US (United States) Code. Title 42. Chapter 7: Social Security

Codificación normativa de EEUU (Estados Unidos). Legislación federal estadounidense # The Public Health and Welfare

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-CITE-

42 USC Sec. 1384 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVI - SUPPLEMENTAL SECURITY INCOME FOR AGED, BLIND, AND

DISABLED

Part B - Procedural and General Provisions

-HEAD-

Sec. 1384. Omitted

-COD-

CODIFICATION

Section, act Aug. 14, 1935, ch. 531, title XVI, Sec. 1604, as

added July 25, 1962, Pub. L. 87-543, title I, Sec. 141(a), 76 Stat.

204, related to operation of State plans, prior to the general

revision of this subchapter by Pub. L. 92-603, Oct. 30, 1972, 86

Stat. 1465, eff. Jan. 1, 1974.

-MISC1-

PUERTO RICO, GUAM, AND VIRGIN ISLANDS

Enactment of subchapter XVI of the Social Security Act [this

subchapter] by Pub. L. 92-603, eff. Jan. 1, 1974, was not

applicable to Puerto Rico, Guam, and the Virgin Islands. See

section 303(b) of Pub. L. 92-603, set out as a note under section

301 of this title. Therefore, as to Puerto Rico, Guam, and the

Virgin Islands, section 1604 of the Social Security Act [this

section] as it existed prior to reenactment of this subchapter by

Pub. L. 92-603 continues to apply and reads as follows:

Sec. 1384. Operation of State plans

If the Commissioner of Social Security, after reasonable notice

and opportunity for hearing to the State agency administering or

supervising the administration of the State plan approved under

this subchapter, finds -

(1) that the plan has been so changed that it no longer

complies with the provisions of section 1332 of this title; or

(2) that in the administration of the plan there is a failure

to comply substantially with any such provision;

the Commissioner of Social Security shall notify such State agency

that further payments will not be made to the State (or, in the

Commissioner's discretion, that payments will be limited to

categories under or parts of the State plan not affected by such

failure), until the Commissioner of Social Security is satisfied

that there will no longer be any such failure to comply. Until the

Commissioner is so satisfied the Commissioner shall make no further

payments to such State (or shall limit payments to categories under

or parts of the State plan not affected by such failure).

(Aug. 14, 1935, ch. 531, title XVI, Sec. 1604, as added July 25,

1962, Pub. L. 87-543, title I, Sec. 141(a), 76 Stat. 204; amended

Aug. 15, 1994, Pub. L. 103-296, title I, Sec. 107(a)(4), 108 Stat.

1478.)

[Amendment by section 107(a)(4) of Pub. L. 103-296 effective Mar.

31, 1995, see section 110(a) of Pub. L. 103-296, set out as an

Effective Date of 1994 Amendment note under section 401 of this

title.]

-End-

-CITE-

42 USC Sec. 1385 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVI - SUPPLEMENTAL SECURITY INCOME FOR AGED, BLIND, AND

DISABLED

Part B - Procedural and General Provisions

-HEAD-

Sec. 1385. Omitted

-COD-

CODIFICATION

Section, act Aug. 14, 1935, ch. 531, title XVI, Sec. 1605, as

added July 25, 1962, Pub. L. 87-543, title I, Sec. 141(a), 76 Stat.

204; amended July 30, 1965, Pub. L. 89-97, title II, Secs.

221(d)(1), (2), 222(b), title IV, Sec. 402(b), 79 Stat. 358, 360,

416, defined "aid to the aged, blind, or disabled" and "medical

assistance for the aged", prior to the general revision of this

subchapter by Pub. L. 92-603, Oct. 30, 1972, 86 Stat. 1465, eff.

Jan. 1, 1974.

-MISC1-

PUERTO RICO, GUAM, AND VIRGIN ISLANDS

Enactment of subchapter XVI of the Social Security Act [this

subchapter] by section 301 of Pub. L. 92-603, eff. Jan. 1, 1974,

was not applicable to Puerto Rico, Guam, and the Virgin Islands.

See section 303(b) of Pub. L. 92-603, set out as a note under

section 301 of this title. Therefore, as to Puerto Rico, Guam, and

the Virgin Islands, section 1605 of the Social Security Act [this

section] as it existed prior to reenactment of this subchapter by

Pub. L. 92-603, and as amended, continues to apply and to read as

follows:

Sec. 1385. Definitions

(a) For purposes of this subchapter, the term "aid to the aged,

blind, or disabled" means money payments to needy individuals who

are 65 years of age or older, are blind, or are 18 years of age or

over and permanently and totally disabled, but such term does not

include -

(1) any such payments to or care in behalf of any individual

who is an inmate of a public institution (except as a patient in

a medical institution); or

(2) any such payments to or care in behalf of any individual

who has not attained 65 years of age and who is a patient in an

institution for tuberculosis or mental diseases.

Such term also includes payments which are not included within the

meaning of such term under the preceding sentence, but which would

be so included except that they are made on behalf of such a needy

individual to another individual who (as determined in accordance

with standards prescribed by the Commissioner of Social Security)

is interested in or concerned with the welfare of such needy

individual, but only with respect to a State whose State plan

approved under section 1382 of this title includes provision for -

(A) determination by the State agency that such needy

individual has, by reason of his physical or mental condition,

such inability to manage funds that making payments to him would

be contrary to his welfare and, therefore, it is necessary to

provide such aid through payments described in this sentence;

(B) making such payments only in cases in which such payments

will, under the rules otherwise applicable under the State plan

for determining need and the amount of aid to the aged, blind, or

disabled to be paid (and in conjunction with other income and

resources), meet all the need [sic] of the individuals with

respect to whom such payments are made;

(C) undertaking and continuing special efforts to protect the

welfare of such individual and to improve, to the extent

possible, his capacity for self-care and to manage funds;

(D) periodic review by such State agency of the determination

under clause (A) of this subsection to ascertain whether

conditions justifying such determination still exist, with

provision for termination of such payments if they do not and for

seeking judicial appointment of a guardian or other legal

representative, as described in section 1311 of this title, if

and when it appears that such action will best serve the

interests of such needy individual; and

(E) opportunity for a fair hearing before the State agency on

the determination referred to in clause (A) of this subsection

for any individual with respect to whom it is made.

At the option of a State (if its plan approved under this

subchapter so provides), such term (i) need not include money

payments to an individual who has been absent from such State for a

period in excess of ninety consecutive days (regardless of whether

he has maintained his residence in such State during such period)

until he has been present in such State for thirty consecutive days

in the case of such an individual who has maintained his residence

in such State during such period or ninety consecutive days in the

case of any other such individual, and (ii) may include rent

payments made directly to a public housing agency on behalf of a

recipient or a group or groups of recipients of aid under such

plan.

(b) Repealed. Pub. L. 97-35, title XXI, Sec. 2184(d)(6)(B), Aug.

13, 1981, 95 Stat. 818.

(Aug. 14, 1935, ch. 531, title XVI, Sec. 1605, as added July 25,

1962, Pub. L. 87-543, title I, Sec. 141(a), 76 Stat. 204; amended

July 30, 1965, Pub. L. 89-97, title II, Secs. 221(d)(1), (2),

222(b), title IV, Sec. 402(b), 79 Stat. 358, 360, 416; Oct. 30,

1972, Pub. L. 92-603, title IV, Secs. 408(d), 409(d), 86 Stat.

1490, 1491; Aug. 13, 1981, Pub. L. 97-35, title XXI, Sec.

2184(d)(6), 95 Stat. 818; Aug. 15, 1994, Pub. L. 103-296, title I,

Sec. 107(a)(4), 108 Stat. 1478.)

[Amendment by section 107(a)(4) of Pub. L. 103-296 effective Mar.

31, 1995, see section 110(a) of Pub. L. 103-296, set out as an

Effective Date of 1994 Amendment note under section 401 of this

title.]

-End-

-CITE-

42 USC SUBCHAPTER XVII - GRANTS FOR PLANNING

COMPREHENSIVE ACTION TO COMBAT MENTAL

RETARDATION 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO COMBAT

MENTAL RETARDATION

-HEAD-

SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO

COMBAT MENTAL RETARDATION

-SECREF-

SUBCHAPTER REFERRED TO IN OTHER SECTIONS

This subchapter is referred to in section 1320a-1 of this title.

-End-

-CITE-

42 USC Sec. 1391 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO COMBAT

MENTAL RETARDATION

-HEAD-

Sec. 1391. Authorization of appropriations

-STATUTE-

For the purpose of assisting the States (including the District

of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands,

Guam, and American Samoa) to plan for and take other steps leading

to comprehensive State and community action to combat mental

retardation, there is authorized to be appropriated the sum of

$2,200,000. There are also authorized to be appropriated, for

assisting such States in initiating the implementation and carrying

out of planning and other steps to combat mental retardation,

$2,750,000 for the fiscal year ending June 30, 1966, and $2,750,000

for the fiscal year ending June 30, 1967.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVII, Sec. 1701, as added Pub. L.

88-156, Sec. 5, Oct. 24, 1963, 77 Stat. 275; amended Pub. L. 89-97,

title II, Sec. 211(a), July 30, 1965, 79 Stat. 356.)

-MISC1-

AMENDMENTS

1965 - Pub. L. 89-97 authorized appropriations of $2,750,000 for

fiscal years ending June 30, 1966 and 1967 for implementation of

mental retardation planning.

SHORT TITLE

For short title of Pub. L. 88-156, which enacted this subchapter,

as the "Maternal and Child Health and Mental Retardation Planning

Amendments of 1963", see section 1 of Pub. L. 88-156, set out as a

Short Title of 1963 Amendment note under section 1305 of this

title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1392 of this title.

-End-

-CITE-

42 USC Sec. 1392 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO COMBAT

MENTAL RETARDATION

-HEAD-

Sec. 1392. Availability of funds during certain fiscal years;

limitation on amount; utilization of grant

-STATUTE-

The sums appropriated pursuant to the first sentence of section

1391 of this title shall be available for grants to States by the

Secretary during the fiscal year ending June 30, 1964, and the

succeeding fiscal year; and the sums appropriated pursuant to the

second sentence of such section for the fiscal year ending June 30,

1966, shall be available for such grants during such year and the

next two fiscal years, and sums appropriated pursuant thereto for

the fiscal year ending June 30, 1967, shall be available for such

grants during such year and the succeeding fiscal year. Any such

grant to a State, which shall not exceed 75 per centum of the cost

of the planning and related activities involved, may be used by it

to determine what action is needed to combat mental retardation in

the State and the resources available for this purpose, to develop

public awareness of the mental retardation problem and of the need

for combating it, to coordinate State and local activities relating

to the various aspects of mental retardation and its prevention,

treatment, or amelioration, and to plan other activities leading to

comprehensive State and community action to combat mental

retardation.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVII, Sec. 1702, as added Pub. L.

88-156, Sec. 5, Oct. 24, 1963, 77 Stat. 275; amended Pub. L. 89-97,

title II, Sec. 211(b), July 30, 1965, 79 Stat. 356.)

-MISC1-

AMENDMENTS

1965 - Pub. L. 89-97 inserted provision making appropriations for

fiscal year ending June 30, 1966, available for grants during such

fiscal year and the next two fiscal years and the appropriation for

fiscal year ending June 30, 1967, available for grants during such

fiscal year and the succeeding fiscal year.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1393 of this title.

