[Federal Register Volume 68, Number 63 (Wednesday, April 2, 2003)]
[Proposed Rules]
[Pages 15973-15978]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-8021]


=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 440

[CMS-2132-P]
RIN 0938-AM26


Medicaid Program; Provider Qualifications for Audiologists

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Proposed rule.

-----------------------------------------------------------------------

SUMMARY: This proposed rule would revise the requirements for 
audiologists furnishing services under the Medicaid program. In 
addition, it would create consistency with the Medicare requirements 
that define a qualified audiologist by recognizing the role of State 
licensure in determining provider qualifications. These revised 
standards would expand State flexibility in choosing qualified 
audiologists.

DATES: We will consider comments if we receive them at the appropriate 
address, as provided below, no later than 5 p.m. on June 2, 2003.

ADDRESSES: In commenting, please refer to file code CMS-2132-P. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission or e-mail.
    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-2132-P, P.O. 
Box 3016, Baltimore, MD 21244-3016.
    Please allow sufficient time for mailed comments to be timely 
received in the event of delivery delays.
    If you prefer, you may deliver (by hand or courier) your written 
comments (one original and two copies) to one of the following 
addresses: Room 445-G, Hubert H. Humphrey Building, 200 Independence 
Avenue, SW., Washington, DC 20201, or Room C5-14-03, 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 could be considered late.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Linda Peltz, (410) 786-3399.

SUPPLEMENTARY INFORMATION:
    Inspection of Public Comments: Comments received timely 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 (410) 786-7195.
    Copies: This Federal Register document is also available from the 
Federal Register online database through GPO Access, a service of the 
U.S. Government Printing Office. The Web site address is: http://www.access.gpo.gov/nara/index.html.

I. Background

A. Legislation

Medicaid Requirements
    Title XIX of the Social Security Act (the Act) authorizes Federal 
grants to States for Medicaid programs that

[[Page 15974]]

provide medical assistance to low-income families, the elderly, 
qualified pregnant minors, and persons with disabilities. The Medicaid 
program is jointly financed by the Federal and State governments and 
administered by the States. Within Federal rules, each State chooses 
eligible groups of beneficiaries, types and ranges of services, payment 
levels for services, and administrative and operating procedures. The 
nature and scope of a State's Medicaid program is described in the 
State plan that the State submits to us for approval. The plan is 
amended whenever necessary to reflect changes in Federal or State law, 
changes in policy, or court decisions. Under section 1902(a)(10) of the 
Act, States must provide certain basic services. Section 1905(a)of the 
Act identifies categories of services States may provide as medical 
assistance.
    Under the Medicaid program, services for individuals with speech, 
hearing, and language disorders historically have been permitted under 
the Secretary's discretionary authority under section 1905(a)(11) of 
the Act. In our regulations, at 42 CFR 440.110(c), we require that the 
beneficiary be referred by a physician or other licensed practitioner 
of the healing arts within the scope of his or her practice under State 
law for services furnished by, or under the direction of, a qualified 
audiologist or speech pathologist. As currently defined at Sec.  
440.110(c)(2), an audiologist or speech pathologist is an individual 
who has a certificate of clinical competence from the American Speech-
Language-Hearing Association (ASHA); completed the equivalent 
educational requirements and work experience necessary for the 
certificate; or completed the academic program and is acquiring 
supervised work experience to qualify for the certificate.
Medicare Requirements
    Section 1861(ll)(2) of the Act defines audiology services to 
include hearing and balance assessment services furnished by a 
qualified audiologist, as the audiologist is legally authorized to 
perform under State law. Section 1861(ll)(3)(B) then identifies the 
minimum qualifications that a qualified audiologist must have to 
participate in the Medicare program by defining a ``qualified 
audiologist'' as an individual with a master's or doctoral degree and 
who--
    [sbull] Is licensed as an audiologist by the State in which the 
individual furnished those services; or
    [sbull] In the case of an individual who furnishes services in a 
State that does not license audiologists, has--
    + Successfully completed 350 clock hours of supervised clinical 
practicum (or is in the process of accumulating that supervised 
clinical experience);
    + Performed not fewer than 9 months of supervised full-time 
audiology services after obtaining a master's or doctoral degree in 
audiology or a related field; and
    + Successfully completed a national examination in audiology 
approved by the Secretary.

