spital service under Subpart A of s part, if furnished to a hospital intient.

b) Transportation services. Transrtation services, whether by ambuice or other means, required to take homebound individual to a hospital, Killed nursing facility, rehabilitation

nter, or other place, in order to furEsh him with items and services mich cannot be supplied to him in his me, are not included as a "home alth service," even though the servees provided at such hospitals, etc., e included as a home health service. (c) Housekeeping services. The serves of housekeepers or food service arngements such as those of "meals1-wheels" programs are not includae as "home health services."

405.238 Home health services; "visits” defined.

For purposes of determining the 100isit home health services limitation pecified in § 405.230(a)(4), one “visit” charged each time a "home health ervice" is furnished to the individual y home health agency personnel (or by personnel furnishing "home health "ervices" under an arrangement with hem made by a home health agency). For example, since one "visit" is harged each time a therapist goes to in individual's home to furnish therapy, if the individual is visited during the same day by both a speech therapist and a visiting nurse (or if provided with the same home health service twice in the same day), two "visits" are charged. Similarly, if an individual is taken to a hospital to receive outpatient therapy that could not be furnished in his own home (e.g., hydrotherapy) and, while at the hospital re-ceives speech therapy and other services, all of which qualify as home = health services under § 405.236, two or ■ more "visits" are charged.

§ 405.239 Option available to patients under a home health plan who rerequire physical therapy or speech therapy services.

A patient under a home health plan may elect to receive required physical or speech therapy services (also known as speech pathology services) as a "medical and other health service"

(see § 405.231 (1) and (m)) rather than as a home health service (see § 405.236(b)) and thereby save home health visits for other covered home health services.

[40 FR 44322, Sept. 26, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

PAYMENT OF BENEFITS

§ 405.240 Payment of supplementary medical Insurance benefits; amounts payable.

In the case of an individual who incurs expenses during his or her coverage period under the supplementary medical insurance plan, payment with respect to the total amount of such expenses incurred during a calendar year shall, subject to the provisions of §§ 405.243 through 405.246, be made as follows:

(a) (1) Eighty percent of the reasonable charges for physicians' services; and

(2) With respect to radiological and pathological services, 100 percent of the reasonable charges for such services furnished to an inpatient of a hospital by a physician in the field of radiology or pathology (see § 405.232 (f) and (g)).

For purposes of this paragraph, “radiological services" means services in which ionizing radiation is used for diagnostic or therapeutic purposes (for example, X-ray and the use of radioisotopes).

(b) Except as specified in paragraphs (g) and (h) of this section, 80 percent of the reasonable charges for medical and health services furnished by other than a participating provider of services;

(c) Except as specified in paragraphs (g) and (h) of this section, 80 percent of the reasonable cost for medical and other health services furnished by (or under arrangements made by) participating providers of services;

(d) (1) [Reserved]

(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; (e) [Reserved]

(f) Eighty percent of the costs payable under Subpart X of this part, which are reasonable and related to the cost of furnishing rural health clinic services or which are based on other tests of reasonableness as specified by the Secretary;

(g) One hundred percent of the reasonable cost for purchase, installation, maintenance, and reconditioning for subsequent use of home dialysis equipement furnished before August 1, 1983, by an ESRD facility that has an agreement with HCFA under § 405.690 (For equipment furnished on or after August 1, 1983, the equipment and services will be paid in accordance with paragraph (i) of this section.);

(h) Eighty percent of the target reimbursement rate for items and services furnished before August 1, 1983, by an ESRD facility that has an agreement with HCFA under § 405.691, except for items and services that are reimbursed under an agreement in accordance with paragraph (g) of this section (these items and services furnished on or after August 1, 1983, will be paid in accordance with paragraph (i) of this section.); and

(i) With regard to items and services specified in section 405.231, (o) and (p) furnished on or after August 1, 1983:

(1) Except as specified under paragraph (i)(2) of this section, eighty percent of the per treatment prospective reimbursement rate established under § 405.439 for outpatient maintenance dialysis furnished by ESRD facilities approved in accordance with Subpart U of this part.

(2) Where an individual who is a home dialysis patient elects to obtain his or her home dialysis supplies or equipment (or both) from a party other than an approved ESRD facility, then reimbursement is made in accordance with paragraphs (b) or (c) of this section.

(j) [Reserved]

(k) One hundred percent of the reasonable charges (or 100 percent of the reasonable cost, in the case of a health maintenance organization reimbursed under section 1876 of the Act) for physicians' services (including all pre- and post-operative services) furnished in connection with surgical procedures as

specified in § 416.65 of this chapter, if the following conditions are met:

(1) The procedures are performed in a participating ambulatory surgical center, on an outpatient basis in a hospital, or in a hospital-affiliated ambulatory surgical center.

(2) The physician accepts assignment with respect to payment for those services furnished in connection with the procedures. For purposes of this section:

(i) Assignment means an assignment under § 405.1675 of the right to receive payment under the Medicare Part B program and payment under § 405.1684 (when an individual dies before assigning payment).

(ii) A physician may authorize an entity specified in § 405.1680(d) (1), (2), or (3) to accept assignment on his or her behalf.

(1) A standard overhead amount as specified in § 416.120(c) of this chapter, for ambulatory surgical center facility services, as described in § 416.61 of this chapter, that are furnished in connection with surgical procedures described in § 416.65 of this chapter and performed in a participating ambulatory surgical center.

