[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR410.43]



[Page 340-341]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 410_SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS--Table of Contents

 

               Subpart B_Medical and Other Health Services

 

Sec. 410.43  Partial hospitalization services: Conditions and exclusions.



    (a) Partial hospitalization services are services that--

    (1) Are reasonable and necessary for the diagnosis or active 

treatment of the individual's condition;

    (2) Are reasonably expected to improve or maintain the individual's 

condition and functional level and to prevent relapse or 

hospitalization; and

    (3) Include any of the following:

    (i) Individual and group therapy with physicians or psychologists or 

other mental health professionals to the extent authorized under State 

law.

    (ii) Occupational therapy requiring the skills of a qualified 

occupational therapist.

    (iii) Services of social workers, trained psychiatric nurses, and 

other staff trained to work with psychiatric patients.

    (iv) Drugs and biologicals furnished for therapeutic purposes, 

subject to the limitations specified in Sec. 410.29.

    (v) Individualized activity therapies that are not primarily 

recreational or diversionary.

    (vi) Family counseling, the primary purpose of which is treatment of 

the individual's condition.

    (vii) Patient training and education, to the extent the training and 

educational activities are closely and clearly related to the 

individual's care and treatment.

    (viii) Diagnostic services.

    (b) The following services are separately covered and not paid as 

partial hospitalization services:



[[Page 341]]



    (1) Physician services that meet the requirements of Sec. 

415.102(a) of this chapter for payment on a fee schedule basis.

    (2) Physician assistant services, as defined in section 

1861(s)(2)(K)(i) of the Act.

    (3) Nurse practitioner and clinical nurse specialist services, as 

defined in section 1861(s)(2)(K)(ii) of the Act.

    (4) Qualified psychologist services, as defined in section 1861(ii) 

of the Act.

    (5) Services furnished to SNF residents as defined in Sec. 

411.15(p) of this chapter.



[59 FR 6577, Feb. 11, 1994, as amended at 65 FR 18536, Apr. 7, 2000]