiency virus (HIV) and is 

also on parole may continue to be 

eligible for medically necessary case 

management services targeted to 

individuals with HIV that are not 

furnished through a non-medical State 

program or for medically necessary 

treatment services. 

In § 441.18(c)(5)), we clarify that 

activities that meet the definition in 

§ 440.169 for case management services 

and under the approved State plan 

cannot be claimed as administrative 

activities, under § 433.15(b). 

Certain activities may be properly 

claimed as administrative costs when 

the activities are directly related to the 

proper and efficient administration of 

the Medicaid State plan. Sometimes 

these activities are commonly referred 

to, by States and others, as 

‘‘administrative case management’’; 

although, statute and regulation do not 

include such terminology. These 

administrative activities are performed 

by State agency staff and may involve 

facilitating access to and coordinating 

Medicaid program services. Some 

examples of these administrative 

activities include Medicaid eligibility 

determinations and re-determinations; 

Medicaid intake processing; Medicaid 

preadmission screening for inpatient 

care; prior authorization for Medicaid 

services; utilization review; and 

Medicaid outreach. These examples are 

not meant to be all-inclusive and CMS 

may make determinations regarding 

whether these or other activities are 

necessary for the proper and efficient 

administration of the State plan. 

A State may not claim costs for 

administrative activities for the proper 

and efficient administration of the State 

plan if the activities are an integral part 

or extension of a direct medical service. 

In addition, unlike case management 

claimed as a service cost which can 

extend to coordinating with programs 

outside of Medicaid, administrative 

activities are strictly related to 

enhancing access to Medicaid services. 

States may not claim, as 

administrative activities, the costs 

related to general public health 

initiatives, overhead costs, or operating 

costs of an agency whose purpose is 

other than the administration of the 

Medicaid program. Activities directed 

toward services not included under the 

Medicaid program, although these 

services may be valuable to Medicaid 

beneficiaries, are not necessary for the 

administration of the Medicaid program, 

and therefore are not allowable 

administrative costs. In addition, with 

regard to any allowable administrative 

claims, payment may only be made for 

the percentage of time spent which is 

actually attributable to Medicaid eligible 

individuals. 

The allocation methodology for costs 

claimed for the proper and efficient 

administration of the State plan must be 

specified in the State’s approved public 

assistance cost allocation plan in 

accordance with subpart E of 45 CFR 

part 95 and ASMB C–10. 

When the costs of any part of case 

management or targeted case 

management are reimbursable under 

another federally funded program, a 

State is directed by section 1915(g)(4)(B) 

of the Act to allocate costs which are 

reimbursable under the other Federal 

program in accordance with OMB 

Circular No. A–87 (or any related or 

successor guidance or regulations 

regarding allocation of costs among 

federally funded programs) under an 

approved cost allocation program. (OMB 

Circular No. A–87, which details the 

cost principles for State, local, and 

Indian Tribal Governments for the 

administration of Federal awards, 

pertains to all Federal agencies whose 

programs, including Medicaid, are 

administered by a State public 

assistance agency.) This requirement is 

set forth in § 441.18(d). OMB Circular 

A–87, Attachment A, paragraph C.3.a 

requires allocation of costs among 

benefiting cost objectives (programs). 

IV. Response to Comments 

Because of the large number of public 

comments we normally receive on 

Federal Register documents, we are not 

able to acknowledge or respond to them 

individually. We will consider all 

comments we receive by the date and 

time specified in the DATES section of 

this preamble, and, when we proceed 

with a subsequent document, we will 

respond to the comments in the 

preamble to that document. 

V. Waiver of Proposed Rulemaking 

Ordinarily, we will publish a notice of 

proposed rulemaking and afford a 

period for public comments in 

accordance with the provisions of the 

Administrative Procedure Act, 5 U.S.C. 

