66, and who enrolls during his initial rollment period, begins on whichever later, July 1, 1966, or the 1st day of: (1) The month in which the eligibility quirements are first met, if he enrolls ring the three preceding months; (2) The month following the month which the eligibility requirements are st met, if he enrolls in the month such quirements are first met; (3) The third month following the onth in which the eligibility requireents are first met, if he enrolls in the onth following the month in which _ch requirements are first met; (4) The fifth month following the onth in which the eligibility requireents are first met, if he enrolls in the cond month following the month in hich such requirements are first met; (5) The sixth month following the onth in which the eligibility requireents are first met, if he enrolls in the ird month following the month such quirements are first met. Example: An individual first meets the gibility requirements for enrollment in oril of 1967. Therefore, his initial enrollent period runs from January through July 67. Depending upon the month in which enrolls, his coverage period will begin as llows: Coverage period begins itial enrollment = period: Enrolls in on (1) January----. Apr. 1 (month eligibility (2) February-(3) March. (4) April_--- (5) May.. (6) June----- (7) July--- requirements first met). Do. Do. May 1 (month following Oct. 1 (sixth month fol- (d) Enrollment during general enrollent period. The coverage period of an dividual who, after failing to enroll uring his initial enrollment period, enolls during a subsequent general enrollent period (1.e., the period October hrough December of each odd-numbered (b) The 1st day of the third month following the month in which the State agreement is entered into (or in the case of Social Security Act or Railroad Retirement Act beneficiaries covered by virtue of a modification described in § 405.217 (c), as of the 1st day of the third month following the month the modification is entered into); (c) The 1st day of the first month in which he is both an eligible individual (§ 405.205) and a member of a coverage group that is specified in such agreement, but without regard to any coverage period terminated prior to 1968; or (d) Such date as may be specified in the agreement, or, where the individual is covered by virtue of the modification described in § 405.217(c), as may be specified in the modification. (e) Notwithstanding the provisions of paragraph (d) of this section; the coverage period of an individual so enrolled shall not begin later than January 1, 1968. § 405.223 Coverage period; manner and time of termination. An individual's coverage period continues until such time as his enrollment is terminated. Enrollment, and the coverage period, may be terminated only as described in this section: (a) Individual requests termination. (1) An individual may, except as provided in subparagraph (2) of this paragraph, notify the Administration in writing, during a general enrollment period (see § 405.213) that he no longer wishes to participate in the supplementary medical insurance plan. In such case, his coverage period terminates effective with the close of the year in which the notice of nonparticipation is submitted to the Administration. (2) An individual entitled to monthly benefits under title II of the Act or to an annuity or pension under the Rail road Retirement Act of 1937, whose coverage attributable to a Federal-State agreement containing the provisions described in § 405.217 (c) is terminated or who ceases to be a member of the coverage group before his coverage under such agreement begins, may, by filing written notice with the Administration before the 1st day of the fourth month which begins after the date of such termination, terminate his enrollment under the supplementary medical insurance plan. In such case, his coverage period is terminated effective with the last day of the third month which begins after the date his coverage period under a FederalState agreement is terminated. (b) Nonpayment of premiums. Enrollment under the supplementary medical insurance plan shall be terminated because of nonpayment of premiums. (c) Enrollees pursuant to State agreements. In the case of an individual enrolled pursuant to a Federal-State agreement (see § 405.217), the coverage period attributable to the agreement ends (subject to the provisions of paragraph (d) of this section) on whichever of the following first occurs: (1) The last day of the month in which he becomes ineligible (as determined by the State) for money payments of a kind specified in the agreement; or (2) The last day of the month preceding the first month in which he becomes entitled to monthly benefits under title II of the Act (see Subpart D of Part 404) or to an annuity or pension under the Railroad Retirement Act of 1937 without regard to the retroactivity of such entitlement; or (3) The last day of the month in which the State agreement is terminated; or (4) The last day of the month in which he dies. (d) Continuation of enrollees coverage period pursuant to State agreements. Notwithstanding paragraph (c) of this section: (1) An individual's coverage period attributable to a Federal-State agreement shall not end when he becomes entitled to monthly benefits under title II of the Act or to an annuity or pension under the Railroad Retirement Act of 1937, if such agreement provides for the inclusion of individuals entitled to such benefits in the coverage group (see § 405.217 (c)). (2) If an individual's coverage pursuant to enrollment under a State agreement is terminated under the provisions of paragraph (c) of this section, such individual is deemed to have enrolled for supplementary medical insurance benefits in the initial enrollment period described in § 405.212 (b) and his coverage period continues until terminated for his failure to pay premiums or by timely filed notice that he wishes to terminate his supplementary medical insurance coverage, as provided in paragraphs (a) and (b) of this section. An individual who is enrolled under a State agreement but who ceases to be a member of the coverage group before his coverage begins is also deemed to have so enrolled and his coverage as an individual begins on the date his coverage under the agreement would have begun had he continued in the coverage group. § 405.224 Good cause for failure to enroll during the initial enrollment period ending May 31, 1966. An individual who first meets the eligibility requirements for enrollment prior to March 1, 1966, and who fails to enroll during the initial enrollment period ending May 31, 1966, may enroll at any time before October 1966 if such individual, or