(f) Laboratory and X-ray services. Laboratory or X-ray services furnished after March 1968 to a patient of a hospital which meets the emergency hospital requirements of § 405.249(a)(1) are not covered as "medical and other health services" under this Subpart B unless the hospital meets the laboratory or radiology requirements (§ 405.1028 or § 405.1029 as applicable) of the conditions of participation for hospitals.

(g) Laboratory and radiology services furnished by a nonparticipating hospital which does not meet the requirements of § 405.249(a)(1). Laboratory and radiology services furnished by a nonparticipating hospital which does not meet the requirements of § 405.249(a)(1) are not considered as "medical and other health services" covered under Part B of title XVIII of the Act unless:

(1) The laboratory of the nonparticipating hospital meets the conditions for coverage of services of independent laboratories set forth in Subpart M of this part; and

(2) The radiology department of the nonparticipating hospital meets the conditions of participation for radiology departments of participating hospitals set forth in § 405.1029.

(h) Diagnostic laboratory and portable X-ray services furnished by a nonparticipating skilled nursing facility. Diagnostic laboratory services and portable X-ray services furnished by a nonparticipating skilled nursing facility are not considered as "medical and other health services" covered under Part B of title XVII of the Act unless:

(1) The laboratory of the nonparticipating skilled nursing facility meets the conditions for coverage of services of independent laboratories set forth in Subpart M of this part; and

(2) The portable X-ray services of the nonparticipating skilled nursing facility meets the conditions for coverage of portable X-ray services set forth in Subpart N of this part.

(i) Ambulance service. (1) For purposes of § 405.231(j) payment will be made for ambulance service only when the use of other means of transportation is contraindicated by the individual's condition and where:

(i) Such individual is transported to an institution, as defined in paragraph (i)(4) of this section, whose locality encompasses the place where the ambulance transportation began and which would ordinarily be expected to have appropriate facilities, or where the institution serving the locality lacks appropriate facilities, the individual is transported to the nearest institution having appropriate facilities; or

(ii) Such individual is transported from one hospital to another or, from one skilled nursing facility to another provided the institution from which he is transported lacks appropriate facilities and the one to which he is transported is the nearest such institution with appropriate facilities; or

(iii) Such individual is transported from an institution to his home provided that his home is within the locality of the institution or the institution in relation to his home is the nearest institution with appropriate facilities.

(2) Where the individual is transported beyond the destinations specified in paragraph (i)(1) of this section:

(i) If the transportation was to an institution, payment is limited to that which would have been made had the individual been transported to the nearest institution with appropriate facilities; or

(ii) If the transportation was to the individual's home, payment is limited to that which would have been made had he been transported from the institution in relation to his home that is the nearest one with appropriate facilities.

(iii) The provisions of this paragraph also apply to any timely filed claim for ambulance service rendered prior to the effective date hereof.

(3) "Ambulance" for the purposes of this paragraph means a specially designed and equipped vehicle (i.e., containing stretcher, linens, first aid supplies, oxygen equipment and such other lifesaving equipment required by State or local law, and manned by personnel trained to render first aid treatment) for transporting the sick or injured.

(4) "Institution" for the purposes of this paragraph means a hospital or skilled nursing facility which meets

the requirements of section 1861(e)(1) or 1861(j)(1) of the Act.

(5) "Locality" for the purposes of this paragraph means the service area surrounding the institution from which individuals normally come or are expected to come for hospital or skilled nursing services.

(6) "Appropriate facilities" for the purposes of this paragraph means that the institution is equipped to provide the needed hospital or skilled nursing care for the illness or injury involved. (j) Outpatient speech pathology services. There shall be excluded from the outpatient speech pathology services described in § 405.231(m) (1) and (2) any item or service which:

(1) Is furnished before January 1, 1973 (with respect to services furnished before such date-see § 405.231(c)); or

(2) Would not be included as inpatient hospital services if furnished to an inpatient of a hospital.

