resident-in-training of such hospital, under a teaching program of such hospital approved as provided in § 405.116(f).

(g) Any of the items or services specified in paragraphs (a) through (f) of this section that are furnished on an outpatient basis at a hospital, skilled nursing facility, or rehabilitation center under an arrangement with the home health agency, even though the items or services could have been provided to him in his home. These items or services must be furnished at the same time that items or services which could not be readily available to him in his home are furnished to him.

[36 FR 16647, Aug. 25, 1971, as amended at 40 FR 44321, Sept. 26, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977, and further amended at 43 FR 49722, Oct. 24, 1978]

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

(a) Items and services not considered as inpatient hospital services. Notwithstanding 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., hydrotherapy) 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) 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 ra

American Psychiatric Association's Diagnostic and Statistical ManualMental 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 621⁄2 percent of $750). Mr. X is required to meet the first $60 as a deductible, and 20 percent of the balance. The remaining 80 percent is payable under this Subpart B.

520 percent of total covered expenses less deductible.

680 percent of total covered expenses less 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 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 pro

visions 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, 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 im

posed 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 payment is made under this Subpart B by the reasonable and customary charge made by the supplier (e.g., physician, hospital, clinic, etc.) for any of the first 3 pints of whole blood or equivalent quantities of packed red blood cells furnished to the individual in such calendar year.

(b) For purposes of the blood deductible described in paragraph (a) of this section:

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

(2) The amount of blood deductible is reduced to the extent that the individual replaces the blood on a pint for pint basis.

§ 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

60-131 O-81--6

(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 comprehen

sive 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]

§ 405.250 Procedures for payment; medical and other health services furnished by participating provider or ESRD facility; 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 for payment is filed by or on behalf of the individual to whom the services were furnished to have such payment made;

(b) A physician certifies, and recertifies (see 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. (If a Professional Standards Review Organization (PSRO) has assumed review responsibility in accordance with the applicable provisions of Part 463 of this chapter for the medical and other health services furnished by or in the participating provider, the certifications must be made by the attending physician under section 1156(d) of the Act in lieu of the physician certification required under this section. See