in the field of radiology or pathology (see § 405.232(f) and (g));

(b) Eighty percent of the reasonable charges for medical and health services furnished by other than a participating provider of services;

(c) Eighty percent of the reasonable cost for medical and other health services furnished by (or under arrangements made by) participating providers of services;

(d) (1) Eighty percent of the reasonable cost of home health services furnished by (or under arrangements made by) a participating home health agency for services furnished prior to January 1, 1973; and

(2) One hundred percent of the reasonable cost of home health services furnished by (or under arrangements made by) a participating home health agency for services furnished after December 31, 1972; and

(e) Eighty percent of the deductible imposed under the hospital insurance benefits plan for outpatient hospital diagnostic services furnished before April 1968 (see § 405.230(b)).

[36 FR 16647, Aug. 25, 1971, as amended at 39 FR 19483, June 3, 1974]

§ 405.241 Payment of supplementary medical insurance benefits; election by group-practice prepayment plan as to method of determining amount of payment.

Notwithstanding the provisions of § 405.240 (a) and (b), payment to a group-practice prepayment plan which has furnished (or arranged for the availability of) items and services qualifying as medical and other health services, may be made on the basis of the reasonable cost of such services rather than on the basis of reasonable charges, even though such organization is other than a provider of services, if the group-practice prepayment plan elects to have payment made on a reasonable cost basis and agrees to charge the individuals to whom the services were provided not more than the amount of any unpaid annual deductible (see § 405.245), if any, plus 20 percent of the difference between the deductible and the reasonable cost.

§ 405.243 Psychiatric services limitation; expenses incurred for physician services.

(a) Limitation. With respect to expenses incurred in any calendar year in connection with the treatment of a men

tal, psychoneurotic, or personality disorder of an individual who is not an inpatient of a hospital (as described in paragraph (b) of this section) at the time such expenses are incurred, only the lesser of (1) $312.50; or (2) 621⁄2 percent of such expenses, is considered as incurred expenses for purposes of §§ 405.240 and 405.245.

(b) Application of limitation. Notwithstanding any other provision of this Subpart B, paragraph (a) of this section applies to specific expenses incurred for physicians' services (with no distinction being made between the services of psychiatrists and nonpsychiatrist physicians) rendered to an individual who is not an inpatient of a hospital, in connection with the treatment of a mental, psychoneurotic, or personality disorder of such individual, and any items or supplies furnished by the physician in connection with his treatment of such disorder. The term "mental, psychoneurotic, or personality disorder" means the specific psychiatric conditions described in the American Psychiatric Association's Diagnostic and Statistical Manual— Mental Disorders. Expenses incurred for services furnished by health personnel other than physicians, including home health services and outpatient services, as well as physicians' services furnished to an individual who is an inpatient of a hospital are not subject to such limitation even though the services are in connection with a condition which is included in the definition of mental, psychoneurotic, or personality disorder. For purposes of this paragraph (b), "hospital" means a hospital which is primarily engaged in providing to inpatients, by or under the supervision of physicians, diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons; or psychiatric services for the diagnosis and treatment of mentally ill persons; or medical services for the diagnosis and treatment of tuberculosis.

Example: As a private patient, Mr. X's only medical expenses during the calendar year 1973 amounted to $750 for physicians' services in connection with the treatment of a mental disorder which did not require inpatient hospitalization. The statutory limit for any calendar year on the amount of these expenses that is covered under this Subpart B is $312.50 ($312.50 being lesser in amount than 62% percent of $750). Mr. X is re

100 percent of expenses incurred while an inpatient. Deductible.

20 percent of total covered expenses less deductible. 80 percent of total covered expenses less deductible. [36 FR 16647, Aug. 25, 1971, as amended at 39 FR 19483, June 3, 1974]

§ 405.244 Incurred expenses; expenses excluded from total expenses or not considered for purposes of the deductibles.