[36 FR 16647, Aug. 25, 1971, as amended at 40 FR 44321, Sept. 23, 1975; 41 FR 20871, May 21, 1976. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.232a Physician defined.

(a) The term "physician," when used in connection with the performance of any function or action means:

(1) A doctor of medicine or osteopthy legally authorized to practice medicine and surgery by the State in which he performs such function or action (including a physician within the meaning of section 1101(a)(7) of the Act);

(2) A doctor of dentistry or of dental oral surgery who is legally authorized to practice dentistry by the State in which he performs such function but only with respect to surgery related to the jaw or any structure contiguous to the jaw, or the reduction of any fracture of the jaw or any facial bone, or the certification required by section 1814(a)(2)(E) of the Act;

(3) Except for the purposes of section 1814(a), section 1835, and subsections (j), (k), (m), and (o) of section 1861 of the Act, a doctor of podiatry or surgical chiropody, but (unless paragraph (a)(1) of this section also applies to him) only with respect to functions which he is legally authorized to per

form as such by the State in which he performs them;

(4) A doctor of optometry who is legally authorized to practice optometry by the State in which he performs such function, but only for the purpose of attesting to the necessity for prosthetic lenses; or

(5) A chiropractor who is licensed as such by the State (or in a State which does not license chiropractors as such, is legally authorized to perform the services of a chiropractor in the jurisdiction in which he performs such services), and who meets uniform minimum standards set forth in § 405.232b(b), but only for the purpose of sections 1861 (s) (1) and 1861 (s) (2) (A) of the Act and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation demonstrated by X-ray to exist) which he is legally authorized to perform by the State or jurisdiction in which such treatment is provided.

(b) For the purposes of section 1862(a)(4) of the Act and subject to the limitations and conditions provided in paragraphs (a)(1) through (a)(5) of this section, the term "physician" includes a doctor of one of the arts, specified in paragraphs (a)(1) through (a)(5) of this section legally authorized to practice such art in the country in which the inpatient hospital services (referred to in such section 1862 (a) (4) of the Act) are furnished. [39 FR 28624, Aug. 9, 1974. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.232b Chiropractors.

(a) Licensure and authorization to practice. A chiropractor must be licensed or legally authorized to furnish chiropractic services by the State or jurisdiction in which he provides them. Reimbursement may not be made for chiropractic services rendered in the State of Louisiana where the practice is not legal.

(b) Uniform minimum standards. (1) Chiropractors licensed or authorized to practice prior to July 1, 1974, and those individuals who commence their studies in a chiropractic college before that date must meet all of the following minimum standards to render reimbursable services under the program:

(i) Preliminary education equal to the requirements for graduation from an accredited high school or other secondary school; and

(ii) Graduation from a college of chiropractic approved by the State's chiropractic examiners which included the completion of a course of study covering a period of not less than 3 school years of 6 months each year in actual continuous attendance covering adequate courses of study in the subjects of anatomy, physiology, symptomatology and diagnosis, hygiene and sanitation, chemistry, histology, pathology, and principles and practice of chiropractice, including clinical instruction in vertebral palpitation, nerve tracing and adjusting; and

(iii) Passage of an examination prescribed by the State's chiropractic examiners covering the subjects listed in paragraph (b)(1)(ii) of this section.

(2) Individuals commencing their studies in a chiropractice college after June 30, 1974, must meet all of the following additional requirements:

(i) Satisfactory completion of 2 years of pre-chiropractic study at the college level;

(ii) Satisfactory completion of a 4year course of 8 months each year (instead of a 3-year course of 6 months each year) at a college or school of chiropractic which includes not less than 4,000 hours in the scientific and chiropractic courses specified in paragraph (b)(1)(ii) of this section plus courses in the use and effect of X-ray and chiropractic analysis; and

(iii) The practitioner must be over 21 years of age.

dence of the medical need for prosthetic lenses. However, optometric examinations for any purpose are not covered.

[39 FR 28624, Aug. 9, 1974. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.233 Home health services; general.

