(a) The plan must specify the amount, duration, and scope of each service that it provides for—
(1) The categorically needy; and
(2) Each covered group of medically needy.
(b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.
(c) The Medicaid agency may not arbitrarily deny or reduce the amount, duration, or scope of a required service under §§ 440.210 and 440.220 to an otherwise eligible beneficiary solely because of the diagnosis, type of illness, or condition.
(d) The agency may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures.
(e) For prior authorization requests for items and services (excluding drugs, as defined in § 431.60(b)(6) of this chapter), the State Medicaid agency must—
(1) Beginning January 1, 2026, make prior authorization decisions within the following timeframes:
(i) For a standard determination, as expeditiously as a beneficiary's health condition requires, but in no case later than 7 calendar days after receiving the request, unless a shorter minimum timeframe is established under State law. The timeframe for standard authorization decisions can be extended by up to 14 calendar days if the beneficiary or provider requests an extension, or if the State agency determines that additional information from the provider is needed to make a decision.
(ii) For an expedited determination, as expeditiously as a beneficiary's health condition requires, but in no case later than 72 hours after receiving the request, unless a shorter minimum timeframe is established under State law.
(2) Provide the beneficiary with notice of the agency's prior authorization decision in accordance with § 435.917 of this chapter and provide fair hearing rights, including advance notice, in accordance with part 431, subpart E, of this chapter.
(3) Beginning in 2026, annually report prior authorization data, excluding data on drugs, as defined in § 431.60(b)(6) of this chapter, at the State level by March 31. The State must make the following data from the previous calendar year publicly accessible by posting them on its website:
(i) A list of all items and services that require prior authorization.
(ii) The percentage of standard prior authorization requests that were approved, aggregated for all items and services.
(iii) The percentage of standard prior authorization requests that were denied, aggregated for all items and services.
(iv) The percentage of standard prior authorization requests that were approved after appeal, aggregated for all items and services.
(v) The percentage of prior authorization requests for which the timeframe for review was extended, and the request was approved, aggregated for all items and services.
(vi) The percentage of expedited prior authorization requests that were approved, aggregated for all items and services.
(vii) The percentage of expedited prior authorization requests that were denied, aggregated for all items and services.
(viii) The average and median time that elapsed between the submission of a request and a determination by the State Medicaid agency, for standard prior authorizations, aggregated for all items and services.
(ix) The average and median time that elapsed between the submission of a request and a decision by the State Medicaid agency for expedited prior authorizations, aggregated for all items and services.
[46 FR 47993, Sept. 30, 1981, as amended at 89 FR 8981, Feb. 8, 2024]
Notes of Decisions
Moore Ex Rel. Moore v. Reese, 637 F.3d 1220 (11th Cir. 2011).
· cites it 23× “9)); see also 42 C.F.R. § 440.230 (d) (providing that state Medicaid agencies “may place appropriate limits on a service based on such criteria as medical necessity”).”
Derek Waskul v. Washtenaw Cnty. Cmty. Mental Health, 979 F.3d 426 (6th Cir. 2020).
· cites it 4× “Instead, Plaintiffs assert that Defendants violated § 1396a(a)(10)(B)’s “sufficiency requirements,” which they say are set forth in 42 C.F.R. § 440.230 (b) and were not waived.”
Rodriguez v. City Of New York, 197 F.3d 611 (2d Cir. 1999).
· cites it 10× “Title 42 C.F.R. 440.230 reads in relevant part as follows: 23 (b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.”
Smith v. Rasmussen, 57 F. Supp. 2d 736 (N.D. Iowa 1999).
· cites it 30× “§ 1396a(a)(17) creates a federal right, which is further defined in 42 C.F.R. § 440.230 (b), that is sufficiently definite to be enforced under § 1983 and because Congress did not intend to foreclose private enforcement of the Medicaid statute, plaintiff Smith states a cause of…”
Bryson v. Shumway, 177 F. Supp. 2d 78 (D.N.H. 2001).