-End-

-CITE-

42 USC Sec. 1393 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO COMBAT

MENTAL RETARDATION

-HEAD-

Sec. 1393. Applications; single State agency designation; essential

planning services; plans for expenditure; final activities report

and other necessary reports; records; accounting

-STATUTE-

In order to be eligible for a grant under section 1392 of this

title, a State must submit an application therefor which -

(1) designates or establishes a single State agency, which may

be an interdepartmental agency, as the sole agency for carrying

out the purposes of this subchapter;

(2) indicates the manner in which provision will be made to

assure full consideration of all aspects of services essential to

planning for comprehensive State and community action to combat

mental retardation, including services in the fields of

education, employment, rehabilitation, welfare, health, and the

law, and services provided through community programs for and

institutions for the mentally retarded;

(3) sets forth its plans for expenditure of such grant, which

plans provide reasonable assurance of carrying out the purposes

of this subchapter;

(4) provides for submission of a final report of the activities

of the State agency in carrying out the purposes of this

subchapter, and for submission of such other reports, in such

form and containing such information, as the Secretary may from

time to time find necessary for carrying out the purposes of this

subchapter and for keeping such records and affording such access

thereto as he may find necessary to assure the correctness and

verification of such reports; and

(5) provides for such fiscal control and fund accounting

procedures as may be necessary to assure proper disbursement of

and accounting for funds paid to the State under this subchapter.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVII, Sec. 1703, as added Pub. L.

88-156, Sec. 5, Oct. 24, 1963, 77 Stat. 275.)

-End-

-CITE-

42 USC Sec. 1394 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO COMBAT

MENTAL RETARDATION

-HEAD-

Sec. 1394. Payments to States; adjustments; advances or

reimbursement; installments; conditions

-STATUTE-

Payment of grants under this subchapter may be made (after

necessary adjustment on account of previously made underpayments or

overpayments) in advance or by way of reimbursement, and in such

installments and on such conditions, as the Secretary may

determine.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVII, Sec. 1704, as added Pub. L.

88-156, Sec. 5, Oct. 24, 1963, 77 Stat. 276.)

-End-

-CITE-

42 USC SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND

DISABLED 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-SECREF-

SUBCHAPTER REFERRED TO IN OTHER SECTIONS

This subchapter is referred to in sections 233, 254b, 254c-16,

254e, 254g, 254h, 256b, 263a, 273, 274c, 296, 297n, 299a, 299b-6,

299c-2, 300b-8, 300e-6, 300t-12, 300x-24, 300bb-2, 300bb-3, 401,

416, 417, 418, 423, 426-1, 434, 704, 902, 904, 907a, 912, 1301,

1302, 1306, 1320a-1, 1320a-3, 1320a-3a, 1320a-5, 1320a-7, 1320a-7a,

1320a-7b, 1320a-7d, 1320a-7f, 1320a-8, 1320b-4, 1320b-5, 1320b-8,

1320b-12, 1320b-13, 1320b-14, 1320c-2, 1320c-3, 1320c-4, 1320c-9,

1320c-10, 1383, 1395x, 1395gg, 1396a, 1396b, 1396d, 1396i, 1396l,

1396m, 1396r, 1396r-4, 1396t, 1396u-2, 1396u-4, 1397d, 1997, 3002,

3013, 5021, 10805, 14402 of this title; title 2 section 906; title

5 section 8904; title 7 sections 2012, 3178; title 8 sections 1182,

1611; title 10 sections 1079, 1086, 1095, 1095c; title 12 sections

1715w, 1715z-7; title 18 section 4006; title 20 sections 6082,

7182; title 23 section 157; title 24 section 170a; title 25

sections 1616m, 1641, 1643, 1644, 1645, 1680c; title 26 sections

220, 420, 856, 1402, 4980B, 6103, 7702B, 9703, 9704, 9712; title 29

sections 623, 720, 1162, 1163; title 31 section 3803; title 38

sections 1781, 7423, 8153; title 45 section 231r; title 49 section

5307.

-End-

-CITE-

42 USC Sec. 1395 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

Sec. 1395. Prohibition against any Federal interference

-STATUTE-

Nothing in this subchapter shall be construed to authorize any

Federal officer or employee to exercise any supervision or control

over the practice of medicine or the manner in which medical

services are provided, or over the selection, tenure, or

compensation of any officer or employee of any institution, agency,

or person providing health services; or to exercise any supervision

or control over the administration or operation of any such

institution, agency, or person.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1801, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 291.)

-MISC1-

SHORT TITLE

For short title of title I of Pub. L. 89-97, which enacted this

subchapter as the "Health Insurance for the Aged Act", see section

100 of Pub. L. 89-97, set out as a Short Title of 1965 Amendment

note under section 1305 of this title.

-End-

-CITE-

42 USC Sec. 1395a 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

Sec. 1395a. Free choice by patient guaranteed

-STATUTE-

(a) Basic freedom of choice

Any individual entitled to insurance benefits under this

subchapter may obtain health services from any institution, agency,

or person qualified to participate under this subchapter if such

institution, agency, or person undertakes to provide him such

services.

(b) Use of private contracts by medicare beneficiaries

(1) In general

Subject to the provisions of this subsection, nothing in this

subchapter shall prohibit a physician or practitioner from

entering into a private contract with a medicare beneficiary for

any item or service -

(A) for which no claim for payment is to be submitted under

this subchapter, and

(B) for which the physician or practitioner receives -

(i) no reimbursement under this subchapter directly or on a

capitated basis, and

(ii) receives no amount for such item or service from an

organization which receives reimbursement for such item or

service under this subchapter directly or on a capitated

basis.

(2) Beneficiary protections

(A) In general

Paragraph (1) shall not apply to any contract unless -

(i) the contract is in writing and is signed by the

medicare beneficiary before any item or service is provided

pursuant to the contract;

(ii) the contract contains the items described in

subparagraph (B); and

(iii) the contract is not entered into at a time when the

medicare beneficiary is facing an emergency or urgent health

care situation.

(B) Items required to be included in contract

Any contract to provide items and services to which paragraph

(1) applies shall clearly indicate to the medicare beneficiary

that by signing such contract the beneficiary -

(i) agrees not to submit a claim (or to request that the

physician or practitioner submit a claim) under this

subchapter for such items or services even if such items or

services are otherwise covered by this subchapter;

(ii) agrees to be responsible, whether through insurance or

otherwise, for payment of such items or services and

understands that no reimbursement will be provided under this

subchapter for such items or services;

(iii) acknowledges that no limits under this subchapter

(including the limits under section 1395w-4(g) of this title)

apply to amounts that may be charged for such items or

services;

(iv) acknowledges that Medigap plans under section 1395ss

of this title do not, and other supplemental insurance plans

may elect not to, make payments for such items and services

because payment is not made under this subchapter; and

(v) acknowledges that the medicare beneficiary has the

right to have such items or services provided by other

physicians or practitioners for whom payment would be made

under this subchapter.

Such contract shall also clearly indicate whether the physician

or practitioner is excluded from participation under the

medicare program under section 1320a-7 of this title.

(3) Physician or practitioner requirements

(A) In general

Paragraph (1) shall not apply to any contract entered into by

a physician or practitioner unless an affidavit described in

subparagraph (B) is in effect during the period any item or

service is to be provided pursuant to the contract.

(B) Affidavit

An affidavit is described in this subparagraph if -

(i) the affidavit identifies the physician or practitioner

and is in writing and is signed by the physician or

practitioner;

(ii) the affidavit provides that the physician or

practitioner will not submit any claim under this subchapter

for any item or service provided to any medicare beneficiary

(and will not receive any reimbursement or amount described

in paragraph (1)(B) for any such item or service) during the

2-year period beginning on the date the affidavit is signed;

and

(iii) a copy of the affidavit is filed with the Secretary

no later than 10 days after the first contract to which such

affidavit applies is entered into.

(C) Enforcement

If a physician or practitioner signing an affidavit under

subparagraph (B) knowingly and willfully submits a claim under

this subchapter for any item or service provided during the

2-year period described in subparagraph (B)(ii) (or receives

any reimbursement or amount described in paragraph (1)(B) for

any such item or service) with respect to such affidavit -

(i) this subsection shall not apply with respect to any

items and services provided by the physician or practitioner

pursuant to any contract on and after the date of such

submission and before the end of such period; and

(ii) no payment shall be made under this subchapter for any

item or service furnished by the physician or practitioner

during the period described in clause (i) (and no

reimbursement or payment of any amount described in paragraph

(1)(B) shall be made for any such item or service).

(4) Limitation on actual charge and claim submission requirement

not applicable

Section 1395w-4(g) of this title shall not apply with respect

to any item or service provided to a medicare beneficiary under a

contract described in paragraph (1).

(5) Definitions

In this subsection:

(A) Medicare beneficiary

The term "medicare beneficiary" means an individual who is

entitled to benefits under part A of this subchapter or

enrolled under part B of this subchapter.

(B) Physician

The term "physician" has the meaning given such term by

section 1395x(r)(1) of this title.

(C) Practitioner

The term "practitioner" has the meaning given such term by

section 1395u(b)(18)(C) of this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1802, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 291; amended

Pub. L. 105-33, title IV, Sec. 4507(a)(1), (2)(A), Aug. 5, 1997,

111 Stat. 439, 441.)

-REFTEXT-

REFERENCES IN TEXT

Parts A and B of this subchapter, referred to in subsec.

(b)(5)(A), are classified to sections 1395c et seq. and 1395j et

seq., respectively, of this title.

-MISC1-

AMENDMENTS

1997 - Pub. L. 105-33 designated existing provisions as subsec.

(a), inserted heading, and added subsec. (b).

EFFECTIVE DATE OF 1997 AMENDMENT

Section 4507(c) of Pub. L. 105-33 provided that: "The amendment

made by subsection (a) [amending this section and section 1395y of

this title] shall apply with respect to contracts entered into on

and after January 1, 1998."

REPORT TO CONGRESS ON EFFECT OF PRIVATE CONTRACTS

Section 4507(b) of title IV of Pub. L. 105-33 provided that: "Not

later than October 1, 2001, the Secretary of Health and Human

Services shall submit a report to Congress on the effect on the

program under this title [see Tables for classification] of private

contracts entered into under the amendment made by subsection (a)

[amending this section and section 1395y of this title]. Such

report shall include -

"(1) analyses regarding -

"(A) the fiscal impact of such contracts on total Federal

expenditures under title XVIII of the Social Security Act [this

subchapter] and on out-of-pocket expenditures by medicare

beneficiaries for health services under such title; and

"(B) the quality of the health services provided under such

contracts; and

"(2) recommendations as to whether medicare beneficiaries

should continue to be able to enter private contracts under

section 1802(b) of such Act [subsec. (b) of this section] (as

added by subsection (a)) and if so, what legislative changes, if

any should be made to improve such contracts."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395x, 1395y of this

title.

-End-

-CITE-

42 USC Sec. 1395b 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

Sec. 1395b. Option to individuals to obtain other health insurance

protection

-STATUTE-

Nothing contained in this subchapter shall be construed to

preclude any State from providing, or any individual from

purchasing or otherwise securing, protection against the cost of

any health services.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1803, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 291.)

-MISC1-

IMPACT OF INCREASED INVESTMENTS IN HEALTH RESEARCH ON FUTURE

MEDICARE COSTS

Pub. L. 105-78, title II, Nov. 13, 1997, 111 Stat. 1484, provided

in part: "That in carrying out its legislative mandate, the

National Bipartisan Commission on the Future of Medicare shall

examine the impact of increased investments in health research on

future Medicare costs, and the potential for coordinating Medicare

with cost-effective long-term care services".

NATIONAL BIPARTISAN COMMISSION ON THE FUTURE OF MEDICARE

Pub. L. 105-33, title IV, Sec. 4021, Aug. 5, 1997, 111 Stat. 347,

established National Bipartisan Commission on the Future of

Medicare which was directed to review and analyze long-term

financial condition of medicare program, identify problems that

threaten financial integrity of Federal Hospital Insurance Trust

Fund and Federal Supplementary Medical Insurance Trust Fund,

analyze potential solutions that will ensure both financial

integrity of medicare program and provision of appropriate benefits

under such program, and make recommendations for, among other

things, restoring solvency of Federal Hospital Insurance Trust Fund

and financial integrity of Federal Supplementary Medical Insurance

Trust Fund, establishing appropriate financial structure of

medicare program as a whole, and establishing appropriate balance

of benefits covered and beneficiary contributions to medicare

program, further provided for membership of Commission, meetings,

personnel and staff matters, powers of Commission, appropriations,

submission of final report to Congress not later than Mar. 1, 1999,

and termination of Commission 30 days after submission of final

report.

