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.