Editorial Note on Part 410
Editorial Note: Nomenclature changes to part 410 appear at 62 FR 46037, Aug. 29, 1997.

§ 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;
( 3 ) Are furnished in accordance with a physician certification and plan of care as specified under § 424.24(e) of this chapter; and
( 4 ) Include any of the following: ( i ) Individual and group therapy with physicians or psychologists or other mental health professionals (including substance use disorder professionals) to the extent authorized under State law.
( ii ) Occupational therapy requiring the skills of a qualified occupational therapist, provided by an occupational therapist, or under appropriate supervision of a qualified occupational therapist by an occupational therapy assistant as specified in part 484 of this chapter.
( iii ) Services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients (including patients with substance use disorder).
( iv ) Drugs and biologicals furnished for therapeutic purposes, subject to the limitations specified in § 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: ( 1 ) Physician services that meet the requirements of § 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 § 411.15(p) of this chapter.
( c ) Partial hospitalization programs are intended for patients who— ( 1 ) Require a minimum of 20 hours per week of therapeutic services as evidenced in their plan of care;
( 2 ) Are likely to benefit from a coordinated program of services and require more than isolated sessions of outpatient treatment;
( 3 ) Do not require 24-hour care;
( 4 ) Have an adequate support system while not actively engaged in the program;
( 5 ) Have a mental health or substance use disorder diagnosis;
( 6 ) Are not judged to be dangerous to self or others; and
( 7 ) Have the cognitive and emotional ability to participate in the active treatment process and can tolerate the intensity of the partial hospitalization program.
[59 FR 6577, Feb. 11, 1994, as amended at 65 FR 18536, Apr. 7, 2000; 72 FR 66399, Nov. 27, 2007; 73 FR 68811, Nov. 18, 2008; 88 FR 82177, Nov. 22, 2023]