EXCLUSION FROM WAGES AND COMPENSATION OF REFUNDS REQUIRED FROM

EMPLOYERS TO COMPENSATE FOR DUPLICATION OF MEDICARE BENEFITS BY

HEALTH CARE BENEFITS PROVIDED BY EMPLOYERS

Pub. L. 101-239, title X, Sec. 10202, Dec. 19, 1989, 103 Stat.

2473, provided that:

"(a) Old-Age, Survivors, and Disability, and Hospital Insurance

Programs. - For purposes of title II of the Social Security Act

[subchapter II of this chapter] and chapter 21 of the Internal

Revenue Code of 1986 [26 U.S.C. 3101 et seq.], the term 'wages'

shall not include the amount of any refund required under section

421 of the Medicare Catastrophic Coverage Act of 1988 [section 421

of Pub. L. 100-360, formerly set out as a note below].

"(b) Railroad Retirement Program. - For purposes of chapter 22 of

the Internal Revenue Code of 1986 [26 U.S.C. 3201 et seq.], the

term 'compensation' shall not include the amount of any refund

required under section 421 of the Medicare Catastrophic Coverage

Act of 1988.

"(c) Federal Unemployment Programs. -

"(1) Federal unemployment tax. - For purposes of chapter 23 of

the Internal Revenue Code of 1986 [26 U.S.C. 3301 et seq.], the

term 'wages' shall not include the amount of any refund required

under section 421 of the Medicare Catastrophic Coverage Act of

1988.

"(2) Railroad unemployment contributions. - For purposes of the

Railroad Unemployment Insurance Act [45 U.S.C. 351 et seq.], the

term 'compensation' shall not include the amount of any refund

required under section 421 of the Medicare Catastrophic Coverage

Act of 1988.

"(3) Railroad unemployment repayment tax. - For purposes of

chapter 23A of the Internal Revenue Code of 1986 [26 U.S.C. 3321

et seq.], the term 'rail wages' shall not include the amount of

any refund required under section 421 of the Medicare

Catastrophic Coverage Act of 1988.

"(d) Reporting Requirements. - Any refund required under section

421 of the Medicare Catastrophic Coverage Act of 1988 shall be

reported to the Secretary of the Treasury or his delegate and to

the person to whom such refund is made in such manner as the

Secretary of the Treasury or his delegate shall prescribe.

"(e) Effective Date. - This section shall apply with respect to

refunds provided on or after January 1, 1989."

UNITED STATES BIPARTISAN COMMISSION ON COMPREHENSIVE HEALTH CARE

Pub. L. 100-360, title IV, subtitle A, Secs. 401-408, July 1,

1988, 102 Stat. 765-768, as amended by Pub. L. 100-647, title VIII,

Sec. 8414, Nov. 10, 1988, 102 Stat. 3801; Pub. L. 101-239, title

VI, Sec. 6220, Dec. 19, 1989, 103 Stat. 2254, established the

United States Bipartisan Commission on Comprehensive Health Care,

also known as the "Claude Pepper Commission" or the "Pepper

Commission", and directed Commission to examine shortcomings in

health care delivery and financing mechanisms that limit or prevent

access of all individuals in United States to comprehensive health

care, and make specific recommendations respecting Federal

programs, policies, and financing needed to assure the availability

of comprehensive long-term care services for elderly and disabled,

as well as comprehensive health care services for all individuals

in the United States, and further provided for membership of

Commission, staff and consultants, powers, authorization of

appropriations, submission of findings and recommendations to

Congress not later than Nov. 9, 1989, and for termination of

Commission 30 days after submissions to Congress.

MAINTENANCE OF EFFORT REGARDING DUPLICATIVE BENEFITS

Pub. L. 100-360, title IV, Sec. 421, July 1, 1988, 102 Stat. 808,

as amended by Pub. L. 100-485, title VI, Sec. 608(a), Oct. 13,

1988, 102 Stat. 2411, which required employers who had been

providing health care benefits to employees that were duplicative

part A and part B benefits to provide the employees with additional

benefits equal to the total actuarial value of such duplicative

benefits, was repealed by Pub. L. 101-234, title III, Sec. 301(a),

Dec. 13, 1989, 103 Stat. 1985. [Repeal not applicable to

duplicative part A benefits for periods before Jan. 1, 1990, see

section 301(e)(1) of Pub. L. 101-234, set out as an Effective Date

of 1989 Amendment note under section 1395u of this title.]

TASK FORCE ON LONG-TERM HEALTH CARE POLICIES

Pub. L. 99-272, title IX, Sec. 9601, Apr. 7, 1986, 100 Stat. 221,

as amended by Pub. L. 105-362, title VI, Sec. 601(b)(3), Nov. 10,

1998, 112 Stat. 3286, directed Secretary of Health and Human

Services, in consultation with National Association of Insurance

Commissioners, to establish Task Force on Long-Term Health Care

Policies to develop recommendations for long-term health care

policies designed to limit marketing and agent abuse for those

policies, to assure dissemination of such information to consumers

as is necessary to permit informed choice in purchasing policies

and to reduce purchase of unnecessary or duplicative coverage, to

assure that benefits provided under policies are reasonable in

relationship to premiums charged, and to promote development and

availability of long-term health care policies which meet these

recommendations, and further provided for composition of Task

Force, definition of long-term health care policy, assurance of

States' jurisdiction, submission of recommendations to Secretary

and Congress not later than 18 months after Apr. 7, 1986, and

termination of Task Force 90 days after submission of

recommendations.

-End-

-CITE-

42 USC Sec. 1395b-1 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

Sec. 1395b-1. Incentives for economy while maintaining or improving

quality in provision of health services

-STATUTE-

(a) Grants and contracts to develop and engage in experiments and

demonstration projects

(1) The Secretary of Health and Human Services is authorized,

either directly or through grants to public or private agencies,

institutions, and organizations or contracts with public or private

agencies, institutions, and organizations, to develop and engage in

experiments and demonstration projects for the following purposes:

(A) to determine whether, and if so which, changes in methods

of payment or reimbursement (other than those dealt with in

section 222(a) of the Social Security Amendments of 1972) for

health care and services under health programs established by

this chapter, including a change to methods based on negotiated

rates, would have the effect of increasing the efficiency and

economy of health services under such programs through the

creation of additional incentives to these ends without adversely

affecting the quality of such services;

(B) to determine whether payments for services other than those

for which payment may be made under such programs (and which are

incidental to services for which payment may be made under such

programs) would, in the judgment of the Secretary, result in more

economical provision and more effective utilization of services

for which payment may be made under such program, where such

services are furnished by organizations and institutions which

have the capability of providing -

(i) comprehensive health care services,

(ii) mental health care services (as defined by section

2691(c) (!1) of this title),

(iii) ambulatory health care services (including surgical

services provided on an outpatient basis), or

(iv) institutional services which may substitute, at lower

cost, for hospital care;

(C) to determine whether the rates of payment or reimbursement

for health care services, approved by a State for purposes of the

administration of one or more of its laws, when utilized to

determine the amount to be paid for services furnished in such

State under the health programs established by this chapter,

would have the effect of reducing the costs of such programs

without adversely affecting the quality of such services;

(D) to determine whether payments under such programs based on

a single combined rate of reimbursement or charge for the

teaching activities and patient care which residents, interns,

and supervising physicians render in connection with a graduate

medical education program in a patient facility would result in

more equitable and economical patient care arrangements without

adversely affecting the quality of such care;

(E) to determine whether coverage of intermediate care facility

services and homemaker services would provide suitable

alternatives to posthospital benefits presently provided under

this subchapter; such experiment and demonstration projects may

include:

(i) counting each day of care in an intermediate care

facility as one day of care in a skilled nursing facility, if

such care was for a condition for which the individual was

hospitalized,

(ii) covering the services of homemakers for a maximum of 21

days, if institutional services are not medically appropriate,

(iii) determining whether such coverage would reduce

long-range costs by reducing the lengths of stay in hospitals

and skilled nursing facilities, and

(iv) establishing alternative eligibility requirements and

determining the probable cost of applying each alternative, if

the project suggests that such extension of coverage would be

desirable;

(F) to determine whether, and if so which type of, fixed price

or performance incentive contract would have the effect of

inducing to the greatest degree effective, efficient, and

economical performance of agencies and organizations making

payment under agreements or contracts with the Secretary for

health care and services under health programs established by

this chapter;

(G) to determine under what circumstances payment for services

would be appropriate and the most appropriate, equitable, and

noninflationary methods and amounts of reimbursement under health

care programs established by this chapter for services, which are

performed independently by an assistant to a physician, including

a nurse practitioner (whether or not performed in the office of

or at a place at which such physician is physically present), and

-

(i) which such assistant is legally authorized to perform by

the State or political subdivision wherein such services are

performed, and

(ii) for which such physician assumes full legal and ethical

responsibility as to the necessity, propriety, and quality

thereof;

(H) to establish an experimental program to provide day-care

services, which consist of such personal care, supervision, and

services as the Secretary shall by regulation prescribe, for

individuals eligible to enroll in the supplemental medical

insurance program established under part B of this subchapter and

subchapter XIX of this chapter, in day-care centers which meet

such standards as the Secretary shall by regulation establish;

(I) to determine whether the services of clinical psychologists

may be made more generally available to persons eligible for

services under this subchapter and subchapter XIX of this chapter

in a manner consistent with quality of care and equitable and

efficient administration;

(J) to develop or demonstrate improved methods for the

investigation and prosecution of fraud in the provision of care

or services under the health programs established by this

chapter; and

(K) to determine whether the use of competitive bidding in the

awarding of contracts, or the use of other methods of

reimbursement, under part B of subchapter XI of this chapter

would be efficient and effective methods of furthering the

purposes of that part.

For purposes of this subsection, "health programs established by

this chapter" means the program established by this subchapter and

a program established by a plan of a State approved under

subchapter XIX of this chapter.

(2) Grants, payments under contracts, and other expenditures made

for experiments and demonstration projects under paragraph (1)

shall be made in appropriate part from the Federal Hospital

Insurance Trust Fund (established by section 1395i of this title)

and the Federal Supplementary Medical Insurance Trust Fund

(established by section 1395t of this title) and from funds

appropriated under subchapter XIX of this chapter. Grants and

payments under contracts may be made either in advance or by way of

reimbursement, as may be determined by the Secretary, and shall be

made in such installments and on such conditions as the Secretary

finds necessary to carry out the purpose of this section. With

respect to any such grant, payment, or other expenditure, the

amount to be paid from each of such trust funds (and from funds

appropriated under such subchapter XIX of this chapter) shall be

determined by the Secretary, giving due regard to the purposes of

the experiment or project involved.

(b) Waiver of certain payment or reimbursement requirements; advice

and recommendations of specialists preceding experiments and

demonstration projects

In the case of any experiment or demonstration project under

subsection (a) of this section, the Secretary may waive compliance

with the requirements of this subchapter and subchapter XIX of this

chapter insofar as such requirements relate to reimbursement or

payment on the basis of reasonable cost, or (in the case of

physicians) on the basis of reasonable charge, or to reimbursement

or payment only for such services or items as may be specified in

the experiment; and costs incurred in such experiment or

demonstration project in excess of the costs which would otherwise

be reimbursed or paid under such subchapters may be reimbursed or

paid to the extent that such waiver applies to them (with such

excess being borne by the Secretary). No experiment or

demonstration project shall be engaged in or developed under

subsection (a) of this section until the Secretary obtains the

advice and recommendations of specialists who are competent to

evaluate the proposed experiment or demonstration project as to the

soundness of its objectives, the possibilities of securing

productive results, the adequacy of resources to conduct the

proposed experiment or demonstration project, and its relationship

to other similar experiments and projects already completed or in

process.

-SOURCE-

(Pub. L. 90-248, title IV, Sec. 402(a), (b), Jan. 2, 1968, 81 Stat.

930, 931; Pub. L. 92-603, title II, Secs. 222(b), 278(b)(2), Oct.