B. Current Medicaid Program Experience

    Since its inception, the Medicaid program has permitted States the 
option of providing services for individuals with speech, hearing, and 
language disorders. Audiology services may be provided in a variety of 
settings at the State discretion. States have the option of providing 
audiology services to their adult Medicaid population, but because of 
the mandatory Early and Periodic Screening, Diagnostic, and Treatment 
(EPSDT) program, must provide audiology services to Medicaid eligible 
persons under 21 years of age who have been evaluated and found in need 
of the service. In fact, Medicaid pays for a substantial number of 
medical services provided to children with disabilities in schools 
(``school-based services'') according to the Individuals with 
Disabilities Education Act (IDEA) (Pub. L. 105-17, enacted on June 4, 
1997). Our current regulations at Sec.  440.110(c)(2), require 
audiologists to hold a certificate of clinical competency from ASHA, or 
its equivalent, to furnish audiology services. Current regulations also 
permit services to be provided under the direction of a qualified (ASHA 
certified) audiologist.

C. Consistency with Medicare Program

    Before the Social Security Amendments of 1994 (Pub. L. 103-432, 
enacted on October 31, 1994), the Medicare and Medicaid regulations 
both required speech pathologists and audiologists to meet the academic 
and clinical experience requirements for a Certificate of Clinical 
Competence granted by ASHA. In accordance with section 146 of the 
Social Security Amendments of 1994, Medicare revised its statutory 
requirements for speech pathologists and audiologists, removing the 
requirement for ASHA certification and placing primary reliance for 
determining provider qualifications on State licensure.
    After the revision of the Medicare requirements in 1994, we began 
receiving letters from audiology professionals and interested parties 
recommending that we adopt the Medicare definition of qualified 
audiologists. In addition, the introductory text of the legislation 
entitled ``The Medicaid Audiology Act of 1999'' (H.R. 1068); and the 
Committee Report for FY 2001 Labor, Health and Human Services, and 
Education Appropriations bill (Report 106-645, page 108), recommended 
that we adopt the Medicare definition of ``qualified audiologist'' in 
the Medicaid program; that is, recognize the role of State licensure in 
determining provider qualifications. The proponents recommending the 
change stated that the Medicaid definition had not changed in over 20 
years and predated the national trend toward greater reliance on State 
determinations of professional qualifications through licensure.
    Last year, after repeated requests to reconcile the differing 
definitions, we agreed to consider possibilities for changing the 
Medicaid regulations to bring them into closer conformity with the 
Medicare requirements by recognizing State licensure in defining a 
qualified audiologist in a manner that would not compromise State 
flexibility and quality of care.
    We began by conducting meetings with stakeholders and interviewing 
national organizations to determine the implications that this change 
would have on Medicaid programs, providers, and beneficiaries. Based on 
the information gained from those encounters, we now believe it is 
possible to enact a change to the Medicaid definition of qualified 
audiologist to recognize the role of State licensure, while 
simultaneously incorporating standards that address our concerns 
regarding quality standards of care.
    The requirements proposed in this rule reflect our goal of 
maintaining Medicaid's quality standards while simultaneously being 
responsive to States, stakeholders, and beneficiaries. Our proposed 
provider standards recognize the role of State licensure in determining 
provider qualifications, while preserving the State's flexibility and 
professional industry standards that aid in ensuring quality services 
to all Medicaid beneficiaries.

II. Provisions of the Proposed Regulations

    This proposed rule only addresses the qualifications of 
audiologists as defined under Sec.  440.110(c)(2). At this time, we do 
not propose to change the requirements under this section pertaining to 
qualified speech-language pathologists.