553. Further, we generally provide for 

final rules to be effective no sooner than 

30 days after the date of publication 

unless we find good cause to waive the 

delay. Section 6052(b) of the DRA 

authorizes the Secretary to promulgate 

regulations to carry out the new 

statutory provisions at section 

1915(g)(2) of the Act ‘‘which may be 

effective and final immediately on an 

interim basis as of the date of the 

interim final regulation.’’ In light of the 

importance of clarifying the definition 

of case management and ensuring the 

fiscal integrity of the Medicaid program, 

we have elected to use this authority to 

issue this rule as an interim final rule 

with comment period. Section 6052(b) 

of the DRA further provides that there 

must be a period for receipt of public 

comments after the date of publication 

of an interim final rule, and that the 

Secretary may revise the regulation after 

completion of the period of public 

comment. We are complying with this 

requirement to provide for a period of 

public comment. 

This rule has been determined to be 

a major rule as defined in the 

Congressional Review Act, 5 U.S.C. 

§ 804(2). These regulations are effective 

March 3, 2008. 

VI. Collection of Information 

Requirements 

Under the Paperwork Reduction Act 

(PRA) of 1995, we are required to 

provide 30-day notice in the Federal 

Register and solicit public comment 


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before a collection of information 

requirement is submitted to the Office of 

Management and Budget (OMB) for 

review and approval. In order to fairly 

evaluate whether an information 

collection should be approved by OMB, 

section 3506(c)(2)(A) of the PRA of 1995 

requires that we solicit comment on the 

following issues: 

• The need for the information 

collection and its usefulness in carrying 

out the proper functions of our agency. 

• The accuracy of our estimate of the 

information collection burden. 

• The quality, utility, and clarity of 

the information to be collected. 

• Recommendations to minimize the 

information collection burden on the 

affected public, including automated 

collection techniques. 

We are soliciting public comment on 

each of these issues for the following 

sections of this document that contain 

information collection requirements 

(ICRs): 

Section 440.169 Case Management 

Services 

Section 440.169(d) states that case 

managers assist eligible individuals by 

providing services such as taking client 

history; identifying the needs of the 

individual, and completing related 

documentation; and gathering 

information from other sources such as 

family members, medical providers, 

social workers, and educators (if 

necessary) to form a complete 

assessment of the eligible individual. 

The case manager must then develop a 

specific care plan based on the 

information collected through the 

assessment. 

The burden associated with this 

requirement is the time and effort put 

forth by the case manager to gather the 

information and develop a specific care 

plan. While this requirement is subject 

to the PRA, we believe this requirement 

meets the requirements of 5 CFR 

1320.3(b)(2), and as such, the burden 

associated with this requirement is 

exempt from the PRA. 

Section 441.18 Case Management 

Services 

Section 441.18(a) requires that if a 

State plan provides for case 

management services, as defined in 

§ 440.169, the State must require 

providers to maintain case records that 

document for all individuals receiving 

case management the name of the 

individual; the date of the case 

management service; the name of the 

provider agency and the person 

providing the case management service; 

and the nature, content, and units of 

case management service. Details of 

what the case records must include are 

located at § 441.18(a)(7). 

The burden associated with this 

requirement is the time and effort 

required for a provider to maintain case 

records. While this requirement is 

subject to the PRA, we believe this 

requirement meets the requirements of 5 

CFR 1320.3(b)(2), and as such, the 

burden associated with this requirement 

is exempt from the PRA. 

If you comment on these information 

collection and record keeping 

requirements, please mail copies 

directly to the following: 

Centers for Medicare & Medicaid 

Services, Office of Strategic 

Operations and Regulatory Affairs, 

Division of Regulations Development, 

Attn.: Melissa Musotto, CMS–2237–

IFC, Room C5–14–03, 7500 Security 

Boulevard, Baltimore, MD 21244–

1850. 

Office of Information and Regulatory 

Affairs, Office of Management and 

Budget, Attn.: Katherine Astrich, CMS 

Desk Officer, CMS–2237–IFC, 

katherine_astrich@omb.eop.gov. Fax 

(202) 395–6974. 

VII. Regulatory Impact Analysis 

[If you choose to comment on issues 

in this section, please indicate the 

caption ‘‘Regulatory Impact’’ at the 

beginning of your comments.] 

We have examined the impacts of this 

rule as required by Executive Order 

12866 (September 1993, Regulatory 

Planning and Review), the Regulatory 

Flexibility Act (RFA) (September 19, 

1980, Pub. L. 96–354), section 1102(b) of 

the Social Security Act, the Unfunded 

Mandates Reform Act of 1995 (Pub. L. 