his representative, establishes to the satisfaction of the Administration that "good cause" exists because such failure was due to. (a) Circumstances beyond the individual's control, such as extended illness. mental or physical impairment, communication difficulties; (b) Incorrect or incomplete information furnished by official sources to the individual or another person acting on his behalf; (c) Difficulty encountered by the individual in obtaining, within a reasonable time before the end of the initial enrollment period, an enrollment form and information about supplementary medical insurance and the manner and time limit in which enrollments may be made; (d) Bona fide unawareness or misunderstanding of the need to enroll within the prescribed time period or of the nature of coverage under this Subpart B; or (e) Other circumstances (as a result of which the individual was deterred from enrolling) in the light of which it would be clearly inequitable to deny him a second chance to enroll. § 405.230 Supplementary medical insurance benefits. Any individual (a) Benefits provided. who is enrolled under the supplementary medical insurance plan established by title XVIII of the Act is, subject to the limitations and conditions described in this Part 405, entitled to have: (1) Payment made to him, or on his behalf, for physicians' services; (2) Payment made to him, or on his behalf, for medical and other health services (see § 405.231) furnished by other than a provider of services; (3) Payment made on his behalf for medical and other health services (see § 405.231) furnished to him by a provider of services (or furnished by others under an arrangement made with them by a provider of services); and (4) Payment made on his behalf for home health services (see § 405.233) for up to 100 visits (as discussed in § 405.238) during a calendar year. (b) Reimbursable expenses. In order to be considered incurred expenses, expenses for physicians' services and for other medical and health services covered under the supplementary medical insurance plan must be for services furnished to an individual during his coverage period. (See §§ 405.221 through 405.223). § 405.231 Medical and other health services; included items and services. Subject to the exclusions set forth in § 405.232, the term "medical and other health services" means the following items or services: (a) Physicians' services; (b) Services and supplies, including drugs and biologicals which cannot be self-administered, furnished as an incident to a physician's professional service, and of kinds which are commonly furnished in a physician's office and are commonly either rendered without charge, or included in the physician's bill; (c) Hospital services (including drugs and biologicals which cannot be selfadministered) incident to physicians' services rendered to outpatients; (d) Diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests; (e) X-ray therapy, radium therapy, and radioactive isotope therapy (includng materials and services of technicians administering such therapies); 635 (f) Surgical dressings, and splints, casts and other devices used for reduction of fractures and dislocations; (g) Rental of durable medical equipment, including iron lungs, oxygen tents, hospital beds, and wheel chairs used in the patient's home (including an institution used as his home); (h) Prosthetic devices (other than dental) which replace all or part of an internal body organ, including replacement of such devices; (i) Leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements if required because of a change in the patient's physical condition; and (j) Ambulance services where the use of other methods of transportation is contraindicated by the individual's condition but only if the individual is being transported to the nearest hospital with appropriate facilities, or to one in the same locality, and under similar restrictions, from one hospital to another, to his home, or to an extended care facility. "Locality" means the service area in the geographic territory surrounding the institution from which individuals normally come or are expected to come for medical services. § 405.232 Medical and other health services; exclusions. In addition to the general exclusions in section 1862 of the Act, the following items and services are also excluded from the term "medical and other health services": (a) Inpatient hospital services or outpatient hospital diagnostic services; extended care services; home health services. If any item or service described in § 405.231 would otherwise constitute inpatient hospital services or outpatient hospital diagnostic services, extended care services, or home health services (see §§ 405.233 through 405.237), it is not considered as a medical or other health service for purposes of § 405.230 (a) (2) or (3). (b) Diagnostic laboratory tests. For purposes of § 405.231(d), diagnostic tests are not considered as "medical or other health services" if performed in a laboratory which is independent of a physician's office or a hospital, unless such laboratory meets the requirements as set forth in subpart M of this part 405. (c) Drugs and biologicals. For purposes of § 405.230(a) (1), (2), or (3), drugs and biologicals which can be selfadministered are excluded from the term "medical and other health services" whether such drugs and biologicals are furnished by a physician, a provider of services, or other than a provider of services. § 405.233 Home health services; general. Home health service benefits are provided under both the supplementary medical insurance plan described in this Subpart B and the hospital insurance benefits plan described in part A of title XVIII of the Act. Home health services qualify for payment under the supplementary medical insurance plan even though the individual has not been an inpatient of a hospital or extended care facility. Payment for home health services for up to 100 visits may be made under the supplementary medical insurance plan in addition to, or as a supplement to, 100 visits under the hospital insurance benefits plan. § 405.234 Home health services; condi tions. The items and services described in § 405.236 are "home health services" (unless excluded under § 405.237) if such items and services are furnished: (a) To an individual who is under the care of a physician; (b) By a home health agency (see Subpart L of this Part 405) or by others under arrangements with them made by such agency; (c) Under a plan designed for such individual, established by a physician and periodically reviewed by a physician; and (d) At a place as described § 405.235. § 405.235 in Home health services; place where items and services