[[Page 15975]]

    We are proposing to make the following revisions to the 
regulations:
    [sbull] In Sec.  440.110(c)(2), to define audiologists separately 
from speech pathologists.
    [sbull] To add a new Sec.  440.110(c)(3) to define ``qualified 
audiologist''. ``A qualified audiologist means an individual with a 
master's or doctoral degree in audiology who--
    (i) Is licensed as an audiologist to perform those services by the 
State in which the individual furnishes those services, providing that 
the State licensure requirements meet or exceed the requirements in 
paragraph (c)(3)(ii)(A) or (c)(3)(ii)(B) of this section;''.
    (ii) In the case of an individual who furnishes audiology services 
in a state that does not license audiologists or that exempts 
audiologists practicing in specific institutions or settings from 
licensure, the individual must meet one of the following standards:
    (A) Has a Certificate of Clinical Competence in Audiology granted 
by the American Speech-Language-Hearing Association; or
    (B) Has successfully completed a minimum of 350 clock-hours of 
supervised clinical practicum (or is in the process of accumulating 
such supervised clinical experience under the supervision of a 
qualified master or doctoral-level audiologist), performed not less 
than 9 months of supervised full-time audiology services after 
obtaining a master's or doctoral degree in audiology, or a related 
field, and successfully completed a national examination in audiology 
approved by the Secretary.
    Similar to Medicare's statutory revision in 1994, our proposed 
regulation will remove the requirement for ASHA certification as the 
sole standard for determining provider qualifications and will place 
primary reliance on State licensing.
    Our goal in revising the Medicaid audiology provider qualification 
standards is to make both programs' requirements consistent where 
possible while also incorporating minimum clinical and academic 
requirements that reflect nationally recognized industry professional 
standards. In doing so, we seek to ensure that regardless of where the 
Medicaid beneficiary receives the audiology services, the services 
would be provided by highly trained professionals.
    To accomplish this goal, our proposed requirements differ from 
Medicare's through the inclusion of minimum provider academic and 
clinical practicum standards applicable in States that license 
audiologists, as well as in States that either exempt audiologists from 
licensure or that do not license audiologists at all.
``Under the Direction of''
    To afford States the flexibility they currently have under Medicaid 
to determine qualified providers, we plan to retain the alternative 
requirement for providers who are not themselves qualified audiologists 
to work ``under the direction of'' a qualified audiologist. Section 
440.110(c)(1) allows for services to be furnished by or ``under the 
direction of'' a qualified audiologist. This means an individual who is 
working under the supervision of a Federally qualified audiologist may 
furnish Medicaid audiology services.
    We interpret the ``under the direction of'' requirement to mean 
that a qualified audiologist who is directly affiliated with the entity 
providing audiology services must supervise each beneficiary's care. To 
meet this requirement, an audiologist must see the beneficiary 
initially, prescribe the type of care provided, and review the need for 
continued services throughout treatment. The audiologist must assume 
professional responsibility for the services provided and ensure that 
the services are medically necessary. The concept of professional 
responsibility implicitly supports face-to-face contact by the 
audiologist at least at the beginning of treatment and periodically 
thereafter. Thus, audiologists must spend as much time as necessary 
directly supervising services to ensure beneficiaries are receiving 
services in a safe and efficient manner in accordance with accepted 
standards of medical practice.
    For an audiologist to be affiliated with an entity, there must be a 
contractual agreement or some other type of formal arrangement between 
the audiologist and the entity which enumerates the audiologist's 
supervisory obligations relating to the care provided to the 
beneficiaries. Moreover, documentation must be kept supporting the 
audiologist's supervision of services and ongoing involvement in the 
treatment. As stated above, we would retain the provision regarding 
services provided under the direction of an audiologist.

III. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995, we are required to 
provide 60-day notice in the Federal Register and solicit public 
comment 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 Paperwork Reduction Act 
of 1995 requires that we solicit comment on the following issues:
    [sbull] The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
    [sbull] The accuracy of our estimate of the information collection 
burden.
    [sbull] The quality, utility, and clarity of the information to be 
collected.
    [sbull] 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 
provisions summarized below that contain information collection 
requirements: Sec.  440.110 Physical therapy, occupational therapy, and 
services for individuals with speech, hearing, and language disorders.
    Section 440.100(c)(3)(iii) states that an individual who provides 
Medicaid audiology services must maintain documentation to demonstrate 
that they meet the standard(s) set forth in this section. While this 
requirement is subject to the PRA, we believe this requirement is a 
usual and customary business activity and the burden associated with 
this requirement is exempt from the PRA, as stipulated under 5 CFR 
1320.3(b)(2) and (b)(3).
    If you comment on any of 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, Room N2-17-23, 7500 Security 
Boulevard, Baltimore, MD 21244-1850, Attn: John Burke CMS-2132-P,
and
Office of Information and Regulatory Affairs, Office of Management and 
Budget, Room 10235, New Executive Office Building, Washington, DC 
20503, Attn.: Brenda Aguilar, CMS-2132-P.

IV. Response to Comments

    Because of the large number of items of correspondence we normally 
receive on Federal Register documents published for comment, 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, if we proceed with a subsequent 
document, we will respond to the major comments in the preamble to that 
document.

[[Page 15976]]

V. Regulatory Impact Statement

A. Overall Impact

    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 16, 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 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 annually).
    We are unable to provide a specific dollar estimate of the economic 
impact this proposed regulation would have on State and local 
governments and participating providers. Because the flexibility 
permitted under Medicaid allows States to provide audiology under 
various Medicaid benefits, it is not possible to capture accurate 
expenditure data.
    We have determined, however, that this proposed rule is not a major 
rule under Executive Order 12866, and the Secretary certifies that this 
proposed rule would not have a significant economic impact on a 
substantial number of small entities. We have made this determination 
because while we believe this rule would permit States to have more 
flexibility in determining who is qualified to provide audiology 
services, we do not anticipate any increase in States' use of audiology 
services due to this regulation. 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--
    [sbull] An annual effect on the economy of $100 million or more;
    [sbull] A major increase in costs or prices for consumers, 
individual industries, Federal, State, or local government agencies, or 
geographic regions; or
    [sbull] Significant adverse effects on competition, employment, 
investment productivity, innovation, or on the ability of United 
States-based enterprises in domestic and export markets.
    In addition, consistent with the Regulatory Flexibility Act (RFA) 
(5 U.S.C. 601 through 612), we prepare and publish an initial 
regulatory flexibility analysis for proposed regulations unless the 
Secretary certifies that the regulations would not have a significant 
impact on a substantial number of small entities. For purposes of the 
RFA, we do not consider States or individuals to be small entities.
    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 government agencies. 
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. For purposes of the RFA, 
audiologists that generate total revenues of $6 million or less in any 
1 year are considered to be small entities. The Small Business 
Administration categorizes small businesses for Audiologists along with 
physical, occupational, and speech therapists. The total number of 
providers within this category that have total revenues of between $5 
million and $7.5 million or less in any one year is 23,823 that they 
consider small businesses. Those firms and establishments with total 
revenue above $7.5 million are not considered small businesses 
according to the SBA. Therefore, approximately 0.92 percent of 
audiologist would be considered small businesses. For further 
information on the SBA size standards see 65 FR 69432. Individuals and 
States are not included in the definition of a small entity.
    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. Such 
an analysis must conform to the provisions of section 603 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 a Metropolitan 
Statistical Area and has fewer than 100 beds. This rule will not have a 
significant impact on small rural hospitals. The Medicaid program 
permits States the flexibility to provide audiology services under a 
variety of mandatory and optional benefits. The majority of States do 
so, mainly as either independent practitioner services, as part of a 
nursing facility service or community-based clinic services, or as part 
of their home health or school-based services programs. In addition, 
current Medicaid rules permit States the flexibility to provide 
audiology services by, or under the direction of, a qualified 
audiologist. This provider flexibility is recognized by states and is 
widely used to provide audiology services to children through school-
based services programs. Because the proposed rule retains the ability 
for audiology services to be provided ``under the direction of,'' the 
changes proposed in this rule would not have an impact on how States 
currently provide services to their Medicaid populations. Therefore, 
small rural hospitals would not be affected.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule that may result in expenditures in any 1 year by 
State, local, or tribal governments, in the aggregate, or by the 
private sector, of $110 million. We do not anticipate this rule would 
have an effect on the States, local or tribal governments, or on 
private sector costs. As we stated earlier, this regulation would give 
States more flexibility in determining qualified audiologists thereby 
giving them the ability to choose from a larger provider pool of 
``qualified'' individuals. However, because we expect the primary users 
of Medicaid audiology services, such as, children and seniors, to 
remain fairly constant, we do not anticipate any significant increase 
in the use of audiology services due to this proposed rule. In 
addition, because Medicaid audiology services are optional for states 
to provide to their Medicaid populations, many states choosing to do so 
limit utilization in some manner. In addition, many states limit the 
use of optional services such as audiology in favor of mandatory 
Medicaid benefits. States providing audiology services to children 
under the EPSDT program primarily do so a part of their school-based 
services program under IDEA. Since all 50 states currently have a 
school based services program in operation, we do not anticipate this 
rule to have any significant effect on audiology services provided to 
Medicaid children. Additionally, recognizing that states currently use 
the flexibility permitted in the Medicaid law to provide audiology 
services ``under the direction of'' a qualified audiologist, we expect 
states will continue to do so by providing audiology services using 
individuals working under the supervision of qualified audiologists.
    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 a State law, or otherwise has 
federalism implications.