30, 1972, 86 Stat. 1391, 1453; Pub. L. 95-142, Sec. 17(d), Oct. 25,

1977, 91 Stat. 1202; Pub. L. 96-88, title V, Sec. 509(b), Oct. 17,

1979, 93 Stat. 695; Pub. L. 97-35, title XXI, Sec. 2193(d), Aug.

13, 1981, 95 Stat. 828; Pub. L. 97-248, title I, Sec. 147, Sept. 3,

1982, 96 Stat. 394; Pub. L. 98-369, div. B, title III, Sec.

2331(b), July 18, 1984, 98 Stat. 1088.)

-REFTEXT-

REFERENCES IN TEXT

Section 222(a) of the Social Security Amendments of 1972,

referred to in subsec. (a)(1)(A), is section 222(a) of Pub. L.

92-603, Oct. 30, 1972, 86 Stat. 1329, which is set out as a note

below.

Section 2691(c) of this title, referred to in subsec.

(a)(1)(B)(ii), was repealed by Pub. L. 94-103, title III, Sec.

302(c), Oct. 4, 1975, 89 Stat. 507.

Part B of this subchapter, referred to in subsec. (a)(1)(H), is

classified to section 1395j et seq. of this title.

Part B of subchapter XI of this chapter, referred to in subsec.

(a)(1)(K), is classified to section 1320c et seq. of this title.

-COD-

CODIFICATION

Section is comprised of subsecs. (a) and (b) of section 402 of

Pub. L. 90-248. Subsec. (c) of such section 402 amended section

1395ll(b) of this title.

Section was enacted as a part of the Social Security Amendments

of 1967, and not as a part of the Social Security Act which

comprises this chapter.

-MISC1-

AMENDMENTS

1984 - Subsec. (a)(1). Pub. L. 98-369 substituted "grants to

public or private agencies" for "grants to public or nonprofit

private agencies" in provisions preceding subpar. (A).

1982 - Subsec. (a)(1)(K). Pub. L. 97-248 added subpar. (K).

1981 - Subsec. (a)(1). Pub. L. 97-35, Sec. 2193(d)(1),

substituted "this subchapter and a program established by a plan of

a State approved under subchapter XIX of this chapter" for "this

subchapter, a program established by a plan of a State approved

under subchapter XIX of this chapter, and a program established by

a plan of a State approved under subchapter V of this chapter".

Subsec. (a)(2). Pub. L. 97-35, Sec. 2193(d)(2), substituted

reference to subchapter XIX of this chapter for reference to

subchapters V and XIX of this chapter in two places.

Subsec. (b). Pub. L. 97-35, Sec. 2193(d)(3), substituted

reference to subchapter XIX of this chapter for reference to

subchapters V and XIX of this chapter.

1977 - Subsec. (a)(1)(J). Pub. L. 95-142 added subpar. (J).

1972 - Subsec. (a). Pub. L. 92-603, Secs. 222(b)(1), 278(b)(2),

substituted provisions spelling out in detail the purposes for

which experiments and demonstration projects may be carried out for

a general statement setting out the increase in efficiency and

economy of health services as the purpose of experiments selected

by the Secretary, inserted references to demonstration projects,

and inserted references to the Federal Hospital Insurance Trust

Fund and the Federal Supplementary Medical Insurance Trust Fund.

Subsec. (b). Pub. L. 92-603, Sec. 222(b)(2), inserted references

to demonstration projects and inserted ", or to reimbursement or

payment only for such services or items as may be specified in the

experiment".

-CHANGE-

CHANGE OF NAME

"Secretary of Health and Human Services" substituted for

"Secretary of Health, Education, and Welfare" in subsec. (a)(1)

pursuant to section 509(b) Pub. L. 96-88, which is classified to

section 3508(b) of Title 20, Education.

-MISC2-

EFFECTIVE DATE OF 1984 AMENDMENT

Amendment by Pub. L. 98-369 effective July 18, 1984, see section

2331(c) of Pub. L. 98-369, set out as a note under section 1310 of

this title.

EFFECTIVE DATE OF 1982 AMENDMENT

Amendment by Pub. L. 97-248 effective with respect to contracts

entered into or renewed on or after Sept. 3, 1982, see section 149

of Pub. L. 97-248, set out as an Effective Date note under section

1320c of this title.

EFFECTIVE DATE OF 1981 AMENDMENT, SAVINGS, AND TRANSITIONAL

PROVISIONS

For effective date, savings, and transitional provisions relating

to amendment by Pub. L. 97-35, see section 2194 of Pub. L. 97-35,

set out as a note under section 701 of this title.

DEMONSTRATION PROJECT FOR DISEASE MANAGEMENT FOR SEVERELY

CHRONICALLY ILL MEDICARE BENEFICIARIES

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 121], Dec. 21, 2000,

114 Stat. 2763, 2763A-474, provided that:

"(a) In General. - The Secretary of Health and Human Services

shall conduct a demonstration project under this section (in this

section referred to as the 'project') to demonstrate the impact on

costs and health outcomes of applying disease management to

medicare beneficiaries with diagnosed, advanced-stage congestive

heart failure, diabetes, or coronary heart disease. In no case may

the number of participants in the project exceed 30,000 at any

time.

"(b) Voluntary Participation. -

"(1) Eligibility. - Medicare beneficiaries are eligible to

participate in the project only if -

"(A) they meet specific medical criteria demonstrating the

appropriate diagnosis and the advanced nature of their disease;

"(B) their physicians approve of participation in the

project; and

"(C) they are not enrolled in a Medicare+Choice plan.

"(2) Benefits. - A beneficiary who is enrolled in the project

shall be eligible -

"(A) for disease management services related to their chronic

health condition; and

"(B) for payment for all costs for prescription drugs without

regard to whether or not they relate to the chronic health

condition, except that the project may provide for modest

cost-sharing with respect to prescription drug coverage.

"(c) Contracts With Disease Management Organizations. -

"(1) In general. - The Secretary of Health and Human Services

shall carry out the project through contracts with up to three

disease management organizations. The Secretary shall not enter

into such a contract with an organization unless the organization

demonstrates that it can produce improved health outcomes and

reduce aggregate medicare expenditures consistent with paragraph

(2).

"(2) Contract provisions. - Under such contracts -

"(A) such an organization shall be required to provide for

prescription drug coverage described in subsection (b)(2)(B);

"(B) such an organization shall be paid a fee negotiated and

established by the Secretary in a manner so that (taking into

account savings in expenditures under parts A and B of the

medicare program under title XVIII of the Social Security Act

[this subchapter]) there will be a net reduction in

expenditures under the medicare program as a result of the

project; and

"(C) such an organization shall guarantee, through an

appropriate arrangement with a reinsurance company or

otherwise, the net reduction in expenditures described in

subparagraph (B).

"(3) Payments. - Payments to such organizations shall be made

in appropriate proportion from the Trust Funds established under

title XVIII of the Social Security Act [this subchapter].

"(d) Application of Medigap Protections to Demonstration Project

Enrollees. - (1) Subject to paragraph (2), the provisions of

section 1882(s)(3) [section 1395ss(s)(3) of this title] (other than

clauses (i) through (iv) of subparagraph (B)) and 1882(s)(4) of the

Social Security Act shall apply to enrollment (and termination of

enrollment) in the demonstration project under this section, in the

same manner as they apply to enrollment (and termination of

enrollment) with a Medicare+Choice organization in a

Medicare+Choice plan.

"(2) In applying paragraph (1) -

"(A) any reference in clause (v) or (vi) of section

1882(s)(3)(B) of such Act [section 1395ss(s)(3)(B) of this title]

to 12 months is deemed a reference to the period of the

demonstration project; and

"(B) the notification required under section 1882(s)(3)(D) of

such Act [section 1395ss(s)(3)(D) of this title] shall be

provided in a manner specified by the Secretary of Health and

Human Services.

"(e) Duration. - The project shall last for not longer than 3

years.

"(f) Waiver. - The Secretary of Health and Human Services shall

waive such provisions of title XVIII of the Social Security Act

[this subchapter] as may be necessary to provide for payment for

services under the project in accordance with subsection (c)(3).

"(g) Report. - The Secretary of Health and Human Services shall

submit to Congress an interim report on the project not later than

2 years after the date it is first implemented and a final report

on the project not later than 6 months after the date of its

completion. Such reports shall include information on the impact of

the project on costs and health outcomes and recommendations on the

cost-effectiveness of extending or expanding the project."

CANCER PREVENTION AND TREATMENT DEMONSTRATION FOR ETHNIC AND RACIAL

MINORITIES

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 122], Dec. 21, 2000,

114 Stat. 2763, 2763A-476, provided that:

"(a) Demonstration. -

"(1) In general. - The Secretary of Health and Human Services

(in this section referred to as the 'Secretary') shall conduct

demonstration projects (in this section referred to as

'demonstration projects') for the purpose of developing models

and evaluating methods that -

"(A) improve the quality of items and services provided to

target individuals in order to facilitate reduced disparities

in early detection and treatment of cancer;

"(B) improve clinical outcomes, satisfaction, quality of

life, and appropriate use of medicare-covered services and

referral patterns among those target individuals with cancer;

"(C) eliminate disparities in the rate of preventive cancer

screening measures, such as pap smears and prostate cancer

screenings, among target individuals; and

"(D) promote collaboration with community-based organizations

to ensure cultural competency of health care professionals and

linguistic access for persons with limited English proficiency.

"(2) Target individual defined. - In this section, the term

'target individual' means an individual of a racial and ethnic

minority group, as defined by section 1707 of the Public Health

Service Act [section 300u-6 of this title], who is entitled to

benefits under part A, and enrolled under part B, of title XVIII

of the Social Security Act [parts A and B of this subchapter].

"(b) Program Design. -

"(1) Initial design. - Not later than 1 year after the date of

the enactment of this Act [Dec. 21, 2000], the Secretary shall

evaluate best practices in the private sector, community

programs, and academic research of methods that reduce

disparities among individuals of racial and ethnic minority

groups in the prevention and treatment of cancer and shall design

the demonstration projects based on such evaluation.

"(2) Number and project areas. - Not later than 2 years after

the date of the enactment of this Act, the Secretary shall

implement at least nine demonstration projects, including the

following:

"(A) Two projects for each of the four following major racial

and ethnic minority groups:

"(i) American Indians, including Alaska Natives, Eskimos,

and Aleuts.

"(ii) Asian Americans and Pacific Islanders.

"(iii) Blacks.

"(iv) Hispanics.

The two projects must target different ethnic subpopulations.

"(B) One project within the Pacific Islands.

"(C) At least one project each in a rural area and inner-city

area.

"(3) Expansion of projects; implementation of demonstration

project results. - If the initial report under subsection (c)

contains an evaluation that demonstration projects -

"(A) reduce expenditures under the medicare program under

title XVIII of the Social Security Act [this subchapter]; or

"(B) do not increase expenditures under the medicare program

and reduce racial and ethnic health disparities in the quality

of health care services provided to target individuals and

increase satisfaction of beneficiaries and health care

providers;

the Secretary shall continue the existing demonstration projects

and may expand the number of demonstration projects.

"(c) Report to Congress. -

"(1) In general. - Not later than 2 years after the date the

Secretary implements the initial demonstration projects, and

biannually thereafter, the Secretary shall submit to Congress a

report regarding the demonstration projects.

"(2) Contents of report. - Each report under paragraph (1)

shall include the following:

"(A) A description of the demonstration projects.

"(B) An evaluation of -

"(i) the cost-effectiveness of the demonstration projects;

"(ii) the quality of the health care services provided to

target individuals under the demonstration projects; and

"(iii) beneficiary and health care provider satisfaction

under the demonstration projects.

"(C) Any other information regarding the demonstration

projects that the Secretary determines to be appropriate.

"(d) Waiver Authority. - The Secretary shall waive compliance

with the requirements of title XVIII of the Social Security Act

[this subchapter] to such extent and for such period as the

Secretary determines is necessary to conduct demonstration

projects.

