42 C.F.R. § 440.20

Outpatient hospital services and rural health clinic services

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(a) Outpatient hospital services means preventive, diagnostic, therapeutic, rehabilitative, or palliative services that—

(1) Are furnished to outpatients;

(2) Are furnished by or under the direction of a physician or dentist; and

(3) Are furnished by an institution that—

(i) Is licensed or formally approved as a hospital by an officially designated authority for State standard-setting; and

(ii) Meets the requirements for participation in Medicare as a hospital; and

(4) May be limited by a Medicaid agency in the following manner: A Medicaid agency may exclude from the definition of “outpatient hospital services” those types of items and services that are not generally furnished by most hospitals in the State.

(b) Rural health clinic services. If nurse practitioners or physician assistants (as defined in § 491.2 of this chapter) are not prohibited by State law from furnishing primary health care, “rural health clinic services” means the following services when furnished by a rural health clinic that has been certified in accordance with part 491 of this chapter.

(1) Services furnished by a physician within the scope of practice of his profession under State law, if the physician performs the services in the clinic or the services are furnished away from the clinic and the physician has an agreement with the clinic providing that he will be paid by it for such services.

(2) Services furnished by a physician assistant, nurse practitioner, nurse midwife or other specialized nurse practitioner (as defined in §§ 405.2401 and 491.2 of this chapter) if the services are furnished in accordance with the requirements specified in § 405.2414(a) of this chapter.

(3) Services and supplies that are furnished as an incident to professional services furnished by a physician, physician assistant, nurse practitioner, nurse midwife, or specialized nurse practitioner. (See §§ 405.2413 and 405.2415 of this chapter for the criteria for determining whether services and supplies are included under this paragraph.)

(4) Part-time or intermittent visiting nurse care and related medical supplies (other than drugs and biologicals) if:

(i) The clinic is located in an area in which the Secretary has determined that there is a shortage of home health agencies (see § 405.2417 of this chapter):

(ii) The services are furnished by a registered nurse or licensed practical nurse or a licensed vocational nurse employed by, or otherwise compensated for the services by, the clinic;

(iii) The services are furnished under a written plan of treatment that is established and reviewed at least every 60 days by a supervising physician of the clinic or that is established by a physician, physician assistant, nurse practitioner, nurse midwife, or specialized nurse practitioner and reviewed and approved at least every 60 days by a supervising physician of the clinic; and

(iv) The services are furnished to a homebound beneficiary. For purposes of visiting nurse care, a “homebound” beneficiary means one who is permanently or temporarily confined to his place of residence because of a medical or health condition. He may be considered homebound if he leaves the place of residence infrequently. For this purpose, “place of residence” does not include a hospital or a skilled nursing facility.

(c) Other ambulatory services furnished by a rural health clinic. If the State plan covers rural health clinic services, other ambulatory services means ambulatory services other than rural health clinic services, as defined in paragraph (b) of this section, that are otherwise included in the plan and meet specific State plan requirements for furnishing those services. Other ambulatory services furnishd by a rural health clinic are not subject to the physician supervision requirements specified in § 491.8(b) of this chapter, unless required by State law or the State plan.

[43 FR 45224, Sept. 29, 1978, as amended at 47 FR 21050, May 17, 1982; 52 FR 47934, Dec. 17, 1987; 60 FR 61486, Nov. 30, 1995; 73 FR 66198, Nov. 7, 2008; 74 FR 31195, June 30, 2009; 85 FR 72909, Nov. 16, 2020]

Notes of Decisions

Cited in 13 cases, 1983–2017 · leading case: Alameda Health Sys. v. Ctrs. for Medicare & Medicaid Servs., 287 F. Supp. 3d 896 (N.D. Cal. 2017).