must be furnished. To be considered "home health services," items and services described in § 405.236 must be: (a) Furnished on a visiting basis to the individual in a place of residence used as his home (e.g., his own home, a relative's home, a boardinghouse, or an old-age home); or (b) Provided on an outpatient basis at a hospital or extended care facility, or at a rehabilitation center if such items or services: (1) Are furnished under arrangements made by a home health agency and such arrangements provide that the costs for such services are to be billed through the home health agency (see Subpart L of this Part 405); and (2) Involve the use of equipment or services which cannot readily be made available to the individual in a place of residence used as his home, or cannot be supplied to him there. § 405.236 Home health services; items and services included. Subject to the provisions described in § 405.237, "home health services" means the following items and services furnished to an individual in accordance with §§ 405.234 and 405.235: (a) Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse; (b) Physical, occupational or speech therapy; (c) Medical social services provided under the direction of a physician; (d) Part-time or intermittent services of a home health aide but only if the duties of the home health aide are comparable to the duties of a nurse's aide in a hospital (e.g., giving bed baths to an ill or bedfast patient); (e) Medical supplies (other than drugs and biologicals) and the use of medical appliances while under the plan described in § 405.234 (c); (f) Medical services provided by an intern or resident-in-training of a hospital if: (1) The home health agency and the hospital are affiliated or under common control; (2) Such services are provided under a teaching program of the hospital; and (3) The teaching program of the hospital is approved by the Council on Medical Education of the American Medical Association, or the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association in the case of an osteopathic hospital, or the Council on Dental Education of the American Dental Association in the case of services in a hospital or osteopathic hospital performed by an intern or resident-intraining in the field of dentistry. Dental services in connection with the care. treatment, filling, removal or replace ment of teeth (or structures directly supporting teeth) are excluded from coverage. However, services including post-operative care with respect to surgery related to the jaw (or any structure contiguous to the jaw) or services with respect to any fracture of the jaw or facial bone are covered home health services if performed by an intern or resident-in-training. (g) Any of the items or services described in paragraphs (a) through (f) of this section which are furnished on an outpatient basis at a hospital, extended care facility, or rehabilitation center under an arrangement with such institution made by the home health agency even though such services could have been provided to him in his home, provided that such services are furnished at the same time that items or services which could not be readily available to him in his home are furnished to him. $405.237 Home health services; items and services not included. (a) Items and services not considered Es inpatient hospital services. Notwithtanding the provisions set forth in 405.236, no item or service listed in 405.236 is includable as a "home health ervice” if the item or service would not e included as an inpatient hospital ervice under part A of title XVIII of the Act, if furnished to a hospital inpatient. (b) Transportation services. Transortation services, whether by ambulance r other means, required to take a homeound individual to a hospital, extended are facility, rehabilitation center, or ther place, in order to furnish him with ems and services which cannot be suplied to him in his home, are not includble as a "home health service," even hough the services provided at such hosital, etc., are included as a home health ervice. (c) Housekeeping services. The serves of housekeepers or food service arangements such as those of "meals-onheels" programs are not includable as home health services." 405.238 Home health services; "visits" defined. For purposes of determining the 100sit home health services limitation ecified in § 405.230 (a) (4), one "visit" charged each time a "home health rvice" is furnished to the individual by home health agency personnel (or by personnel furnishing "home health services" under an arrangement with them made by a home health agency). For example, since one "visit" is charged each time a therapist goes to an individual's home to furnish therapy, if the individual is visited during the same day by both a speech therapist and a visiting nurse (or is provided with the same home health service twice in the same day), two "visits" are charged. Similarly, if an individual is taken to a hospital to receive outpatient therapy that could not be furnished in his own home (e.g., hydrotherapy) and, while at the hospital receives speech therapy and other services, all of which qualify as home health services under § 405.236 (g), two or more "visits" are charged. § 405.240 Payment of supplementary medical insurance benefits; amounts payable. In the case of an individual who incurs expenses during his coverage period under the supplementary medical insurance plan, payment shall be made for a portion of the total amount of expenses incurred during a calendar year (less the applicable medical insurance deductible (see § 405.245)) as follows: (a) 80 percent of the reasonable charges for medical and health services furnished by other than a provider of services; (b) 80 percent of the reasonable cost for medical and other health services furnished by (or under arrangements made by) providers of services; (c) 80 percent of the reasonable cost of home health services furnished by (or under arrangements made by) a home health agency; and (d) 80 percent of the deductible imposed under the hospital insurance benefits plan for outpatient hospital diagnostic services. Example: Mr. Z incurred expenses covered under the hospital insurance benefits plan of $75 for an outpatient hospital diagnostic study for which he paid the $20 outpatient hospital deductible. The diagnostic study was followed by a series of visits to his physician's office for which Mr. Z incurred expenses, covered under the supplementary medical insurance plan, amounting to $100. All of Mr. Z's medical expenses were incurred during 1 calendar year. Since the amount of an outpatient hospital diagnostic study deductible in a year is counted in determin |