104–4), and Executive Order 13132. 

Executive Order 12866 (as amended 

by Executive Order 13258, which 

merely reassigns responsibility of 

duties) directs agencies to assess all 

costs and benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and 

equity). A regulatory impact analysis 

(RIA) must be prepared for major rules 

with economically significant effects 

($100 million or more in any 1 year). 

Section 804(2) of title 5, United States 

Code (as added by section 251 of Pub. 

L. 104–121), specifies that a ‘‘major 

rule’’ is any rule that the Office of 

Management and Budget finds is likely 

to result in—

• An annual effect on the economy of 

$100 million or more; 

• A major increase in costs or prices 

for consumers, individual industries, 

Federal, State, or local government 

agencies, or geographic regions; or 

• Significant adverse effects on 

competition, employment, investment 

productivity, innovation, or on the 

ability of United States based 

enterprises to compete with foreign 

based enterprises in domestic and 

export markets. 

The RFA requires agencies to analyze 

options for regulatory relief of small 

businesses. For purposes of the RFA, 

small entities include small businesses, 

nonprofit organizations, and small 

governmental jurisdictions. Most 

hospitals and most other providers and 

suppliers are small entities, either by 

nonprofit status or by having revenues 

of $6 million to $29 million in any 1 

year. This rule affects only States 

directly. For purposes of the RFA, we do 

not consider States or individuals to be 

small entities. Therefore, the Secretary 

certifies that this rule will not have a 

significant economic impact on a 

substantial number of small entities. 

Section 1915(g) of the Act provides 

for Medicaid coverage of a new optional 

State plan service, case management 

services, and permits those services to 

be targeted. This regulation incorporates 

that statutory provision in the Federal 

regulations. 

Under section 1915(g) of the Act, 

States may, without securing a waiver, 

furnish case management services, or 

targeted case management services to 

specified Medicaid groups on a 

statewide basis or in a particular 

geographic area of the State by 

requesting approval of a State plan 

amendment. If a State elects to furnish 

case management services (or targeted 

case management services), FFP will be 

available to the State to assist 

individuals receiving Medicaid in 

gaining access to needed medical, 

social, educational, and other services. 

Thus, the Medicaid case management 

service adds value to services that 

would otherwise be received through 

Medicaid and other programs in the 

absence of Medicaid case management 

services. For example, case management 

services provided to women with a high 

risk pregnancy can prevent low birth 

weight infants and case management of 

chronic problems can reduce hospital 

emergency room visits. Individuals 

retain the right to select among qualified 

medical providers of case management 

(or targeted case management) services. 

Ambiguity concerning what services 

are reimbursable as case management 

and targeted case management services 

has resulted in questionable cost 

shifting of services onto Medicaid, 

which increases costs. Although the 

Medicaid program will continue to pay 


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for case management and targeted case 

management services, this regulation 

clarifies and conforms to current 

statutory requirements of the regulatory 

definition. In fiscal year 2006, Federal 

and State expenditures for targeted case 

management services were $2,842 

million. Table 1 contains the Federal 

and State expenditures for targeted case 

management. These amounts do not 

reflect changes that may have occurred 

in other services during the projection 

period as a result of the provision of 

case management services. 

TABLE 1.—MEDICAID TARGETED CASE MANAGEMENT SPENDING

2001 2002 2003 2004 2005 2006 

Federal ............................................................................. 1,176 1,384 1,641 1,628 1,620 1,643 

State ................................................................................. 837 1,020 1,118 1,092 1,185 1,199 

Total .......................................................................... 2,012 2,405 2,759 2,720 2,805 2,842 

Source: CMS–64 Data 

Data is reported by Federal fiscal year 

All amounts in millions of dollars 

Section 6052 of DRA 2005 specifies 

that FFP is only available for case 

management services or targeted case 

management services if there are no 

other third parties liable to pay for those 

services, including as reimbursement 

under a medical, social, educational, or 

other program. Due to this regulation, it 

is estimated that Federal Medicaid 

spending on case management and 

targeted case management services will 

be reduced by $1,280 million between 

FY 2008 and FY 2012. This reduction in 

spending is expected to occur as case 

management services spending that 

could be paid for by other third parties 

or other Federal programs, but received 

by the States as FFP, will no longer be 

reimbursable. 

