C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 447—PAYMENTS FOR SERVICES › Subpart A—Payments: General Provisions

42 C.F.R. § 447.25

Direct payments to certain beneficiaries for physicians' or dentists' services

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(a) Basis and purpose. This section implements section 1905(a) of the Act by prescribing requirements applicable to States making direct payments to certain beneficiaries for physicians' or dentists' services.

(b) State plan requirements. Except for groups specified in paragraph (c) of this section, a State may make direct payments to beneficiaries for physicians' or dentists' services. If it does so, the State plan must—

(1) Provide for direct payments; and

(2) Specify the conditions under which payments are made.

(c) Federal financial participation. No FFP is available in expenditures for direct payment for physicians' or dentists' services to any beneficiary—

(1) Who is receiving assistance under the State's approved plan under title I, IV-A, X, XIV or XVI (AABD) of the Act; or

(2) To whom supplemental security benefits are being paid under title XVI of the Act; or

(3) Who is receiving or eligible for a State supplementary payment or would be eligible if he were not in a medical institution, and who is eligible for Medicaid as a categorically needy beneficiary.

(d) Federal requirements. (1) Direct payments to beneficiaries under this section are an alternative to payments directly to providers and are subject to the same conditions; for example, the State's reasonable charge schedules are applicable.

(2) Direct payments must be supported by providers' bills for services.

Notes of Decisions
Cited in 4 cases (1 in the last 5 years), 1988–2025 · leading case: Teresa Barney and Randy Barney, Bonita Waldron, on Behalf of Themselves and Others Similarly Situated, Intervenor-Appell
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Teresa Barney and Randy Barney, Bonita Waldron, on Behalf of Themselves and Others Similarly Situated, Intervenor-Appell (1997) ca6 “to individuals” who meet certain eligibility requirements) (emphasis added); 42 C.F.R. § 447.25 (a), (b) (implementing 42 U.”
Equal Access for El Paso, Inc. v. Hawkins (2009) ca5 “”); see also 42 C.F.R. § 447.25 (d)(1) (“Direct payments to recipients .”
Hennessey v. Berger (1988) mass “Federal law does not mandate physician participation, see 42 C.F.R. § 447.25 (1987), but instead seeks to attract physicians voluntarily by requiring that States offer adequate financial incentives.”
In re: FT, by and through Aloha Nursing Rehab Centre v. Department of Human Services. ICA s.d.o., filed 04/19/2024 [ada] (2025) haw “[t]o [certain beneficiaries receiving the payment for physicians’ or dentists’ services per 42 CFR § 447.25 .]”); see HAR § 17-1739.2-3 (requiring DHS to reimburse long-term care providers for services delivered).”
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