"(e) Funding. -

"(1) Demonstration projects. -

"(A) State projects. - Except as provided in subparagraph

(B), the Secretary shall provide for the transfer from the

Federal Hospital Insurance Trust Fund and the Federal

Supplementary [Medical] Insurance Trust Fund under title XVIII

of the Social Security Act [this subchapter], in such

proportions as the Secretary determines to be appropriate, of

such funds as are necessary for the costs of carrying out the

demonstration projects.

"(B) Territory projects. - In the case of a demonstration

project described in subsection (b)(2)(B), amounts shall be

available only as provided in any Federal law making

appropriations for the territories.

"(2) Limitation. - In conducting demonstration projects, the

Secretary shall ensure that the aggregate payments made by the

Secretary do not exceed the sum of the amount which the Secretary

would have paid under the program for the prevention and

treatment of cancer if the demonstration projects were not

implemented, plus $25,000,000."

LIFESTYLE MODIFICATION PROGRAM DEMONSTRATION

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 128], Dec. 21, 2000,

114 Stat. 2763, 2763A-480, provided that:

"(a) In General. - The Secretary of Health and Human Services

shall carry out the demonstration project known as the Lifestyle

Modification Program Demonstration, as described in the Health Care

Financing Administration Memorandum of Understanding entered into

on November 13, 2000, and as subsequently modified, (in this

section referred to as the 'project') in accordance with the

following requirements:

"(1) The project shall include no fewer than 1,800 medicare

beneficiaries who complete under the project the entire course of

treatment under the Lifestyle Modification Program.

"(2) The project shall be conducted over a course of 4 years.

"(b) Study on Cost-Effectiveness. -

"(1) Study. - The Secretary shall conduct a study on the

cost-effectiveness of the Lifestyle Modification Program as

conducted under the project. In determining whether such Program

is cost-effective, the Secretary shall determine (using a control

group under a matched paired experimental design) whether

expenditures incurred for medicare beneficiaries enrolled under

the project exceed expenditures for the control group of medicare

beneficiaries with similar health conditions who are not enrolled

under the project.

"(2) Reports. -

"(A) Initial report. - Not later that [sic] 1 year after the

date on which 900 medicare beneficiaries have completed the

entire course of treatment under the Lifestyle Modification

Program under the project, the Secretary shall submit to

Congress an initial report on the study conducted under

paragraph (1).

"(B) Final report. - Not later that [sic] 1 year after the

date on which 1,800 medicare beneficiaries have completed the

entire course of treatment under such Program under the

project, the Secretary shall submit to Congress a final report

on the study conducted under paragraph (1)."

MEDICARE COORDINATED CARE DEMONSTRATION PROJECT

Pub. L. 105-33, title IV, Sec. 4016, Aug. 5, 1997, 111 Stat. 343,

as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V,

Sec. 535], Nov. 29, 1999, 113 Stat. 1536, 1501A-390, provided that:

"(a) Demonstration Projects. -

"(1) In general. - The Secretary of Health and Human Services

(in this section referred to as the 'Secretary') shall conduct

demonstration projects for the purpose of evaluating methods,

such as case management and other models of coordinated care,

that -

"(A) improve the quality of items and services provided to

target individuals; and

"(B) reduce expenditures under the medicare program under

title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.)

for items and services provided to target individuals.

"(2) Target individual defined. - In this section, the term

'target individual' means an individual that has a chronic

illness, as defined and identified by the Secretary, and is

enrolled under the fee-for-service program under parts A and B of

title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.;

1395j et seq.).

"(b) Program Design. -

"(1) Initial design. - The Secretary shall evaluate best

practices in the private sector of methods of coordinated care

for a period of 1 year and design the demonstration project based

on such evaluation.

"(2) Number and project areas. - Not later than 2 years after

the date of enactment of this Act [Aug. 5, 1997], the Secretary

shall implement at least 9 demonstration projects, including -

"(A) 5 projects in urban areas;

"(B) 3 projects in rural areas; and

"(C) 1 project within the District of Columbia which is

operated by a nonprofit academic medical center that maintains

a National Cancer Institute certified comprehensive cancer

center.

"(3) Expansion of projects; implementation of demonstration

project results. -

"(A) Expansion of projects. - If the initial report under

subsection (c) contains an evaluation that demonstration

projects -

"(i) reduce expenditures under the medicare program; or

"(ii) do not increase expenditures under the medicare

program and increase the quality of health care services

provided to target individuals and satisfaction of

beneficiaries and health care providers;

the Secretary shall continue the existing demonstration projects

and may expand the number of demonstration projects.

"(B) Implementation of demonstration project results. - If a

report under subsection (c) contains an evaluation as described

in subparagraph (A), the Secretary may issue regulations to

implement, on a permanent basis, the components of the

demonstration project that are beneficial to the medicare

program.

"(c) Report to Congress. -

"(1) In general. - Not later than 2 years after the Secretary

implements the initial demonstration projects under this section,

and biannually thereafter, the Secretary shall submit to Congress

a report regarding the demonstration projects conducted under

this section.

"(2) Contents of report. - The report in paragraph (1) shall

include the following:

"(A) A description of the demonstration projects conducted

under this section.

"(B) An evaluation of -

"(i) the cost-effectiveness of the demonstration projects;

"(ii) the quality of the health care services provided to

target individuals under the demonstration projects; and

"(iii) beneficiary and health care provider satisfaction

under the demonstration project.

"(C) Any other information regarding the demonstration

projects conducted under this section that the Secretary

determines to be appropriate.

"(d) Waiver Authority. - The Secretary shall waive compliance

with the requirements of title XVIII of the Social Security Act (42

U.S.C. 1395 et seq.) to such extent and for such period as the

Secretary determines is necessary to conduct demonstration

projects.

"(e) Funding. -

"(1) Demonstration projects. -

"(A) In general. -

"(i) State projects. - Except as provided in clause (ii),

the Secretary shall provide for the transfer from the Federal

Hospital Insurance Trust Fund and the Federal Supplementary

[Medical] Insurance Trust Fund under title XVIII of the

Social Security Act (42 U.S.C. 1395i, 1395t), in such

proportions as the Secretary determines to be appropriate, of

such funds as are necessary for the costs of carrying out the

demonstration projects under this section.

"(ii) Cancer hospital. - In the case of the project

described in subsection (b)(2)(C), the Secretary shall

provide for the transfer from the Federal Hospital Insurance

Trust Fund and the Federal Supplementary Insurance Trust Fund

[Medical] under title XVIII of the Social Security Act (42

U.S.C. 1395i, 1395t), in such proportions as the Secretary

determines to be appropriate, of such funds as are necessary

to cover costs of the project, including costs for

information infrastructure and recurring costs of case

management services, flexible benefits, and program

management.

"(B) Limitation. - In conducting the demonstration project

under this section, the Secretary shall ensure that the

aggregate payments made by the Secretary do not exceed the

amount which the Secretary would have paid if the demonstration

projects under this section were not implemented.

"(2) Evaluation and report. - There are authorized to be

appropriated such sums as are necessary for the purpose of

developing and submitting the report to Congress under subsection

(c)."

INFORMATICS, TELEMEDICINE, AND EDUCATION DEMONSTRATION PROJECT

Pub. L. 105-33, title IV, Sec. 4207, Aug. 5, 1997, 111 Stat. 379,

as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title IV,

Sec. 413], Nov. 29, 1999, 113 Stat. 1536, 1501A-377, provided that:

"(a) Purpose and Authorization. -

"(1) In general. - Not later than 9 months after the date of

enactment of this section [Aug. 5, 1997], the Secretary of Health

and Human Services shall provide for a demonstration project

described in paragraph (2). The Secretary shall make an award for

such project not later than 3 months after the date of the

enactment of the Medicare, Medicaid, and SCHIP Balanced Budget

Refinement Act of 1999 [Nov. 29, 1999]. The Secretary shall

accept the proposal adjudged to be the best technical proposal as

of such date of enactment without the need for additional review

or resubmission of proposals.

"(2) Description of project. -

"(A) In general. - The demonstration project described in

this paragraph is a single demonstration project to use

eligible health care provider telemedicine networks to apply

high-capacity computing and advanced networks to improve

primary care (and prevent health care complications) to

medicare beneficiaries with diabetes mellitus who are residents

of medically underserved rural areas or residents of medically

underserved inner-city areas that qualify as Federally

designated medically underserved areas or health professional

shortage areas at the time of enrollment of beneficiaries under

the project.

"(B) Medically underserved defined. - As used in this

paragraph, the term 'medically underserved' has the meaning

given such term in section 330(b)(3) of the Public Health

Service Act (42 U.S.C. 254b(b)(3)).

"(3) Waiver. - The Secretary shall waive such provisions of

title XVIII of the Social Security Act [this subchapter] as may

be necessary to provide for payment for services under the

project in accordance with subsection (d).

"(4) Duration of project. - The project shall be conducted over

a 4-year period.

"(b) Objectives of Project. - The objectives of the project

include the following:

"(1) Improving patient access to and compliance with

appropriate care guidelines for individuals with diabetes

mellitus through direct telecommunications link with information

networks in order to improve patient quality-of-life and reduce

overall health care costs.

"(2) Developing a curriculum to train health professionals

(particularly primary care health professionals) in the use of

medical informatics and telecommunications.

"(3) Demonstrating the application of advanced technologies,

such as video-conferencing from a patient's home, remote

monitoring of a patient's medical condition, interventional

informatics, and applying individualized, automated care

guidelines, to assist primary care providers in assisting

patients with diabetes in a home setting.

"(4) Application of medical informatics to residents with

limited English language skills.

"(5) Developing standards in the application of telemedicine

and medical informatics.

"(6) Developing a model for the cost-effective delivery of

primary and related care both in a managed care environment and

in a fee-for-service environment.

"(c) Eligible Health Care Provider Telemedicine Network Defined.

- For purposes of this section, the term 'eligible health care

provider telemedicine network' means a consortium that includes at

least one tertiary care hospital (but no more than 2 such

hospitals), at least one medical school, no more than 4 facilities

in rural or urban areas, and at least one regional

telecommunications provider and that meets the following

requirements:

"(1) The consortium is located in an area with a high

concentration of medical schools and tertiary care facilities in

the United States and has appropriate arrangements (within or

outside the consortium) with such schools and facilities,

universities, and telecommunications providers, in order to

conduct the project.

"(2) The consortium submits to the Secretary an application at

such time, in such manner, and containing such information as the

Secretary may require, including a description of the use to

which the consortium would apply any amounts received under the

project.

"(3) The consortium guarantees that it will be responsible for

payment for all costs of the project that are not paid under this

section and that the maximum amount of payment that may be made

to the consortium under this section shall not exceed the amount

specified in subsection (d)(3).

"(d) Coverage as Medicare Part B Services. -

"(1) In general. - Subject to the succeeding provisions of this

subsection, services related to the treatment or management of

(including prevention of complications from) diabetes for

medicare beneficiaries furnished under the project shall be

considered to be services covered under part B of title XVIII of

the Social Security Act [part B of this subchapter].

"(2) Payments. -

"(A) In general. - Subject to paragraph (3), payment for such

services shall be made for the costs that are related to the

provision of such services. In computing such costs, the

Secretary shall include costs described in subparagraph (B),

but may not include costs described in subparagraph (C).

"(B) Costs that may be included. - The costs described in

this subparagraph are the permissible costs (as recognized by

the Secretary) for the following:

"(i) The acquisition of telemedicine equipment for use in

patients' homes or at sites providing health care to patients

located in medically underserved areas.

"(ii) Curriculum development and training of health

professionals in medical informatics and telemedicine.

"(iii) Payment of telecommunications costs (including

salaries and maintenance of equipment), including costs of

telecommunications between patients' homes and the eligible

network and between the network and other entities under the

arrangements described in subsection (c)(1).

"(iv) Payments to practitioners and providers under the

medicare programs.

"(C) Costs not included. - The costs described in this

subparagraph are costs for any of the following:

"(i) The purchase or installation of transmission equipment

(other than such equipment used by health professionals for

activities related to the project).

"(ii) The establishment or operation of a

telecommunications common carrier network.

