HI 00610.480 Noninpatient Psychiatric Services Limitation — Expenses Incurred for Physician's Services
Regardless of the actual expenses for physician's services incurred in connection
with the treatment of mental, psychoneurotic or personality disorders of persons who
are not inpatients of hospitals, the amount of such expenses that can be counted in
a calendar year is limited to the lesser of $312.50 or 62.5 percent of the reasonable
charges. The computation of noninpatient psychiatric expenses for deductible purposes
is also subject to the 62.5 percent rule. Since $312.50 represents 62.5 percent of
$500, any amount of noninpatient psychiatric service expense incurred after the reasonable
charge limit of $500 has been reached, would not be covered and, therefore would not
be considered in computing incurred expenses subject to reimbursement; since the program's
share of covered incurred expenses (after the deductible) is 80 percent of the reasonable
charges, the maximum possible payment for services would be 80 percent of $312.50,
i.e., $250. For services rendered in 1982, this maximum could be reached only if the
individual had met all of the cash deductible with allowed charges for other than
noninpatient psychiatric service expenses. Where the beneficiary does not have any
incurred expenses other than the noninpatient psychiatric service expenses, the maximum
possible payment by the program is $190. Charges for initial diagnostic services (i.e.,
psychiatric testing and evaluation used to diagnose the patient's illness) are not subject to this limitation. The limitation is applied only to therapeutic services
(e.g., psychotherapy and to follow-up diagnostic services which are performed to evaluate
the treatment.