Due to this regulation, the Assistant 

Secretary for Resources and Technology 

estimates that Federal spending on title 

IV-E foster care services will increase by 

$369 million between FY 2008 and FY 

2012. This increase is expected to occur 

because State foster care program 

expenditures on case management will 

no longer be reimbursed as Medicaid 

expenditures and would instead need to 

be paid by other Federal programs or 

payment sources. 

We are unable to estimate additional 

net costs/savings that might result from 

case management under section 1915(g) 

of the Act for the following reasons. The 

use of case management services may 

result in increased access to other 

services, including those covered under 

Medicaid. Conversely, provision of case 

management services may work to lower 

both Federal and State costs by 

encouraging the use of cost-effective 

medical care through transitioning 

individuals out of institutions, referrals 

to qualified providers, and by 

discouraging inappropriate utilization of 

costly services such as emergency room 

care for routine procedures. The use of 

case management services also may 

eliminate unnecessary care and overutilization of services. Further, by 

facilitating early treatment, the use of 

case management services can preclude 

the need for more costly ‘‘last resort’’

treatment alternatives. 

Because it is estimated that Federal 

Medicaid spending on case management 

and targeted case management services 

will be reduced by $1,280 million 

between FY 2008 and FY 2012 (and thus 

the annual effect on the economy is 

$100 million or more), we have 

determined that this interim final rule 

with comment period is a major rule 

under Executive Order 12866. The 

Secretary certifies that this rule will not 

have a significant economic impact on 

a substantial number of small entities. 

In addition, section 1102(b) of the Act 

requires us to prepare a regulatory 

impact analysis if a rule may have a 

significant impact on the operations of 

a substantial number of small rural 

hospitals. This analysis must conform to 

the provisions of section 604 of the 

RFA. For purposes of section 1102(b) of 

the Act, we define a small rural hospital 

as a hospital that is located outside of 

a Core-Based Statistical Area and has 

fewer than 100 beds. We have 

determined that this interim final rule 

with comment period will not have a 

significant effect on the operations of a 

substantial number of small rural 

hospitals because there will be no 

change in the administration of the 

provisions related to small rural 

hospitals. Therefore, the Secretary 

certifies that this rule will not have a 

significant impact on small rural 

hospitals and, accordingly, we are not 

preparing an analysis for section 1102(b) 

of the Act. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 also 

requires that agencies assess anticipated 

costs and benefits before issuing any 

rule whose mandates require spending 

in any 1 year of $100 million in 1995 

dollars, updated annually for inflation. 

That threshold level is currently 

approximately $120 million. This 

interim final rule with comment period 

has no consequential effect on State, 

local, or tribal governments or on the 

private sector. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

requirement costs on State and local 

governments, preempts State law, or 

otherwise has Federalism implications. 

Since this regulation does not impose 

any costs on State or local governments, 

the requirements of E.O. 13132 are not 

applicable. 

Accounting Statement 

As required by OMB Circular A–4 

(available at http:// 

www.whitehouse.gov/omb/circulars/

a004/a-4.pdf), in table 2, we have 

prepared an accounting statement 

showing the classification of the savings 

associated with the provisions of this 

interim final rule with comment period. 

Tables 2 and 3 provide our best estimate 

of the savings to the Federal 

Government as a result of the changes 

presented in this interim final rule with 

comment period based on the estimate 

in the President’s FY 2008 Budget that 

Federal Medicaid spending on case 

management and targeted case 

management services will be reduced by 

approximately $210 million in FY 2008 

and will be reduced by $1,280 million 

between FY 2008 and FY 2012. All 

savings are classified as transfers from 

the State Government to Federal 

Government. 


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Federal Register / Vol. 72, No. 232 / Tuesday, December 4, 2007 / Rules and Regulations 68091 

TABLE 2.—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED SAVINGS, FROM FY 2008 TO FY 2012 (IN

MILLIONS) 

Category Primary estimates Year dollar 

Units discount rate 

(percent) 

Period covered 

Federal Annualized Monetized (millions/year) ................................................................ $252.6 

254.5 

....................