"(iii) Construction (except for minor renovations related

to the installation of reimbursable equipment) or the

acquisition or building of real property.

"(3) Limitation. - The total amount of the payments that may be

made under this section shall not exceed $30,000,000 for the

period of the project (described in subsection (a)(4)).

"(4) Cost-sharing. - The project may not impose cost-sharing on

a medicare beneficiary for the receipt of services under the

project. Project costs will cover all costs to medicare

beneficiaries and providers related to participation in the

project.

"(e) Reports. - The Secretary shall submit to the Committee on

Ways and Means and the Committee [on] Commerce [now Committee on

Energy and Commerce] of the House of Representatives and the

Committee on Finance of the Senate interim reports on the project

and a final report on the project within 6 months after the

conclusion of the project. The final report shall include an

evaluation of the impact of the use of telemedicine and medical

informatics on improving access of medicare beneficiaries to health

care services, on reducing the costs of such services, and on

improving the quality of life of such beneficiaries.

"(f) Definitions. - For purposes of this section:

"(1) Interventional informatics. - The term 'interventional

informatics' means using information technology and virtual

reality technology to intervene in patient care.

"(2) Medical informatics. - The term 'medical informatics'

means the storage, retrieval, and use of biomedical and related

information for problem solving and decision-making through

computing and communications technologies.

"(3) Project. - The term 'project' means the demonstration

project under this section."

CLARIFICATION OF SECRETARIAL WAIVER AUTHORITY FOR RURAL HOSPITAL

DEMONSTRATIONS

Pub. L. 101-508, title IV, Sec. 4008(i)(1), Nov. 5, 1990, 104

Stat. 1388-50, as amended by Pub. L. 103-66, title XIII, Sec.

13507, Aug. 10, 1993, 107 Stat. 579, provided that: "The Secretary

of Health and Human Services is authorized to waive such provisions

of title XVIII of the Social Security Act [this subchapter] as are

necessary to conduct any demonstration project for limited-service

rural hospitals with respect to which the Secretary has entered

into an agreement before the date of the enactment of the Omnibus

Budget Reconciliation Act of 1989 [Dec. 19, 1989]. The Secretary

shall continue any such demonstration project until at least July

1, 1997."

VOLUNTEER SENIOR AIDES DEMONSTRATION PROJECTS FOR BASIC MEDICAL

ASSISTANCE AND SUPPORT TO FAMILIES WITH DISABLED OR ILL CHILDREN

Pub. L. 101-239, title X, Sec. 10404, Dec. 19, 1989, 103 Stat.

2488, provided that:

"(a) Number of Projects. - In order to determine whether, and if

so, the extent to which, the use of volunteer senior aides to

provide basic medical assistance and support to families with

moderately or severely disabled or chronically ill children

contributes to reducing the costs of care for such children, not

more than 10 communities may conduct demonstration projects under

this section.

"(b) Duties of the Secretary. -

"(1) Consideration of applications. - The Secretary of Health

and Human Services (in this section referred to as the

'Secretary') shall consider all applications received from

communities desiring to conduct demonstration projects under this

section.

"(2) Approval of certain applications. - The Secretary shall

approve not more than 10 applications to conduct projects which

appear likely to contribute significantly to the achievement of

the purpose of this section.

"(3) Grants. - The Secretary shall make grants to each

community the application of which to conduct a demonstration

project under this section is approved by the Secretary to assist

the community in carrying out the project.

"(c) Requirements. - Each community receiving a grant with

respect to a demonstration project under this section shall conduct

the project in accordance with such requirements as the Secretary

may prescribe.

"(d) Limitation on Authorization of Appropriations. - For grants

under this section, there are authorized to be appropriated to the

Secretary of Health and Human Services not to exceed -

"(1) $1,000,000 for each of the fiscal years 1990 and 1991; and

"(2) $2,000,000 for each of the fiscal years 1992, 1993, and

1994.

"(e) Effective Date. - This section shall take effect on October

1, 1989."

TREATMENT OF CERTAIN NURSING EDUCATION PROGRAMS

Pub. L. 100-647, title VIII, Sec. 8411, Nov. 10, 1988, 102 Stat.

3800, as amended by Pub. L. 101-239, title VI, Sec. 6205(a)(1)(B),

Dec. 19, 1989, 103 Stat. 2243, provided that:

"(a) Demonstration of Joint Nursing Graduate Education Programs.

-

"(1) The Secretary of Health and Human Services shall provide

for demonstration programs under this subsection in each of 5

hospitals for cost reporting periods beginning on or after July

1, 1989, and before July 1, 1994.

"(2) Under each demonstration project, subject to paragraph

(4), the reasonable costs incurred by a hospital pursuant to a

written agreement with an educational institution for the

activities described in paragraph (3) conducted as part of an

approved educational program that -

"(A) involves a substantial clinical component (as determined

by the Secretary), and

"(B) leads to a master's or doctoral degree in nursing,

shall be allowable as reasonable costs under title XVIII of the

Social Security Act [this subchapter] and reimbursed under such

title on the same basis as if they were allowable direct costs of

a hospital-operated approved educational program (other than an

approved graduate medical education program).

"(3) The activities described in this paragraph are the

activities for which the reasonable costs of conducting such

activities are allowable under title XVIII of the Social Security

Act if conducted under a hospital-operated approved educational

program (other than an approved graduate medical education

program), but only to the extent such activities are directly

related to the operation of the educational program conducted

pursuant to the written agreement between the hospital and the

educational institution.

"(4) The amount paid under a demonstration program under this

subsection to a hospital for a cost reporting period may not

exceed $200,000.

"(5) The Secretary shall report to Congress, by not later than

January 1, 1995, on the demonstration programs conducted under

this subsection and on the supply and characteristics of nurses

trained under such programs.

"(b) Joint Undergraduate Education Program. - In the case of a

hospital which (1) was paid under a waiver under section 402 of the

Social Security Amendments of 1967 [section 402 of Pub. L. 90-248,

enacting this section and amending section 1395ll of this title]

and section 222 of the Social Security Amendments of 1972 [section

222 of Pub. L. 92-603, amending this section and section 1395ll of

this title and enacting provisions set out below], which waiver

expired on September 30, 1985, and (2) during its cost reporting

period beginning in fiscal year 1985 and for each subsequent cost

reporting period, has been and is associated with, and has incurred

and incurs substantial costs with respect to, a nursing college

with which it has shared and shares common directors, educational

activities of the nursing college shall be considered to be

educational activities operated directly by such hospital for

purposes of title XVIII of the Social Security Act [this

subchapter], and shall be allowable as reasonable costs under such

title and reimbursed under such title on the same basis as if they

were allowable direct costs of a hospital-operated approved

educational program (other than an approved graduate medical

education program), for hospital cost reporting periods beginning

in fiscal years 1986 though 1991."

RESEARCH ON LONG-TERM CARE SERVICES FOR MEDICARE BENEFICIARIES

Pub. L. 100-360, title II, Sec. 207, July 1, 1988, 102 Stat. 732,

which provided for research on issues relating to the delivery and

financing of long-term care services for medicare beneficiaries,

was repealed by Pub. L. 101-234, title II, Sec. 201(a), Dec. 13,

1989, 103 Stat. 1981.

ADJUSTMENT OF CONTRACTS WITH PREPAID HEALTH PLANS

For requirement that Secretary of Health and Human Services

modify contracts with health maintenance organizations under

subsec. (a) of this section and section 222(a) of Pub. L. 92-603,

set out below, so as to apply to such organizations and contracts

the requirements imposed by the amendments made by Pub. L. 100-360,

see section 222 of Pub. L. 100-360, set out as a note under section

1395mm of this title.

CASE MANAGEMENT DEMONSTRATION PROJECTS

Pub. L. 101-508, title IV, Sec. 4207(f), formerly Sec. 4027(f),

Nov. 5, 1990, 104 Stat. 1388-123, as renumbered by Pub. L. 103-432,

title I, Sec. 160(d)(4), Oct. 31, 1994, 108 Stat. 4444, provided

that:

"(1) In general. - Notwithstanding any other provision of law,

the Secretary of Health and Human Services shall resume the 3 case

management demonstration projects described in paragraph (2) and

approved under section 425 of the Medicare Catastrophic Coverage

Act of 1988 [Pub. L. 100-360, formerly set out below] (in this

subsection referred to as 'MCCA').

"(2) Project descriptions. - The demonstration projects referred

to in paragraph (1) are -

"(A) the project proposed to be conducted by Providence

Hospital for case management of the elderly at risk for acute

hospitalization as described in Project No. 18-P-99379/5-01;

"(B) the project proposed to be conducted by the Iowa

Foundation for Medical Care to study patients with chronic

congestive conditions to reduce repeated hospitalizations of such

patients as described in Project No. P-99399/4-01; and

"(C) the project proposed to be conducted by Key Care Health

Resources, Inc., to examine the effects of case management on

2,500 high cost medicare beneficiaries as described in Project

No. 18-P-99396/5.

"(3) Terms and conditions. - Except as provided in paragraph (4),

the demonstration projects resumed pursuant to paragraph (1) shall

be subject to the same terms and conditions established under

section 425 of MCCA. In determining the 2-year duration period of a

project resumed pursuant to paragraph (1), the Secretary may not

take into account any period of time for which the project was in

effect under section 425 of MCCA.

"(4) Authorization of appropriations. - Notwithstanding section

425(g) of MCCA, there are authorized to be appropriated for

administrative costs in carrying out the demonstration projects

resumed pursuant to paragraph (1) $2,000,000 in each of fiscal

years 1991 and 1992."

Pub. L. 100-360, title IV, Sec. 425, July 1, 1988, 102 Stat. 813,

which directed Secretary of Health and Human Services to establish

4 demonstration projects under which an appropriate entity agreed

to provide case management services, was repealed by Pub. L.

101-234, title III, Sec. 301(a), Dec. 13, 1989, 103 Stat. 1985.

DEMONSTRATION PROJECTS WITH RESPECT TO CHRONIC VENTILATOR-DEPENDENT

UNITS IN HOSPITALS

Pub. L. 100-360, title IV, Sec. 429, July 1, 1988, 102 Stat. 817,

as amended by Pub. L. 100-647, title VIII, Sec. 8404(a), Nov. 10,

1988, 102 Stat. 3800, directed Secretary of Health and Human

Services, in consultation with the Prospective Payment Assessment

Commission, to provide for at least 5 demonstration projects, for

at least 3 years each, to review appropriateness of classifying

chronic ventilator-dependent units in hospitals as rehabilitation

units.

RESEARCH AND DEMONSTRATION PROJECTS ON RURAL AND INNER-CITY HEALTH

ISSUES

Pub. L. 100-203, title IV, Sec. 4403, Dec. 22, 1987, 1330-226, as

amended by Pub. L. 100-360, title IV, Sec. 411(m)(2)(A), July 1,

1988, 102 Stat. 806, provided that:

"(a) Set Asides for Issues of Health Care in Rural Areas and In

Inner-City Areas. - (1) Not less than ten percent of the total

amounts annually appropriated to, and expended by, the Health Care

Financing Administration for the conduct of research and

demonstration projects in fiscal years 1988, 1989, and 1990 shall

be expended for research and demonstration projects relating

exclusively or substantially to rural health issues, including (but

not limited to) the impact of the payment methodology under section

1886(d) of the Social Security Act [section 1395ww(d) of this

title] on the financial viability of small rural hospitals, the

effect of medicare payment policies on the ability of rural areas

(and rural hospitals in particular) to attract and retain

physicians and other health professionals, the appropriateness of

medicare conditions of participation and staffing requirements for

small rural hospitals, and the impact of medicare policies on

access to (and the quality of) health care in rural areas.

"(2) Not less than ten percent of the total amounts annually

appropriated to, and expended by, the Health Care Financing

Administration for the conduct of research and demonstration

projects in fiscal years 1988, 1989, and 1990 shall be expended for

research and demonstration projects relating exclusively or

substantially to issues of providing health care in inner-city

areas, including (but not limited to) the impact of the payment

methodology under section 1886(d) of the Social Security Act on the

financial viability of inner-city hospitals and the impact of

medicare policies on access to (and the quality of) health care in

inner-city areas.