(a) To the extent that an individual is entitled (or would be entitled except for application of the deductible or coinsurance amounts described in section 1813 of the Act (other than the outpatient hospital diagnostic deductiblesee 8405.230(b))) to have payment made under the provisions contained in Subpart A of this part with respect to services furnished to him, no payment may be made under the provisions described in this Subpart B with respect to such services and the costs or charges for such services are not considered as incurred expenses for purposes of §§405240, 405.245, and 405.246.

(b) To the extent that an indivdual incurred expenses in meeting the medi

cal insurance blood deductible (including the value of replacements made for such blood-see § 405.246), no payment may be made under the provisions described in this Subpart B with respect to such expenses (or value), and the costs or charges incurred in meeting such deductible are not considered incurred expenses for purposes of §§ 405.240 and 405.245.

(c) To the extent that an individual incurred expenses with respect to radiɔlogical and pathological services for which payment is made in an amount equal to 100 percent of the reasonable charges for such services (see § 405.240 (a) (2)), the costs or charges for such services are not considered as incurred expenses for purposes of §§ 405.245 and 405.246 and are not subject to the supplementary medical insurance benefits deductible.

[36 FR 16647, Aug. 25, 1971, as amended at 39 FR 19483, June 3, 1974]

§ 405.245 The supplementary medical insurance benefits deductible.

Subject to the provisions of § 405.244, the total amount of expenses incurred by an individual during a calendar year is reduced, prior to applying the payment percentages in § 405.240, by a deductible in an amount equal to:

(a) $60 (except that with respect to expenses incurred prior to 1973 the deductible amount shall be $50); less

(b) The amount of any expenses incurred by such individual in the last three months of the preceding calendar year and applied toward such individual's deductible under this section for such preceding year.

Example: During 1973, Mr. Jones incurred total expenses of $350 for covered medical and other health services furnished to him. Ordinarily, a deductible of $60 would be imposed in determining the amount payable under the supplementary medical insurance plan. However, during November of 1972, Mr. Jones had incurred expenses of $35 for covered medical and other health services which had been applied toward his supplementary medical insurance deductible for 1972. Since any expenses incurred in the last quarter of the prior calendar year, and applied toward the supplementary medical insurance benefits deductible for such year, can be carried over to the following year and applied toward the deductible, Mr. Jones' 1973 supplementary medical insurance benefits deductible is only $25 (860–$35). [39 FR 19483, June 3, 1974]

05.246 Supplementary medical insurance blood deductible.

a) Subject to the provisions of 105.244 and 405.245, where an indiual incurs expenses for whole blood equivalent quantities of packed red is furnished to him as part of "medi

and other health services" (see 05.231) during a calendar year after 57, the total amount of expenses inred by such individual in such calenryear shall, after being reduced in cordance with the provisions of 05.245, be further reduced before yment is made under this Subpart B the reasonable and customary charge de by the supplier (e.g., physician, spital, clinic, etc.) for any of the first pints of whole blood or equivalent antities of packed red blood cells rnished to the individual in such caldar year.

(b) For purposes of the blood dectible described in paragraph (a) of is section:

(1) A unit of packed red cells is conlered equivalent to a pint of whole Dod; and

(2) The amount of blood deductible is duced to the extent that the individual places the blood on a pint for pint sis.

405.249 Payment to a nonparticipat

ing hospital furnishing emergency outpatient services.

(a) Payment (in amounts determined accordance with § 405.240(c)) may be ade to a hospital even though the hostal is not a participating provider (1.e., has not entered into an agreement th the Secretary, pursuant to section 66 of the Act-see § 405.606) if:

(1) The hospital meets the requireents of section 1861(e) (5) and (7) of e Act (see § 405.1001(a)); and

(i) Is primarily engaged in providing der the supervision of a doctor of edicine or osteopathy the services deribed in section 1861 (e) (1); and

(ii) Is not primarily engaged in proding the services described in section 361(j) (1) (A) (see § 405.1101(a)); and (2) The services furnished are emercy outpatient services (see paragraph b) of this section) furnished on or after pril 1, 1968, to an individual who is rolled under the supplementary medial insurance plan. (With respect to mergency outpatient hospital diagnostic

services furnished before Apr. 1, 1968see 405.152.)