· cites it 14× “§§ 1396a(a)(17) and (19) & 42 C.F.R. §§ 440.230 (b) and (d) — Right to Effective Service In Count I, plaintiffs claim that they have been denied effective services to which they are entitled under the Medicaid Act.”
Davis v. Shah, 821 F.3d 231 (2d Cir. 2016).
· cites it 2× “As interpreted by HHS, that provision requires that each service administered by a state “be sufficient in amount, duration, and scope to reasonably achieve its purpose,” 42 C.F.R. § 440.230 (b), though a state may place ‘‘appropriate limits” on its' services “based on such…”
Bontrager v. Indiana Fam. & Soc. Servs. Admin., 829 F. Supp. 2d 688 (N.D. Ind. 2011).
· cites it 15× “Of particular relevance to this case is 42 C.F.R. § 440.230 , which states in full as follows: (a) The plan must specify the amount, duration, and scope of each service that it provides for— (1) The categorically needy; and (2) Each covered group of medically needy.”
Henry Pashby v. Albert Delia, 709 F.3d 307 (4th Cir. 2013).
· cites it 2× “” 42 C.F.R. § 440.230 (d). A state therefore does not violate the comparability provision of the Medicaid Act even when it provides different coverage to different categorically needy individuals, for example, so long as the coverage it provides bears a “reasonable relation to…”
Bontrager v. Indiana Fam. & Soc. Servs. Admin., 697 F.3d 604 (7th Cir. 2012).
· cites it 4× “Under those regulations, a state’s Medicaid plan must “specify the amount, duration, and scope of each service that it provides,” 42 C.F.R. § 440.230 (a), and “[e]ach service must be sufficient in amount, duration, and scope to reasonably achieve its purpose,” id.”
Smith v. Palmer, 24 F. Supp. 2d 955 (N.D. Iowa 1998).
· cites it 9× “42 C.F.R. § 440.230 Plaintiff Smith also seeks relief on his claim that defendant Palmer’s refusal to provide him with a sex reassignment surgery violates the requirement, set forth in 42 C.”
Maxwell Kadel v. Dale Folwell, 100 F.4th 122 (4th Cir. 2024).
· cites it 3× “” 42 C.F.R. § 440.230 (b). States can “place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures.”
— 42 C.F.R. § 440.230(C)(2) — 1 case
— 42 C.F.R. § 440.230(a) — 1 case
— 42 C.F.R. § 440.230(b) — 8 cases
Rodriguez v. City Of New York, 197 F.3d 611 (2d Cir. 1999).
“Title 42 C.F.R. 440.230 reads in relevant part as follows: 23 (b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.”
Davis v. Shah, 821 F.3d 231 (2d Cir. 2016).
“As interpreted by HHS, that provision requires that each service administered by a state “be sufficient in amount, duration, and scope to reasonably achieve its purpose,” 42 C.F.R. § 440.230 (b), though a state may place ‘‘appropriate limits” on its' services “based on such…”
Smith v. Palmer, 24 F. Supp. 2d 955 (N.D. Iowa 1998).
“42 C.F.R. § 440.230 Plaintiff Smith also seeks relief on his claim that defendant Palmer’s refusal to provide him with a sex reassignment surgery violates the requirement, set forth in 42 C.”
— 42 C.F.R. § 440.230(c) — 6 cases
Rodriguez v. City Of New York, 197 F.3d 611 (2d Cir. 1999).
“Title 42 C.F.R. 440.230 reads in relevant part as follows: 23 (b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.”
— 42 C.F.R. § 440.230(d) — 8 cases
Bontrager v. Indiana Fam. & Soc. Servs. Admin., 829 F. Supp. 2d 688 (N.D. Ind. 2011).
“Of particular relevance to this case is 42 C.F.R. § 440.230 , which states in full as follows: (a) The plan must specify the amount, duration, and scope of each service that it provides for— (1) The categorically needy; and (2) Each covered group of medically needy.”
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