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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that partial hospitalization programs (PHPs) are structured to provide intensive psychiatric care
through active treatment that utilizes a combination of the clinically recognized items and services described in
1861(ff) of the Social Security Act (the Act). The treatment program of a PHP closely resembles that of a
highly structured, short-term hospital inpatient program. It is treatment at a level more intense than outpatient
day treatment or psychosocial rehabilitation. Programs providing primarily social, recreational, or diversionary
activities are not considered partial hospitalization.
PHPs work best as part of a community continuum of mental health services which range from the most
restrictive inpatient hospital setting to less restrictive outpatient care and support. Program objectives should
focus on ensuring important community ties and closely resemble the real-life experiences of the patients
served. PHPs may be covered under Medicare when they are provided by a hospital outpatient department or a
Medicare-certified CMHC.
Partial hospitalization is active treatment that incorporates an individualized treatment plan which describes a
coordination of services wrapped around the needs of the patient and includes a multidisciplinary team
approach to patient care under the direction of a physician. The program reflects a high degree of structure and
scheduling. According to current practice guidelines, the treatment goals should be measurable, functional,
time-framed, medically necessary, and directly related to the reason for admission.
A program comprised primarily of diversionary activity, social, or recreational therapy does not constitute a
PHP. Psychosocial programs which provide only a structured environment, socialization, and/or vocational
rehabilitation are not covered by Medicare. A program that only monitors the management of medication for
patients whose psychiatric condition is otherwise stable, is not the combination, structure, and intensity of
services which make up active treatment in a PHP.
Patients must meet benefit requirements for receiving the partial hospitalization services as defined in
1861(ff) and 1835(a)(2)(F) of the Act. Patients admitted to a PHP must be under the care of a physician who
certifies the need for partial hospitalization and require a minimum of 20 hours per week of therapeutic
services, as evidenced by their plan of care. The patients also require a comprehensive, structured, multimodal
treatment requiring medical supervision and coordination, provided under an individualized plan of care,
because of a mental disorder which severely interferes with multiple areas of daily life, including social,
vocational, and/or educational functioning. Such dysfunction generally is of an acute nature. In addition, PHP
patients must be able to cognitively and emotionally participate in the active treatment process, and be capable
of tolerating the intensity of a PHP program.
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual,
Publication 100-02, Medicare Benefit Policy Manual Chapter 6, Section 70.3.
The rules say that Medicare will not pay any expenses for items or services which are not medically necessary
and reasonable for the diagnosis or treatment of illness or injury. This exclusion extends to claims for services
which are provided in inappropriate settings. You can find this rule in the Social Security Act, Section
1862(a)(1).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.