(3) The services are furnished by the hospital or by others under an arrangement made by the hospital;

(4) The hospital agrees to comply, with respect to the services furnished, with the provisions of Subpart F of this Part 405 regarding the charges for such services which may be imposed on the individual or any other person, and the return of any money incorrectly collected;

(5) The hospital has filed, and the Administration has accepted, the hospital's election to claim payment from the health insurance program for all emergency services furnished in the current calendar year under title XVIII of the Act (see § 405.658);

(6) Written request for payment is filled by or on behalf of the individual to whom such services were furnished;

(7) Payment for the services would have been made if an agreement under 405.606 had been in effect with the hospital and the hospital otherwise met the conditions for payment;

(8) The hospital's claim for payment is filed with the Administration and is accompanied (attached thereto or as part thereof) by a physician's statement describing the nature of the emergency and stating that the emergency services rendered were necessary to prevent the death of the individual or the serious impairment of his health. The statement must be sufficiently comprehensive to support a finding that an emergency existed.

(b) For purposes of the supplementary medical insurance benefits plan "emergency outpatient services" are those outpatient hospital diagnostic and therapeutic services which are necessary to prevent the death or serious impairment of the health of the individual, and which, because of the threat to the life or health of the individual, necessitate the use of the most accessible hospital available and equipped to furnish such services.

(c) The requirements as to medical necessity for emergency outpatient services and as to whether the most accessible hospital available and equipped to furnish such services was utilized, wil be made in accordance with the provisions of §§ 405.191 and 405.192.

§ 405.250

Procedures for payment; medical and other health services furnished by participating provider; home health services.

Payment for medical and other health services (see §§ 405.230(a) (3), 405.231, and 405.232), and for home health services (see §§ 405.230(a) (4), 405.233 through 405.236), furnished by a participating provider of services is made to such provider only if:

(a) A written request is filed by or on behalf of the individual to whom the services were furnished to have such payment made; and

(b) A physician certifies, and recertifies (ree Subpart P of this part) when required, that:

(1) In the case of medical and other health services (except services described in § 405.231 (c), (k), and (1)), such services were medically required; or

(2) In the case of home health services:

(1) Such services were required because the individual was confined to his home (except when receiving items and services referred to in § 405.236(g)) and needed skilled nursing care on an intermittent basis, or physical or speech therapy, as the case may be; and

(ii) A written plan for furnishing such services to the individual has been established, and is periodically reviewed, by a physician; and

(iii) Such services were furnished while the individual was under the care of a physician.

(3) In the case of outpatient physical therapy and speech pathology services:

(i) Such services were required because the individual needed physical therapy or speech pathology services (and with respect to outpatient physical therapy services furnished before October 30, 1972, such services were required because the individual needed physical therapy services on an outpatient basis— see § 405.231(1) (1) ); and

(ii) A written plan for furnishing such services has been established, and is periodically reviewed, by a physician (se § 405.250a); and

(iii) Such services were furnished while the individual was under the care of a physician.

[36 FR 16647, Aug. 25, 1971, as amended at 40 FR 44322, Sept. 26, 1975]

§ 405.250a Outpatient physical therapy and speech pathology services furnished by participating provider; plan of treatment requirements. Outpatient physical therapy and speech pathology services furnished by a participating provider of services (see § 405.230 (a) (5) and § 405.231(1) (1), (1) (3), and (m)), must be furnished under a written plan, established and periodically reviewed by a physician after any necessary consultation with the physical therapist or speech pathologist, as appropriate, which meets the following requirements:

(a) The plan must be established (i.e., put into writing) before treatment is begun and promptly signed by the ordering physician; and

(b) The plan must prescribe the type, amount, frequency, and duration of the physical therapy or speech pathology services that are to be furnished the individual and indicate the diagnosis and anticipated goals. Any changes to this plan must be made in writing and signed by the physician. Changes to the plan may also be made pursuant to the oral orders given by the physician to a qualified physical therapist, a qualified speech pathologist, a registered professional nurse, or a physician on the staff of the provider. Such changes must be immediately recorded in the patient's records and signed by the individual receiving the orders; and

(c) The plan must be reviewed by the physician, at such intervals as the severity of the individual's condition requires, but at least once every 30 days. Each review of the plan should contain the initials of the physician and the date performed.