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Alameda Health Sys. v. Ctrs. for Medicare & Medicaid Servs., 287 F. Supp. 3d 896 (N.D. Cal. 2017). · cites it 8× “Among other things, the 2007 Proposed Outpatient Rule amended 42 C.F.R. § 440.20 , which set forth definitions of "Outpatient Hospital Services" and "Rural Health Clinic Services," to "specify the scope of facility services covered under the Medicaid program[;]" to "modify the…”

Carson City Hosp. v. Dep't of Cmty. Health, 656 N.W.2d 366 (Mich. Ct. App. 2003). · cites it 6× “The portion of Michigan’s plan pertaining to rhc services states that “rural health clinic services, as specified in 42 CFR 440.20(b)” are covered when provided by a certified rhc.”

Arizona Health Care Cost Containment Sys. v. McClellan, 508 F.3d 1243 (9th Cir. 2007). · cites it 2× “10 (“Inpatient hospital services”) and 42 CFR 440.20 (“Outpatient hospital services and rural health facility services”)[.”

Louisiana Dep't of Health & Hospitals v. Ctr. for Medicare & Medicaid Servs., 346 F.3d 571 (5th Cir. 2003). · cites it 4× “” 42 C.F.R. § 440.20 . Louisiana asserts that services provided by hospital-based RHCs indisputably satisfy the first part of the definition, being “preventative, diagnostic, therapeutic, rehabilitative, or palliative.”

Dunakin v. Quigley, 99 F. Supp. 3d 1297 (W.D. Wash. 2015). · cites it 2× “Dunakin in his complaint do not relate to comparability but rather to topics such as outpatient hospital services and rural health clinics, which were not pleaded.”

MacArthur v. San Juan Cnty., 416 F. Supp. 2d 1098 (D. Utah 2005). “42 C.F.R. § 440.20 (D)(8), Attachment 4.19B pg.”

Michigan Hosp. Ass'n v. Dep't of Soc. Servs., 555 F. Supp. 675 (E.D. Mich. 1983). “) 42 CFR 440.20 defines covered outpatient hospital services under Medicaid, and HCFA policy has held that it is the hospital that specifies what its outpatient services are.”

Orthopaedic Hosp. v. Belshe, 103 F.3d 1491 (9th Cir. 1997). “42 C.F.R. § 440.20 (a). Many procedures that oncé required a lengthy inpatient stay, can now be provided on an outpatient basis.”

Ellenbecker v. Centers for Medicare & Medicaid Servs., 335 F. Supp. 2d 999 (D.S.D. 2003). “10 (“Inpatient hospital services”) and 42 CFR 440.20 (“Outpatient hospital services and rural health facility services”) For most facilities, services are furnished within the physical confínes of the facility.”

North Dakota Ex Rel. Olson v. Centers for Medicare & Medicaid Servs., 286 F. Supp. 2d 1080 (D.N.D. 2003). “10 (“Inpatient hospital services”) and 42 CFR 440.20 (“Outpatient hospital services and rural health facility services”).”

Agency for Persons With Disabilities v. C.B., 130 So. 3d 713 (Fla. 1st DCA 2013). “at 2-4; see 42 C.F.R. § 440.20 (2)(d) (2011) (providing that the state Medicaid agency "may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures”).”

Arizona Health Care v. McClellan (9th Cir. 2007). · cites it 2× “10 (“Inpatient hospital ser- vices”) and 42 CFR 440.20 (“Outpatient hospital services and rural health facility services”)[.”

Show all 13 citing cases →

— 42 C.F.R. § 440.20(a) — 1 case

Louisiana Dep't of Health & Hospitals v. Ctr. for Medicare & Medicaid Servs., 346 F.3d 571 (5th Cir. 2003). “” 42 C.F.R. § 440.20 . Louisiana asserts that services provided by hospital-based RHCs indisputably satisfy the first part of the definition, being “preventative, diagnostic, therapeutic, rehabilitative, or palliative.”

— 42 C.F.R. § 440.20(b) — 1 case

Carson City Hosp. v. Dep't of Cmty. Health, 656 N.W.2d 366 (Mich. Ct. App. 2003). “The portion of Michigan’s plan pertaining to rhc services states that “rural health clinic services, as specified in 42 CFR 440.20(b)” are covered when provided by a certified rhc.”

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