Home health service benefits are provided under both the supplementary medical insurance plan described in this Subpart B and also under the hospital insurance benefits plan described in Subpart A of this part. Home health services qualify for payment under the supplementary medical insurance plan even though the individual has not been an inpatient of a hospital or skilled nursing facility. Payments for home health services for up to 100 visits (as defined in § 405.238) in a calendar year may be made under the supplementary medical insurance plan. This is entirely separate from the 100 health visits available (after the beginning of one spell of illness and before the beginning of the next) under the hospital insurance plan during the 1-year period after the individual's latest discharge from a qualifying inpatient stay.

§ 405.234 Home health services; conditions.

The items and services described in § 405.236 are "home health services" (unless excluded under § 405.237) if such items and services are furnished:

(a) To an individual who is under the care of a physician (other than a doctor of podiatry or surgical chiropody) and confined to his home;

(b) By a participating home health agency (see Subpart L of this Part 405) or by others under arrangements with them made by such agency;

(c) Under a written plan designed for such individual, established by a physician (other than a doctor of podiatry or surgical chiropody) and periodically reviewed by a physician (other than a doctor of podiatry or surgical chiropody); and

§ 405.235 Home health services; place where items and services must be furnished.

To be considered "home health services," items and services described in § 405.236 must be:

(a) Furnished on a visiting basis to the individual in a place of residence used as his home. The term "home" does not include an institution which meets the requirements of section 1861(e)(1) or 1861(j)(1) of the Act (see §§ 405.1001 and 405.1101); or

(b) Provided on an outpatient basis at a hospital or skilled nursing facility, or at a rehabilitation center if such items or services:

(1) Are furnished under arrangements made by a participating home health agency and such arrangements provide that payment to the agency discharges the liability of the patient or any other person to pay for the services; and

(2) Involve (or are furnished while the individual is there to receive) the use of equipment which cannot readily be made available to the individual in a place of residence used as his home, or cannot be supplied to him there (see also § 405.238).

§ 405.236 Home health services; items and services included.

Subject to the provisions described in §405.237, "home health services" means the following items and services furnished to an individual in accordance with §§ 405.234 and 405.235:

(a) Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse;

(b) Physical, occupational, or speech therapy (see § 405.239);

(c) Medical social services provided under the direction of a physician;

(d) Part-time or intermittent services of a home health aide;

(e) Medical supplies (other than drugs and biologicals) and the use of medical appliances while under the plan described in § 405.234(c);

(f) In the case of a home health agency which is affiliated or under common control with a hospital, medical services provided by an intern or resident-in-training of such hospital, under a teaching program of such hos

§ 405.237 Home health services; items and services not included.

(a) Items and services not considered as inpatient hospital services. Notwith tanding the provisions set forth in § 405.236, no item or service listed in § 405.236 is includable as a "home health service" if the item or service would not be included as an inpatient hospital service under Subpart A of this part, if furnished to a hospital inpatient.

(b) Transportation services. Transportation services, whether by ambulance or other means, required to take a homebound individual to a hospital, skilled nursing facility, rehabilitation center, or other place, in order to furnish him with items and services which cannot be supplied to him in his home, are not included as a "home health service," even though the services provided at such hospitals, etc., are included as a home health service.

(c) Housekeeping services. The services of housekeepers or food service arrangements such as those of "mealson-wheels" programs are not includable as "home health services."

§ 405.238 Home health services; "visits" defined.

For purposes of determining the 100visit home health services limitation specified in § 405.230(a)(4), one "visit" is charged each time a "home health service" is furnished to the individual by home health agency personnel (or by personnel furnishing "home health services" under an arrangement with them made by a home health agency). For example, since one "visit" is charged each time a therapist goes to an 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., hydroth

erapy) and, while at the hospital receives 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]

medical insurance benefits; amounts payable.

In the case of an individual who incurs expenses during his 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 §§ 405.243-405.246, be made as follows:

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

(2) Effective April 1, 1968, 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));

(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. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 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 8405.245), 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 mental, 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) 622 percent of such expenses, is considered as incurred expenses for purposes of §§ 405.240 and 405.245.