2008 

....................

2008 

7 

....................

....................

2008–2012 

....................

2008–2012 

256.0 .................... .................... ....................

.................... 2008 0 2008–2012 

From Whom to Whom? State Government to Federal Government 

TABLE 3.—ANNUAL DISCOUNTED TRANSFERS—CASE MANAGEMENT RULE (IN MILLIONS) 

Discount rate 

(percent) 2008 2009 2010 2011 2012 Total 

0 ............................................................................................................... 210 230 250 280 310 1,280 

3 ............................................................................................................... 204 217 229 249 267 1,166 

7 ............................................................................................................... 196 201 204 214 221 1,036 

In accordance with the provisions of 

Executive Order 12866, this regulation 

was reviewed by the Office of 

Management and Budget. 

List of Subjects 

42 CFR Part 431 

Grant programs-health, Health 

facilities, Medicaid, Privacy, Reporting 

and recordkeeping requirements. 

42 CFR Part 440 

Grant programs-health, Medicaid. 

42 CFR Part 441 

Family planning, Grant programshealth, Infants and children, Medicaid, 

Penalties, Prescription drugs, Reporting 

and recordkeeping requirements. 

■ For the reasons set forth in the 

preamble, the Centers for Medicare & 

Medicaid Services amends 42 CFR 

chapter IV, subchapter C as set forth 

below: 

PART 431—STATE ORGANIZATION 

AND GENERAL ADMINISTRATION 

■ 1. The authority citation for part 431 

continues to read as follows: 

Authority: Sec. 1102 of the Social Security 

Act (42 U.S.C. 1302). 

■ 2. Section 431.51 is amended by—

■ A. Republishing the introductory text 

to paragraph (c). 

■ B. Removing the colon and the word 

‘‘or’’ at the end of paragraph (c)(2) and 

adding a semicolon and the word ‘‘or’’

in its place. 

■ C. Removing the period at the end of 

paragraph (c)(3) and adding in its place 

a semicolon and the word ‘‘or’’. 

■ D. Adding a new paragraph (c)(4). 

The revisions read as follows: 

§ 431.51 Free choice of providers. 

* * * * * 

(c) Exceptions. Paragraph (b) of this 

section does not prohibit the agency 

from—

* * * * * 

(4) Limiting the providers who are 

available to furnish targeted case 

management services defined in 

§ 440.169 of this chapter to target groups 

that consist solely of individuals with 

developmental disabilities or with 

chronic mental illness. This limitation 

may only be permitted so that the 

providers of case management services 

for eligible individuals with 

developmental disabilities or with 

chronic mental illness are capable of 

ensuring that those individuals receive 

needed services. 

* * * * * 

■ 3. Section 431.54 is amended by—

■ A. Revising paragraph (a). 

■ B. Adding a new paragraph (g). 

The revision and addition read as 

follows: 

§ 431.54 Exceptions to certain State plan 

requirements. 

(a) Statutory basis—(1) Section 

1915(a) of the Act provides that a State 

shall not be deemed to be out of 

compliance with the requirements of 

sections 1902(a)(1), (10), or (23) of the 

Act solely because it has elected any of 

the exceptions set forth in paragraphs 

(b) and (d) through (f) of this section. 

(2) Section 1915(g) of the Act provides 

that a State may provide, as medical 

assistance, targeted case management 

services under the plan without regard 

to the requirements of sections 

1902(a)(1) and 1902(a)(10)(B) of the Act. 

* * * * * 

(g) Targeted case management 

services. The requirements of 

§ 431.50(b) relating to the statewide 

operation of a State plan and § 440.240 

of this chapter related to comparability 

of services do not apply with respect to 

targeted case management services 

defined in § 440.169 of this chapter. 

PART 440—SERVICES: GENERAL 

PROVISIONS 

■ 6. The authority citation for part 440 

continues to read as follows: 

Authority: Sec. 1102 of the Social Security 

Act (42 U.S.C. 1302). 

■ 7. A new § 440.169 is added to subpart 

A to read as follows: 

§ 440.169 Case management services. 