"(b) Agenda. - The Secretary of Health and Human Services shall

establish an agenda of research and demonstration projects,

relating exclusively or substantially to rural health issues or to

inner-city health issues, that are in progress or have been

proposed, and shall include such agenda in the annual report

submitted pursuant to section 1875(b) of the Social Security Act

[section 1395ll(b) of this title]. The agenda shall be accompanied

by a statement setting forth the amounts that have been obligated

and expended with respect to such projects in the current and most

recently completed fiscal years."

ALZHEIMER'S DISEASE DEMONSTRATION PROJECTS

Pub. L. 99-509, title IX, Sec. 9342, Oct. 21, 1986, 100 Stat.

2038, as amended by Pub. L. 101-508, title IV, Sec. 4164(a)(2),

Nov. 5, 1990, 104 Stat. 1388-101; Pub. L. 103-66, title XIII, Sec.

13552, Aug. 10, 1993, 107 Stat. 591, required Secretary of Health

and Human Services to conduct at least 5 (and not more than 10)

demonstration projects, each over a period of 5 years, to determine

effectiveness, cost, and impact on health status and functioning of

providing comprehensive services for individuals entitled to

benefits under this subchapter who are victims of Alzheimer's

disease or related disorders and to report to Congress upon

completion of the projects.

SPECIAL TREATMENT OF STATES FORMERLY UNDER WAIVER

For treatment of hospitals in States which have had a waiver

approved under this section, upon termination of waiver, see

section 9202(j) of Pub. L. 99-272, as amended, set out as a note

under section 1395ww of this title.

EXTENSION OF CERTAIN MEDICARE MUNICIPAL HEALTH SERVICES

DEMONSTRATION PROJECTS

Pub. L. 99-272, title IX, Sec. 9215, Apr. 7, 1986, 100 Stat. 180,

as amended by Pub. L. 101-239, title VI, Sec. 6135, Dec. 19, 1989,

103 Stat. 2222; Pub. L. 103-66, title XIII, Sec. 13557, Aug. 10,

1993, 107 Stat. 592; Pub. L. 105-33, title IV, Sec. 4017, Aug. 5,

1997, 111 Stat. 345; Pub. L. 106-113, div. B, Sec. 1000(a)(6)

[title V, Sec. 534], Nov. 29, 1999, 113 Stat. 1536, 1501A-390; Pub.

L. 106-554, Sec. 1(a)(6) [title VI, Sec. 633], Dec. 21, 2000, 114

Stat. 2763, 2763A-568, provided that:

"(a) The Secretary of Health and Human Services shall extend

through December 31, 1997, approval of four municipal health

services demonstration projects (located in Baltimore, Cincinnati,

Milwaukee, and San Jose) authorized under section 402(a) of the

Social Security Amendments of 1967 [subsec. (a) of this section].

The Secretary shall submit a report to Congress on the waiver

program with respect to the quality of health care, beneficiary

costs, costs to the medicaid program and other payers, access to

care, outcomes, beneficiary satisfaction, utilization differences

among the different populations served by the projects, and such

other factors as may be appropriate. Subject to subsection (c), the

Secretary may further extend such demonstration projects through

December 31, 2004, but only with respect to individuals who

received at least one service during the period beginning on

January 1, 1996, and ending on the date of the enactment of the

Balanced Budget Act of 1997 [Aug. 5, 1997].

"(b) The Secretary shall work with each such demonstration

project to develop a plan, to be submitted to the Committee on Ways

and Means and the Committee on Commerce of the House of

Representatives and the Committee on Finance of the Senate by March

31, 1998, for the orderly transition of demonstration projects and

the project participants to a non-demonstration project health care

delivery system, such as through integration with a private or

public health plan, including a medicaid managed care or

Medicare+Choice plan.

"(c) A demonstration project under subsection (a) which does not

develop and submit a transition plan under subsection (b) by March

31, 1998, or, if later, 6 months after the date of the enactment of

the Balanced Budget Act of 1997 [Aug. 5, 1997], shall be

discontinued as of December 31, 1998. The Secretary shall provide

appropriate technical assistance to assist in the transition so

that disruption of medical services to project participants may be

minimized."

DEMONSTRATION PROGRAM FOR REDUCTION OF DISABILITY AND DEPENDENCY

THROUGH PROVISION OF PREVENTIVE HEALTH SERVICES UNDER MEDICARE

Pub. L. 99-272, title IX, Sec. 9314, Apr. 7, 1986, 100 Stat. 194,

as amended by Pub. L. 99-509, title IX, Sec. 9344(d), Oct. 21,

1986, 100 Stat. 2042; Pub. L. 101-508, title IV, Sec. 4164(a)(1),

Nov. 5, 1990, 104 Stat. 1388-100, required Secretary of Health and

Human Services to establish a 5-year demonstration program designed

to reduce disability and dependency through the provision of

preventive health services to individuals entitled to benefits

under this subchapter and to submit reports to Congress including a

final report on the project not later than April 1, 1995.

PAYMENT FOR COSTS OF HOSPITAL-BASED MOBILE INTENSIVE CARE UNITS

Section 2320 of Pub. L. 98-369 provided that:

"(a)(1) In the case of a project described in subsection (b), the

Secretary of Health and Human Services shall provide, except as

provided in paragraph (2), that the amount of payments to hospitals

covered under the project during the period described in paragraph

(3) shall include payments for their operation of hospital-based

mobile intensive care units (as defined by State statute) if the

State provides satisfactory assurances that the total amount of

payments to such hospitals under titles XVIII and XIX of the Social

Security Act [this subchapter and subchapter XIX of this chapter]

under the demonstration project (including any such additional

amount of payment) would not exceed the total amount of payments

which would have been paid under such titles if the demonstration

project were not in effect.

"(2) Paragraph (1) shall not apply if the State in which the

project is located notifies the Secretary, within 30 days after the

date of the enactment of this section [July 18, 1984], that the

State does not want paragraph (1) to apply to that project.

"(3) The period referred to in paragraph (1) begins on the date

of the enactment of this section and continues so long as the

Secretary continues the Statewide waiver referred to in subsection

(b), but in no case ends earlier than 90 days after the date final

regulations to implement section 1886(c) of the Social Security Act

[section 1395ww(c) of this title] are published.

"(b) The project referred to in subsection (a) is the statewide

demonstration project established in the State of New Jersey under

section 402 of the Social Security Amendments of 1967, as amended

by section 222(b) of the Social Security Amendments of 1972 (Public

Law 92-603) [this section], which project provides for payments to

hospitals in the State on a prospective basis and related to a

classification of patients by diagnosis-related groups.

"(c) Payment for services described in this section shall be

considered to be payments for services under part A of title XVIII

of the Social Security Act [part A of this subchapter]."

CONTINUATION OF SECRETARY'S AUTHORITY REGARDING EXPERIMENTS AND

DEMONSTRATION PROJECTS

Pub. L. 98-21, title VI, Sec. 603(b), Apr. 20, 1983, 97 Stat.

167, provided that:

"(1) Except as provided in paragraph (2), the amendments made by

this title [amending sections 1320a-1, 1320c-2, 1395f, 1395i-2,

1395n, 1395r, 1395v, 1395w, 1395x, 1395y, 1395cc, 1395mm, 1395oo,

1395rr, 1395ww, and 1395xx of this title, enacting provisions set

out as notes under this section and sections 1395r, 1395x, 1395y,

1395cc, and 1395ww of this title, and amending provisions set out

as a note under section 1395x of this title] shall not affect the

authority of the Secretary to develop, carry out, or continue

experiments and demonstration projects.

"(2) The Secretary shall provide that, upon the request of a

State which has a demonstration project, for payment of hospitals

under title XVIII of the Social Security Act [this subchapter]

approved under section 402(a) of the Social Security Amendments of

1967 [subsec. (a) of this section] or section 222(a) of the Social

Security Amendments of 1972 [set out as a note below], which (A) is

in effect as of March 1, 1983, and (B) was entered into after

August 1982 (or upon the request of another party to demonstration

project agreement), the terms of the demonstration agreement shall

be modified so that the demonstration project is not required to

maintain the rate of increase in medicare hospital costs in that

State below the national rate of increase in medicare hospital

costs."

ALTERNATIVE CARE DEMONSTRATION PROJECTS IN HOSPITALS SHORT OF

SKILLED NURSING FACILITIES

Pub. L. 98-21, title VI, Sec. 603(d), Apr. 20, 1983, 97 Stat.

168, provided that: "The Secretary shall conduct demonstrations

with hospitals in areas with critical shortages of skilled nursing

facilities to study the feasibility of providing alternative

systems of care or methods of payment."

CONTINUATION OF HOSPICE DEMONSTRATION PROJECTS; REPORT TO CONGRESS

Section 122(i), formerly Sec. 122(h), of Pub. L. 97-248, as

redesignated and amended by Pub. L. 97-448, title III, Sec.

309(a)(6), (e), Jan. 12, 1983, 96 Stat. 2408, 2410, provided that:

"(1) Notwithstanding any provision of law which has the effect of

restricting the time period of a hospice demonstration project in

effect on July 15, 1982, pursuant to section 402(a) of the Social

Security Amendments of 1967 [subsec. (a) of this section], the

Secretary of Health and Human Services, upon request of the hospice

involved, shall permit continuation of the project until November

1, 1983, or, if later, the date on which payments can first be made

to any hospice program under the amendments made by this section.

"(2) Prior to September 30, 1983, the Secretary shall submit to

Congress a report on the effectiveness of demonstration projects

referred to in paragraph (1), including an evaluation of the

cost-effectiveness of hospice care, the reasonableness of the

40-percent cap amount for hospice care as provided in section

1814(i) of the Social Security Act [section 1395f(i) of this title]

(as added by this section), proposed methodology for determining

such cap amount, proposed standards for requiring and measuring the

maintenance of effort for utilizing volunteers as required under

section 1861(dd) of such Act [section 1395x(dd) of this title], an

evaluation of physician reimbursement for services furnished as a

part of hospice care and for services furnished to individuals

receiving hospice care but which are not reimbursed as a part of

the hospice care, and any proposed legislative changes in the

hospice care provisions of title XVIII of such Act [this

subchapter].

"(3)(A) Notwithstanding the provisions of paragraph (1), the

Secretary of Health and Human Services, upon request of the hospice

involved, shall permit continuation of a hospice demonstration

project described in paragraph (1) until September 30, 1986, if the

hospice involved in such demonstration project does not provide

hospice care directly but acts as a channeling agency for the

provision of hospice care.

"(B) During the period after the date on which a hospice

demonstration project described in subparagraph (A) would otherwise

have terminated under the provisions of paragraph (1), and prior to

September 30, 1986, any such hospice demonstration project shall be

subject to the same requirements as are imposed under the hospice

program provided for under the amendments made by this section

[amending sections 1395c to 1395f, 1395h, and 1395x to 1395cc of

this title and section 231f of Title 45, Railroads, and enacting

provisions set out as notes under sections 1395c and 1395f of this

title] with respect to reimbursement and benefits, other than the

requirement that certain benefits be provided directly by the

hospice involved."

STATE MEDICARE HOSPITAL REIMBURSEMENT DEMONSTRATION PROJECT

LIMITATION

Pub. L. 96-499, title IX, Sec. 903(c), Dec. 5, 1980, 94 Stat.

2615, which provided for a maximum number of six Statewide medicare

hospital reimbursement demonstration projects, was repealed by Pub.

L. 97-35, title XXI, Sec. 2154, Aug. 13, 1981, 95 Stat. 802.

STUDY OF NEED FOR DUAL PARTICIPATION OF SKILLED NURSING FACILITIES

Pub. L. 96-499, title IX, Sec. 919, Dec. 5, 1980, 94 Stat. 2627,

required study of need for dual participation of skilled nursing

facilities and submission of a report and recommendations to

Congress within one year after Dec. 5, 1980.

