What does it mean for a Medicaid service to be sufficient in amount, duration, and scope under 42 CFR 440.230? Answer in under 100 words.
Details / How it works
The sufficiency requirement under 42 CFR § 440.230 mandates that each service covered by the State Medicaid plan must be adequate to fulfill its intended purpose for recipients. The State Medicaid agency is prohibited from arbitrarily denying or reducing the amount, duration, or scope of a required service under 42 CFR §§ 440.210 and 440.220 to an otherwise eligible beneficiary solely because of diagnosis, type of illness, or condition. However, the agency may place appropriate limits on a service based on criteria such as medical necessity or utilization control procedures.
Exceptions & edge cases
The State Medicaid agency may place appropriate limits on a covered service using criteria such as medical necessity or utilization control procedures, which can shape the sufficiency of the service provided. Required services under 42 CFR §§ 440.210 and 440.220 cannot be arbitrarily denied or reduced; any limits must be based on reasonable standards.
Sources
- [1]U.S. National Archives, Electronic Code of Federal Regulations — 42 CFR 440.230 — Sufficiency of amount, duration, and scope · as of 2026-08-26
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