(a) Case management services means 

services furnished to assist individuals, 

eligible under the State plan who reside 

in a community setting or are 

transitioning to a community setting, in 

gaining access to needed medical, 

social, educational, and other services, 

in accordance with § 441.18 of this 

chapter. 

(b) Targeted case management 

services means case management 

services furnished without regard to the 

requirements of § 431.50(b) of this 

chapter (related to statewide provision 

of services) and § 440.240 (related to 

comparability). Targeted case 

management services may be offered to 

individuals in any defined location of 

the State or to individuals within 

targeted groups specified in the State 

plan. 

(c) For purposes of case management 

services, individuals (except individuals 

between ages 22 and 64 in an IMD or 


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68092 Federal Register / Vol. 72, No. 232 / Tuesday, December 4, 2007 / Rules and Regulations 

individuals who are inmates of public 

institutions) may be considered to be 

transitioning to a community setting 

during the last 60 consecutive days (or 

a shorter time period as specified by the 

State) of a covered long-term, 

institutional stay that is 180 consecutive 

days or longer in duration. For a 

covered, short-term, institutional stay of 

less than 180 consecutive days, 

individuals may be considered to be 

transitioning to a community setting 

during the last 14 days prior to 

discharge. 

(d) The assistance that case managers 

provide in assisting eligible individuals 

obtain services includes—

(1) Comprehensive assessment and 

periodic reassessment of individual 

needs, to determine the need for any 

medical, educational, social, or other 

services. These assessment activities 

include the following: 

(i) Taking client history. 

(ii) Identifying the needs of the 

individual, and completing related 

documentation. 

(iii) Gathering information from other 

sources, such as family members, 

medical providers, social workers, and 

educators (if necessary) to form a 

complete assessment of the eligible 

individual. 

(2) Development (and periodic 

revision) of a specific care plan based on 

the information collected through the 

assessment, that includes the following: 

(i) Specifies the goals and actions to 

address the medical, social, educational, 

and other services needed by the 

eligible individual. 

(ii) Includes activities such as 

ensuring the active participation of the 

eligible individual and working with the 

individual (or the individual’s 

authorized health care decision maker) 

and others to develop those goals. 

(iii) Identifies a course of action to 

respond to the assessed needs of the 

eligible individual. 

(3) Referral and related activities 

(such as scheduling appointments for 

the individual) to help the eligible 

individual obtain needed services, 

including activities that help link the 

individual with medical, social, and 

educational providers or other programs 

and services that are capable of 

providing needed services to address 

identified needs and achieve goals 

specified in the care plan. 

(4) Monitoring and follow-up 

activities, including activities and 

contacts that are necessary to ensure 

that the care plan is effectively 

implemented and adequately addresses 

the needs of the eligible individual and 

which may be with the individual, 

family members, service providers, or 

other entities or individuals and 

conducted as frequently as necessary, 

and including at least one annual 

monitoring, to help determine whether 

the following conditions are met: 

(i) Services are being furnished in 

accordance with the individual’s care 

plan. 

(ii) Services in the care plan are 

adequate. 

(iii) There are changes in the needs or 

status of the eligible individual. 

Monitoring and follow-up activities 

include making necessary adjustments 

in the care plan and service 

arrangements with providers. 

(e) Case management may include 

contacts with non-eligible individuals 

that are directly related to the 

identification of the eligible individual’s 

needs and care, for the purposes of 

helping the eligible individual access 

services, identifying needs and supports 

to assist the eligible individual in 

obtaining services, providing case 

managers with useful feedback, and 

alerting case managers to changes in the 

eligible individual’s needs. 

§ 440.250 [Amended] 

■ 8. Section 440.250 is amended by—

■ A. Adding and reserving paragraph 

(q). 

■ B. Adding a new paragraph (r). 

The addition reads as follows: 

§ 440.250 Limits on comparability of 

services. 

* * * * * 

(q) [Reserved] 

(r) If specified in the plan, targeted 

case management services may be 

limited to the following: 

(1) Certain geographic areas within a 

State, without regard to the statewide 

requirements in § 431.50 of this chapter. 

(2) Targeted groups specified by the 

State. 