[40 FR 44322, Sept. 26, 1975] § 405.251

Procedures for payment; medical and other health services furnished by other than a participating provider.

Payment for medical and other health services furnished by other than a participating provider of services (see §§ 405.230 (a) (1) and (2), 405.231 and 405.232) may be made to the individual who incurred such expenses, or to the person who provided such services, under the following circumstances:

(a) Payment to the individual. Payment may be made to an individual who

incurred expenses for medical and other health services furnished him by other than a participating provider of services if:

(1) He files a written request for payment:

(2) An itemized bill (which may be receipted or unpaid) is submitted which shows in detail the services provided;

(3) The items or services furnished such individual are "medical and other health services" (including "emergency outpatient services," if payment cannot be made under the provisions of § 405.249 solely because the hospital furnishing such services has not elected to claim such payment) for which payment may be made under the provisions set forth in § 405.230(a) (1) and (2).

(b) Payment to the person who furnished the services. Payment in the amount determined in accordance with § 405.240 may be made to a person (or organization) other than a participating provider of services who furnishes an enrolled individual medical and other health services for which payment may be made under the provisions set forth in §§ 405.230(a) (1) and (2), 405.231, and 405.232, if:

(1) The individual who was furnished the services executes an assignment of benefits to the person or organization which furnished the services;

(2) The assignment is properly filed; (3) The items or services furnished are "medical and other health services" for which payment may be made under § 405.230(a) (1) and (2) in an amount as determined under the provisions of 405.240; and

(4) The person or organization to whom such assignment has been made:

(i) Agrees to accept the individual's assignment of the right to receive payment for such services;

(ii) Agrees that the reasonable charge for such services shall be the full charge for such services;

(iii) Agrees to charge the individual not more than the amount of any unpaid annual deductible (see & 405.245), if any, tne blood deductible (see § 405.246), if applicable, plus 20 percent of the difference between the deductibles and the reasonable charge (as determined in subdivision (ii) of this subparagraph); and

(iv) Where payment has already been inade under this paragraph and such payment has been determined to be incorrect, agrees not to charge for items and services for which such individual was not entitled to have payment made under this part if:

(A) Such payment is incorrect by reason of paragraph (k) of § 405.310:

(B) The individual was without fault in incurring the expenses for such items or services; and

(C) The determination of the carrier, the intermediary, or the Social Security Administration, as appropriate, that the payment was incorrect was made subsequent to the third year following the year in which the payment notice was sent to the individual.

[36 FR 16647, Aug. 25, 1971, as amended at 41 FR 1492, Jan. 8, 1976]

§ 405.252 Conditions prohibiting pay. ment of benefits.

In addition to any other limitation, condition, or exclusion in the regulations in this subpart, payment of supplementary medical insurance benefits may not be made under the following circumstances:

(a) No payment unless information furnished. No payment may be made to any person, organization or to any provider of services unless the information necessary to determine the amount due has been furnished.

(b) Federal provider; Federal agency. No payment may be made to any Federal provider of services or other Federal agency, except a provider of services which may be determined by the Secretary to be providing services to the public generally as a community institution or agency.

(c) Services furnished at public expense. No payment may be made to any provider of services or other person or organization for any item or service which such provider, person, or organization is obligated by a law of, or contract with, the United States to render at public expense.

(d) Alien is outside the United States for 6 full calendar months. No payment may be made under this Subpart B with respect to items or services furnished to an individual who is not a citizen or national of the United States in any month for which monthly benefits are