[[Page 15977]]

We do not believe this proposed rule in any way would impose 
substantial direct compliance costs on State and local governments or 
preempts or supersedes State or local law. This proposed rule would 
permit States to use State licensed audiologists to provide Medicaid 
audiology services, thereby giving them increased flexibility in 
providing Medicaid audiology services. In addition, after researching 
national audiology usage and reviewing States' currently approved 
Medicaid States Plans, we anticipate that most, if not all, qualified 
audiologists currently enrolled in the Medicaid program would continue 
to be qualified as a result of the continued flexibility proposed in 
this rule. We also anticipate that States will continue to provide 
audiology services by using the additional flexibility already granted 
under the Medicaid program to provide audiology services using 
individuals meeting State provider qualifications and working within 
State practice acts ``under the direction of'' a qualified Medicaid 
audiologist. We believe the additional flexibility proposed in this 
rule to recognize State licensure will serve to enhance States ability 
to provide services. We do not, however, anticipate this rule will have 
a significant affect on the actual provision of audiology services in 
State Medicaid programs and therefore does not have Federalism 
implications.

B. Anticipated Effects

    We anticipate this proposed rule will give States increased 
flexibility in determining who is a Medicaid qualified audiologist. We 
also anticipate that the quality care standards proposed in this rule 
would help ensure that Medicaid audiology services continue to be 
provided by, or under the direction of, highly qualified and trained 
individuals. Additionally, we believe conforming the Medicare and 
Medicaid provider requirements would help eliminate any confusion 
providers may experience in complying with Federal rules and help 
reduce or eliminate conflict where audiologists provide services to 
both the Medicaid and Medicare populations (such as in nursing 
facilities or through home health care agency providers). Additionally, 
this proposed rule also serves to eliminate inconsistencies in Medicaid 
provider standards by no longer recognizing equivalency rulings. Under 
the current Medicaid rules, states can seek equivalency rulings from 
their State Attorney General in instances where they believe State 
licensure is equivalent to ASHA certification. Since the proposed rule 
recognizes State licensure that meets Medicare-equivalent standards, 
equivalency rulings are no longer necessary or required. We believe 
States would look favorably on the elimination of equivalency rulings 
since they proved administratively burdensome and time-consuming to 
obtain.