(Sec. 1102, 1833, 1861(aa), 1871, Social Security Act; 49 Stat. 647, 79 Stat, 302, 322, and 331, 91 Stat. 1485; 42 U.S.C. 1302, 13951, 1395hh, and 1395x(aa))

[36 FR 16647, Aug. 25, 1971. Redesignated at 42 FR 52826, Sept. 30, 1977, and amended at 43 FR 4430, Feb. 2, 1978; 43 FR 49722, Oct. 24, 1978; 45 FR 56062, Aug. 22, 1980; 47 FR 34092, Aug. 5, 1982; 48 FR 21277, May 11, 1983]

§ 405.241 Payment of supplementary medical insurance benefits to prepayment organizations.

A prepayment organization that has not qualified as a health care prepayment plan (HCPP), health maintenance organization (HMO), or competitive medical plan (CMP) will be paid through its Medicare carrier, for Part B services furnished to its Medicare enrollees, on the basis of reasonable charges in accordance with

§ 405.240 and § 405.251. These organizations will be paid 80 percent of reasonable charges after subtracting their enrollees' deductible amounts and taking the other limitations under

Part B into consideration. (See 42 FR Part 417 of this chapter for aplicable definitions and regulations overning reimbursement of HCPPS, MOS, and CMPs.)

50 FR 1345, Jan. 10, 1985]

405.243 Psychiatric services limitation; expenses incurred for physician services and comprehensive outpatient rehabilitation facility services.

(a) Definitions. As used in this section, unless the context indicates otherwise, “Mental, psychoneurotic, or personality disorder" means the specific psychiatric conditions described in the American Psychiatric Association's Diagnostic and Statistical Manual-Mental Disorders. “Hospital” means any hospital that is primarily Fengaged in providing, by or under the supervision of physicians, diagnostic and therapeutic services for the medical diagnosis, treatment, and care of injured, disabled or sick persons, or re· habilitation services for the rehabilita- tion of injured, disabled or sick persons; or psychiatric services for the diagnosis and treatment of mentally ill persons; and medical services for the diagnosis and treatment of tuberculosis.

(b) Services subject to limitation. The psychiatric services limitation applies to physician services and CORF services (furnished by physicians or nonphysicians) for the treatment of a mental, psychoneurotic, or personality disorder, when the services are furnished to an individual who is not an inpatient in a hospital.

(c) Limitation. Of the expenses incurred during any calendar year for services specified in paragraph (b) of this section, only $312.50 or 621⁄2 percent of the expenses (whichever is less) will be considered reimbursable under Medicare Part B, subject to the amount of payment and deductible provisions set forth in §§ 405.240 and 405.245.

(d) Example.

As a private patient, Mr. X's only medical expenses during the calendar year 1982 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 ex

[47 FR 56291, Dec. 15, 1982]

§ 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 deductible-see § 405.230(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 §§ 405.240, 405.245, and 405.246.

(b) To the extent that an individual incurred expenses in meeting the medical 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 radiological 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. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.244-1 Payment of supplementary medical insurance benefits; kidney donor services and ambulatory surgical services.

Notwithstanding any other provisions in this title, there are no deductible or coinsurance requirements with respect to:

(a) Services furnished to an individual in connection with the donation of a kidney for transplant surgery;

(b) Physicians' services (including all pre- and post-operative services) when the physician accepts assignment, as described in § 405.240(k)(2), and provides services in connection with a covered surgical procedure, as specified in § 416.65 of this chapter, performed in a participating ambulatory surgical center, on an outpatient basis in a hospital or in a hospital-affiliated ambulatory surgical facility; or

(c) Facility services, as described in § 416.65 of this chapter, furnished in connection with surgical procedures as specified in § 416.65 of this chapter, when those procedures are performed

in a participating ambulatory surgical center.

[47 FR 34092, Aug. 5, 1982]

§ 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 ($60$35).

[39 FR 19483, June 3, 1974. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.246 Supplementary medical insurance blood deductible.

(a) Subject to the provisions of §§ 405.244 and 405.245, where an individual incurs expenses for whole blood or equivalent quantities of packed red cells furnished to him as part of "medical and other health services" (see § 405.231) during a calendar year after 1967, the total amount of expenses incurred by such individual in such calendar year shall, after being reduced in accordance with the provisions of § 405.245, be further reduced before

§ 405.249 Payment to a nonparticipating hospital furnishing emergency outpatient services.

(a) Payment (in amounts determined in accordance with § 405.240(c)) may be made to a hospital even though the hospital is not a participating provider (i.e., it has not entered into an agreement with the Secretary, pursuant to section 1866 of the Act-see § 405.606) if:

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

(i) Is primarily engaged in providing under the supervision of a doctor of medicine or osteopathy the services described in section 1861(e)(1); and

(ii) Is not primarily engaged in providing the services described in section 1861(j)(1)(A) (see § 405.1101(a)); and

(2) The services furnished are emergency outpatient services (see paragraph (b) of this section) furnished on or after April 1, 1968, to an individual who is enrolled under the supplementary medical insurance plan;

(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 Health Care Financing 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 filed 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 Health Care Financing 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, will be made in accordance with the provisions of §§ 405.191 and 405.192.

[36 FR 16647, Aug. 25, 1971. Redesignated at 42 FR 52826, Sept. 30, 1977, and amended at 43 FR 4430, Feb. 2, 1978]