Title 42: Public Health
PART 410—SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS
Subpart I—Payment of SMI Benefits
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§ 410.155 Outpatient mental health treatment limitation.
(a) Limitation. Only 621/2 percent of the expenses incurred for services subject to the limit as specified in paragraph (b) of this section are considered incurred expenses under Medicare Part B when determining the amount of payment and deductible under §§410.152 and 410.160, respectively.
(b) Application of the limitation—(1) Services subject to the limitation. Except as specified in paragraph (b)(2) of this section, the following services are subject to the limitation if they are furnished in connection with the treatment of a mental, psychoneurotic, or personality disorder (that is, any condition identified by a diagnosis code within the range of 290 through 319) and are furnished to an individual who is not an inpatient of a hospital:
(i) Services furnished by physicians and other practitioners, whether furnished directly or as an incident to those practitioners' services.
(ii) Services provided by a CORF.
(2) Services not subject to the limitation. Services not subject to the limitation include the following:
(i) Services furnished to a hospital inpatient.
(ii) Brief office visits for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic, or personality disorders.
(iii) Partial hospitalization services not directly provided by a physician.
(iv) Diagnostic services, such as psychological testing, that are performed to establish a diagnosis.
(v) Medical management, as opposed to psychotherapy, furnished to a patient diagnosed with Alzheimer's disease or a related disorder.
(c) Examples. (1) A clinical psychologist submitted a claim for $200 for outpatient treatment of a beneficiary's mental disorder. The Medicare approved amount was $180. Since clinical psychologists must accept assignment, the beneficiary is not liable for the $20 in excess charges. The beneficiary previously satisfied the $100 annual Part B deductible. The limitation reduces the amount of incurred expenses to 621/2 percent of the approved amount. After subtracting any unmet deductible, Medicare pays 80 percent of the remaining incurred expenses. Medicare payment and beneficiary liability are computed as follows:
1. Actual charges............................................. $200.002. Medicare approved amount................................... 180.003. Medicare incurred expenses (0.625 x line 2)................ 112.504. Unmet deductible........................................... 0.005. Remainder after subtracting deductible (line 3 minus line 112.50 4)...........................................................6. Medicare payment (0.80 x line 5)........................... 90.007. Beneficiary liability (line 2 minus line 6)................ 90.00
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(2) A clinical social worker submitted a claim for $135 for outpatient treatment of a beneficiary's mental disorder. The Medicare approved amount was $120. Since clinical social workers must accept assignment, the beneficiary is not liable for the $15 in excess charges. The beneficiary previously satisfied $70 of the $100 annual Part B deductible, leaving $30 unmet.
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1. Actual charges............................................. $135.002. Medicare approved amount................................... 120.003. Medicare incurred expenses (0.625 x line 2)................ 75.004. Unmet deductible........................................... 30.005. Remainder after subtracting deductible (line 3 minus line 45.00 4)...........................................................6. Medicare payment (0.80 x line 5)........................... 36.007. Beneficiary liability (line 2 minus line 6)................ 84.00
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(3) A physician who did not accept assignment submitted a claim for $780 for services in connection with the treatment of a mental disorder that did not require inpatient hospitalization. The Medicare approved amount was $750. Because the physician did not accept assignment, the beneficiary is liable for the $30 in excess charges. The beneficiary had not satisfied any of the $100 Part B annual deductible.
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1. Actual charges............................................. $780.002. Medicare approved amount................................... 750.003. Medicare incurred expenses (0.625 x line 2)................ 468.754. Unmet deductible........................................... 100.005. Remainder after subtracting deductible (line 3 minus line 368.75 4)...........................................................6. Medicare payment (0.80 x line 5)........................... 295.007. Beneficiary liability (line 1 minus line 6)................ 485.00
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(4) A beneficiary's only Part B expenses during 1995 were for a physician's services in connection with the treatment of a mental disorder that initially required inpatient hospitalization. The remaining services were furnished on an outpatient basis. The beneficiary had not satisfied any of the $100 annual Part B deductible in 1995. The physician, who accepted assignment, submitted a claim for $780. The Medicare-approved amount was $750. The beneficiary incurred $350 of the approved amount while a hospital inpatient and incurred the remaining $400 of the approved amount for outpatient services. Only $400 of the approved amount is subject to the 621/2 percent limitation because the statutory limitation does not apply to services furnished to hospital inpatients.
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1. Actual charges............................................. $780.002. Medicare approved amount................................... $750.00 2A. Inpatient portion....................................... $350 2B. Outpatient portion...................................... $4003. Medicare incurred expenses................................. $600.00 3A. Inpatient portion....................................... $350 3B. Outpatient portion (0.625 x line 2B).................... $2504. Unmet deductible........................................... $100.005. Remainder after subtracting deductible (line 3 minus line $500.00 4)...........................................................6. Medicare payment (0.80 x line 5)........................... $400.007. Beneficiary liability (line 2 minus line 6)................ $350.00