PART 441—SERVICES: 

REQUIREMENTS AND LIMITS 

APPLICABLE TO SPECIFIC SERVICES 

■ 9. The authority citation for part 441 

continues to read as follows: 

Authority: Sec. 1102 of the Social Security 

Act (42 U.S.C. 1302). 

■ 2. Section 441.10 is amended by 

adding a new paragraph (m) to read as 

follows: 

§ 441.10 Basis. 

* * * * * 

(m) Section 1905(a)(19) and 1915(g) of 

the Act for case management services as 

set forth in § 441.18 and section 8435 of 

the Technical and Miscellaneous 

Revenue Act of 1988. 

■ 10. A new § 441.18 is added to subpart 

A to read as follows: 

§ 441.18 Case management services. 

(a) If a State plan provides for case 

management services (including 

targeted case management services), as 

defined in § 440.169 of this chapter, the 

State must meet the following 

requirements: 

(1) Allow individuals the free choice 

of any qualified Medicaid provider 

within the specified geographic area 

identified in the plan when obtaining 

case management services, in 

accordance with § 431.51 of this 

chapter, except as specified in 

paragraph (b) of this section. 

(2) Not use case management 

(including targeted case management) 

services to restrict an individual’s 

access to other services under the plan. 

(3) Not compel an individual to 

receive case management services, 

condition receipt of case management 

(or targeted case management) services 

on the receipt of other Medicaid 

services, or condition receipt of other 

Medicaid services on receipt of case 

management (or targeted case 

management) services. 

(4) Indicate in the plan that case 

management services provided in 

accordance with section 1915(g) of the 

Act will not duplicate payments made 

to public agencies or private entities 

under the State plan and other program 

authorities; 

(5) Provide comprehensive case 

management services, on a one-to-one 

basis, to an individual through one case 

manager. 

(6) Prohibit providers of case 

management services from exercising 

the agency’s authority to authorize or 

deny the provision of other services 

under the plan. 

(7) Require providers to maintain case 

records that document for all 

individuals receiving case management 

as follows: 

(i) The name of the individual. 

(ii) The dates of the case management 

services. 

(iii) The name of the provider agency 

(if relevant) and the person providing 

the case management service. 

(iv) The nature, content, units of the 

case management services received and 

whether goals specified in the care plan 

have been achieved. 

(v) Whether the individual has 

declined services in the care plan. 

(vi) The need for, and occurrences of, 

coordination with other case managers. 

(vii) A timeline for obtaining needed 

services. 

(viii) A timeline for reevaluation of 

the plan. 


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Federal Register / Vol. 72, No. 232 / Tuesday, December 4, 2007 / Rules and Regulations 68093 

(8) Include a separate plan 

amendment for each group receiving 

case management services that includes 

the following: 

(i) Defines the group (and any 

subgroups within the group) eligible to 

receive the case management services. 

(ii) Identifies the geographic area to be 

served. 

(iii) Describes the case management 

services furnished, including the types 

of monitoring. 

(iv) Specifies the frequency of 

assessments and monitoring and 

provides a justification for those 

frequencies. 

(v) Specifies provider qualifications 

that are reasonably related to the 

population being served and the case 

management services furnished. 

(vi) Specifies the methodology under 

which case management providers will 

be paid and rates are calculated that 

employs a unit of service that does not 

exceed 15 minutes. 

(vii) Specifies if case management 

services are being provided to Medicaideligible individuals who are in 

institutions (except individuals between 

ages 22 and 64 who are served in IMDs 

or individuals who are inmates of 

public institutions). 

(viii) Specifies if case management 

services are being provided to 

individuals with long-term stays of 180 

consecutive days or longer or to 

individuals with short-term stays of less 

than 180 consecutive days. When States 

choose to provide case management 

services to individuals in institutions to 

facilitate transition to the community, 

the State plan must include the 

following requirements: 

(A) Specify the time period or other 

conditions under which case 

management may be provided in this 

manner. The time period that case 

management is provided in an 

institution must not exceed an 

individual’s length of stay; 

(B) Specify the case management 

activities and include an assurance that 

these activities are coordinated with and 

do not duplicate institutional discharge 

planning; 

(C) Include an assurance that the 

amount, duration, and scope of the case 

management activities would be 

documented in an individual’s plan of 

care which includes case management 

activities prior to and post-discharge, to 

facilitate a successful transition to 

community living; and 

(D) Specify that case management is 

only provided by and reimbursed to 

community case management providers; 

(E) Specify that Federal Financial 

Participation is only available to 

community providers and will not be 

claimed on behalf of an individual until 

discharge from the medical institution 

and enrollment in community services; 

and 

(F) Describe the system and process 

the State will use to monitor providers’

compliance with these provisions. 