C. Alternatives Considered

    In developing the policies set forth in this proposed rule, we met 
with professional organizations and interested parties to solicit their 
ideas and concerns. We also worked with our national regional office 
Staffs to review currently approved Medicaid state plans for 
information on the provision of audiology services in States' Medicaid 
programs. We considered the role of audiology services in the Medicaid 
program and the potential impact changes in the standards for audiology 
providers would have overall. We considered several options that 
included (1) no change to the current Medicaid audiology requirements, 
(2) retain current requirements but issue updated policy guidance on 
issues such as provider equivalency authority, (3) rewrite the current 
Medicaid regulations to adopt the current Medicare requirements, and 
(4) rewrite the current Medicaid regulations to adopt the Medicare 
standards, but with minimum standards that would apply in States that 
do not license or that exempt some practitioners from State licensure 
requirements.
    After much research and consideration of the impact of each of the 
options, we concluded that option 4--the standards proposed in this 
rule--best satisfy the commitment made by the Secretary and address the 
request raised by interested parties to conform the definition of a 
qualified audiologist under the Medicare and Medicaid programs by 
recognizing the role of state licensure as a Medicaid provider 
requirement. We also concluded that the standards proposed in this rule 
best continue to recognize states rights under Medicaid by retaining 
program flexibility while at the same time also building in quality 
standards that continue to ensure Medicaid services are provided to all 
Medicaid-eligible individuals by recognized, highly trained 
professionals.

D. Conclusion

    For the reason stated above, we are not preparing analyses for 
either the RFA or section 1102(b) of the Act because we have 
determined, and we certify, that this rule would not have a significant 
economic impact on a substantial number of small entities or a 
significant impact on the operations of a substantial number of small 
rural hospitals.
    In accordance with the provisions of Executive Order 12866, this 
regulation was reviewed by the Office of Management and Budget.

List of Subjects in 42 CFR Part 440

    Grant programs--Health, Medicaid.
    For the reasons set forth in the preamble, the Centers for Medicare 
& Medicaid Services would amend 42 CFR chapter IV, part 440 as set 
forth below:

PART 440--SERVICES: GENERAL PROVISIONS

Subpart A--Definitions

    1. The authority citation for part 440 continues to read as 
follows:

    Authority: Sec. 1102 of the Social Security Act (42 U.S.C. 
1302).

    2. In Sec.  440.110(c), the introductory text of paragraph (c)(2) 
is revised, and a new paragraph (c)(3) is added to read as follows:


Sec.  440.110  Physical therapy, occupational therapy, and services for 
individuals with speech, hearing, and language disorders.

* * * * *
    (c) Services for individuals with speech, hearing, and language 
disorders.
* * * * *
    (2) A ``speech pathologist'' is an individual who--
* * * * *
    (3) A ``qualified audiologist'' means an individual with a master's 
or doctoral degree in audiology who--(i) Is licensed as an audiologist 
to perform those services by the State in which the individual 
furnishes those services, providing that the State licensure 
requirements meet or exceed those in paragraph (c)(3)(ii)(A) or 
(c)(3)(ii)(B) of this section;
    (ii) In the case of an individual who furnishes audiology services 
in a State that does not license audiologists, or that exempts 
audiologists practicing in specific institutions or settings from 
licensure, the individual must meet one of the following standards:
    (A) Have a Certificate of Clinical
    Competence in Audiology granted by the American Speech-Language-
Hearing Association; or
    (B) Have successfully completed a minimum of 350 clock-hours of 
supervised clinical practicum (or is in the process of accumulating 
that supervised clinical experience under the supervision of a 
qualified master or doctoral-level audiologist), performed not fewer 
than 9 months of supervised

[[Page 15978]]

full-time audiology services after obtaining a master's or doctoral 
degree in audiology, or a related field, and successfully completed a 
national examination in audiology approved by the Secretary.
    (iii) Individuals who provide Medicaid audiology services must 
maintain documentation to demonstrate that they meet the standard(s) 
set forth in this section.

(Catalog of Federal Domestic Assistance Program No. 93.778, Medical 
Assistance Program)

    Dated: November 26, 2003.
Thomas A Scully,
Administrator, Centers for Medicare & Medicaid Services.

    Approved: January 28, 2003.
Tommy G. Thompson,
Secretary.
[FR Doc. 03-8021 Filed 3-31-03; 8:45 am]
BILLING CODE 4120-01-P