(9) Include a separate plan 

amendment for each subgroup within a 

group if any of the following differs 

among the subgroups: 

(i) The case management services to 

be furnished; 

(ii) The qualifications of case 

management providers; or 

(iii) The methodology under which 

case management providers will be 

paid. 

(b) If the State limits qualified 

providers of case management services 

for target groups of individuals with 

developmental disability or chronic 

mental illness, in accordance with 

§ 431.51(a)(4) of this chapter, the plan 

must identify any limitations to be 

imposed on the providers and specify 

how these limitations enable providers 

to ensure that individuals within the 

target groups receive needed services. 

(c) Case management does not 

include, and FFP is not available in 

expenditures for, services defined in 

§ 440.169 of this chapter when any of 

the following conditions exist: 

(1) Case management activities are an 

integral component of another covered 

Medicaid service. 

(2) The case management activities 

constitute the direct delivery of 

underlying medical, educational, social, 

or other services to which an eligible 

individual has been referred, including, 

but not limited to, services under parole 

and probation programs, public 

guardianship programs, special 

education programs, child welfare/child 

protective services, and foster care 

programs. 

(3) The activities are integral to the 

administration of foster care programs, 

including but not limited to the 

following: 

(i) Research gathering and completion 

of documentation required by the foster 

care program. 

(ii) Assessing adoption placements. 

(iii) Recruiting or interviewing 

potential foster care parents. 

(iv) Serving legal papers. 

(v) Home investigations. 

(vi) Providing transportation. 

(vii) Administering foster care 

subsidies. 

(viii) Making placement 

arrangements. 

(4) The activities, for which an 

individual may be eligible, are integral 

to the administration of another nonmedical program, such as a 

guardianship, child welfare/child 

protective services, parole, probation, or 

special education program except for 

case management that is included in an 

individualized education program or 

individualized family service plan 

consistent with section 1903(c) of the 

Act. 

(5) Activities that meet the definition 

of case management services in 

§ 440.169 and under the approved State 

plan cannot be claimed as 

administrative activities under 

§ 433.15(b). 

(d) After the State assesses whether 

the activities are within the scope of the 

case management benefit (applying the 

limitations described above), in 

determining the allowable costs for case 

management (or targeted case 

management) services that are also 

furnished by another federally-funded 

program, the State must use cost 

allocation methodologies, consistent 

with OMB Circular A–87, CMS policies, 

or any subsequent guidance and 

reflected in an approved cost allocation 

plan. 

(Catalog of Federal Domestic Assistance 

Program, No. 93.778, Medical Assistance 

Program.) 

Dated: June 23, 2006. 

Mark B. McClellan, 

Administrator, Centers for Medicare & 

Medicaid Services. 

Approved: August 27, 2007. 

Michael O. Leavitt, 

Secretary. 

[FR Doc. 07–5903 Filed 11–30–07; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF COMMERCE 

National Oceanic and Atmospheric 

Administration 

50 CFR Part 300 

RIN 0648–XD77 

Notification of U.S. Fish Quotas and an 

Effort Allocation in the Northwest 

Atlantic Fisheries Organization (NAFO) 

Regulatory Area 

AGENCY: National Marine Fisheries 

Service (NMFS), National Oceanic and 

Atmospheric Administration (NOAA), 

Commerce. 

ACTION: Final rule. 

SUMMARY: NMFS announces that fish 

quotas and an effort allocation are 

available for harvest by U.S. fishermen 

in the Northwest Atlantic Fisheries 

Organization (NAFO) Regulatory Area. 

This action is necessary to make 


sroberts on PROD1PC70 with RULES