DEMONSTRATION PROJECTS FOR PHYSICIAN-DIRECTED CLINICS IN URBAN

MEDICALLY UNDERSERVED AREAS; REPORT SUBMITTED NO LATER THAN JANUARY

1, 1981

Pub. L. 95-210, Sec. 3, Dec. 13, 1977, 91 Stat. 1489, required

the Secretary to provide, through demonstration projects,

reimbursement on a cost basis for services provided by

physician-directed clinics in urban medically underserved areas for

which payment may be made under this subchapter and,

notwithstanding any other provision of this subchapter, for

services provided by a physician assistant or nurse practitioner

employed by such clinics which would otherwise be covered under

this subchapter if provided by a physician. The Secretary was to

evaluate the relative advantages and disadvantages of reimbursement

on the basis of costs and fee-for-service for physician-directed

clinics employing a physician assistant or nurse practitioner, the

appropriate method of determining the compensation for physician

services on a cost basis for the purposes of reimbursement of

services provided in such clinics, the appropriate definition for

such clinics, the appropriate criteria to use for the purposes of

designating urban medically underserved areas, and such other

possible changes in the provisions of this subchapter as might be

appropriate for the efficient and cost-effective reimbursement of

services provided in such clinics. Grants, payments under

contracts, and other expenditures made for demonstration projects

were to be made in appropriate part from the Federal Hospital

Insurance Trust Fund and the Federal Supplementary Medical

Insurance Trust Fund. The Secretary was to submit to the Congress,

no later than Jan. 1, 1981, a complete detailed report on the

demonstration projects.

SCOPE OF GRANTS FOR EXPERIMENTS AND DEMONSTRATION PROJECTS TO

DETERMINE METHODS FOR PROSPECTIVE PAYMENTS TO HOSPITALS, SKILLED

NURSING FACILITIES, AND OTHER PROVIDERS OF SERVICES

Pub. L. 94-182, title I, Sec. 107, Dec. 31, 1975, 89 Stat. 1053,

provided that: "Nothing contained in section 222(a) of Public Law

92-603 [set out below] shall be construed to preclude or prohibit

the Secretary of Health, Education, and Welfare [now Health and

Human Services] from including in any grant otherwise authorized to

be made under such section moneys which are to be used for

payments, to a participant in a demonstration or experiment with

respect to which the grant is made, for or on account of costs

incurred or services performed by such participant for a period

prior to the date that the project of such participant is placed in

operation, if -

"(1) the applicant for such grant is a State or an agency

thereof,

"(2) such participant is an individual practice association

which has been in existence for at least 3 years prior to the

date of enactment of this section [Dec. 31, 1975] and which has

in effect a contract with such State (or an agency thereof),

entered into prior to the date on which the grant is approved by

the Secretary, under which such association will, for a period

which begins before and ends after the date such grant is so

approved, provide health care services for individuals entitled

to care and services under the State plan of such State which is

approved under title XIX of the Social Security Act [subchapter

XIX of this chapter].

"(3) the purpose of the inclusion of the project of such

association is to test the utility of a particular rate-setting

methodology, designed to be employed in prepaid health plans, in

an individual practice association operation, and

"(4) the applicant for such grant affirms that the use of

moneys from such grant to make such payments to such individual

practice association is necessary or useful in assuring that such

association will be able to continue in operation and carry out

the project described in clause (3)."

EXPERIMENTS AND DEMONSTRATION PROJECTS TO DETERMINE METHODS FOR

PROSPECTIVE PAYMENTS TO HOSPITALS, SKILLED NURSING FACILITIES, AND

OTHER PROVIDERS OF SERVICES FOR CARE AND SERVICES FURNISHED; SCOPE;

WAIVER OF PAYMENT REQUIREMENTS; SOURCE AND MANNER OF PAYMENTS FOR

GRANTS, ETC.; REPORTS TO CONGRESS

Section 222(a) of Pub. L. 92-603, as amended by Pub. L. 97-35,

title XXI, Sec. 2193(e), Aug. 13, 1981, 95 Stat. 828, provided

that:

"(1) The Secretary of Health, Education, and Welfare [now Health

and Human Services], directly or through contracts with, or grants

to, public or private agencies or organizations, shall develop and

carry out experiments and demonstration projects designed to

determine the relative advantages and disadvantages of various

alternative methods of making payment on a prospective basis to

hospitals, skilled nursing facilities, and other providers of

services for care and services provided by them under title XVIII

of the Social Security Act [this subchapter] and under State plans

approved under title XIX of such Act [subchapter XIX of this

chapter], including alternative methods for classifying providers,

for establishing prospective rates of payment, and for implementing

on a gradual, selective, or other basis the establishment of a

prospective payment system, in order to stimulate such providers

through positive (or negative) financial incentives to use their

facilities and personnel more efficiently and thereby to reduce the

total costs of the health programs involved without adversely

affecting the quality of services by containing or lowering the

rate of increase in provider costs that has been and is being

experienced under the existing system of retroactive cost

reimbursement.

"(2) The experiments and demonstration projects developed under

paragraph (1) shall be of sufficient scope and shall be carried out

on a wide enough scale to permit a thorough evaluation of the

alternative methods of prospective payment under consideration

while giving assurance that the results derived from the

experiments and projects will obtain generally in the operation of

the programs involved (without committing such programs to the

adoption of any prospective payment system either locally or

nationally).

"(3) In the case of any experiment or demonstration project under

paragraph (1), the Secretary may waive compliance with the

requirements of titles XVIII and XIX of the Social Security Act

[this subchapter and subchapter XIX of this chapter] insofar as

such requirements relate to methods of payment for services

provided; and costs incurred in such experiment or project in

excess of those which would otherwise be reimbursed or paid under

such titles [subchapters] may be reimbursed or paid to the extent

that such waiver applies to them (with such excess being borne by

the Secretary). No experiment or demonstration project shall be

developed or carried out under paragraph (1) until the Secretary

obtains the advice and recommendations of specialists who are

competent to evaluate the proposed experiment or project as to the

soundness of its objectives, the possibilities of securing

productive results, the adequacy of resources to conduct it, and

its relationship to other similar experiments or projects already

completed or in process; and no such experiment or project shall be

actually placed in operation unless at least 30 days prior thereto

a written report, prepared for purposes of notification and

information only, containing a full and complete description

thereof has been transmitted to the Committee on Ways and Means of

the House of Representatives and to the Committee on Finance of the

Senate.

"(4) Grants, payments under contracts, and other expenditures

made for experiments and demonstration projects under this

subsection shall be made in appropriate part from the Federal

Hospital Insurance Trust Fund (established by section 1817 of the

Social Security Act [section 1395i of this title]) and the Federal

Supplementary Medical Insurance Trust Fund (established by section

1841 of the Social Security Act [section 1395t of this title]) and

from funds appropriated under title XIX of such Act [subchapter XIX

of this chapter]. Grants and payments under contracts may be made

either in advance or by way of reimbursement, as may be determined

by the Secretary, and shall be made in such installments and on

such conditions as the Secretary finds necessary to carry out the

purpose of this subsection. With respect to any such grant,

payment, or other expenditure, the amount to be paid from each of

such trust funds (and from funds appropriated under such title XIX)

shall be determined by the Secretary, giving due regard to the

purposes of the experiment or project involved.

"(5) The Secretary shall submit to the Congress no later than

July 1, 1974, a full report on the experiments and demonstration

projects carried out under this subsection and on the experience of

other programs with respect to prospective reimbursement together

with any related data and materials which he may consider

appropriate. Such report shall include detailed recommendations

with respect to the specific methods which could be used in the

full implementation of a system of prospective payment to providers

of services under the programs involved."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395cc, 1395ll, 1395nn,

1395ww of this title.

-FOOTNOTE-

(!1) See References in Text note below.

-End-

-CITE-

42 USC Sec. 1395b-2 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

Sec. 1395b-2. Notice of medicare benefits; medicare and medigap

information

-STATUTE-

(a) Notice of medicare benefits

The Secretary shall prepare (in consultation with groups

representing the elderly and with health insurers) and provide for

distribution of a notice containing -

(1) a clear, simple explanation of the benefits available under

this subchapter and the major categories of health care for which

benefits are not available under this subchapter,

(2) the limitations on payment (including deductibles and

coinsurance amounts) that are imposed under this subchapter, and

(3) a description of the limited benefits for long-term care

services available under this subchapter and generally available

under State plans approved under subchapter XIX of this chapter.

Such notice shall be mailed annually to individuals entitled to

benefits under part A or part B of this subchapter and when an

individual applies for benefits under part A of this subchapter or

enrolls under part B of this subchapter.

(b) Medicare and medigap information

The Secretary shall provide information via a toll-free telephone

number on the programs under this subchapter.

(c) Contents of notice

The notice provided under subsection (a) of this section shall

include -

(1) a statement which indicates that because errors do occur

and because medicare fraud, waste, and abuse is a significant

problem, beneficiaries should carefully check any explanation of

benefits or itemized statement furnished pursuant to section

1395b-7 of this title for accuracy and report any errors or

questionable charges by calling the toll-free phone number

described in paragraph (4);

(2) a statement of the beneficiary's right to request an

itemized statement for medicare items and services (as provided

in section 1395b-7(b) of this title);

(3) a description of the program to collect information on

medicare fraud and abuse established under section 1395b-5(b) of

this title; and

(4) a toll-free telephone number maintained by the Inspector

General in the Department of Health and Human Services for the

receipt of complaints and information about waste, fraud, and

abuse in the provision or billing of services under this

subchapter.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1804, as added Pub. L.

100-360, title II, Sec. 223(a), July 1, 1988, 102 Stat. 747;

amended Pub. L. 103-432, title I, Sec. 171(j)(1), Oct. 31, 1994,

108 Stat. 4450; Pub. L. 105-33, title IV, Sec. 4311(a)(1), Aug. 5,

1997, 111 Stat. 384.)

-REFTEXT-

REFERENCES IN TEXT

Parts A and B of this subchapter, referred to in subsec. (a), are

classified to sections 1395c et seq. and 1395j et seq.,

respectively, of this title.

-MISC1-

AMENDMENTS

1997 - Subsec. (c). Pub. L. 105-33 added subsec. (c).

1994 - Pub. L. 103-432 inserted "; medicare and medigap

information" in section catchline, designated existing provisions

as subsec. (a), and added subsec. (b).

EFFECTIVE DATE OF 1997 AMENDMENT

Section 4311(a)(2) of Pub. L. 105-33 provided that: "The

amendment made by this subsection [amending this section] shall

apply to notices provided on or after January 1, 1998."

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by Pub. L. 103-432 effective as if included in the

enactment of Pub. L. 101-508, see section 171(l) of Pub. L.

103-432, set out as a note under section 1395ss of this title.

EFFECTIVE DATE

Section 223(d)(1) of Pub. L. 100-360 provided that: "The

Secretary of Health and Human Services shall first distribute the

notice required by the amendment made by subsection (a) [enacting

this section] not later than January 31, 1989."

STATE REGULATORY PROGRAMS

For provisions relating to changes required to conform State

regulatory programs to amendments by section 171 of Pub. L.

103-432, see section 171(m) of Pub. L. 103-432, set out as a note

under section 1395ss of this title.

DEMONSTRATION PROJECTS

Section 4361(b) of Pub. L. 101-508 provided that: "The Secretary

of Health and Human Services is authorized to conduct demonstration

projects in up to 5 States for the purpose of establishing

statewide toll-free telephone numbers for providing information on

medicare benefits, medicare supplemental policies available in the

State, and benefits under the State medicaid program."

NOTICE OF CHANGES UNDER REPEAL OF MEDICARE CATASTROPHIC COVERAGE

Pub. L. 101-234, title II, Sec. 203(c), Dec. 13, 1989, 103 Stat.

1984, provided that: "The Secretary of Health and Human Services

shall provide, in the notice of medicare benefits provided under

section 1804 of the Social Security Act [this section] for 1990,

for a description of the changes in benefits under title XVIII of

such Act [this subchapter] made by the amendments made by this Act

[see Tables for classification]."

BENEFITS COUNSELING AND ASSISTANCE DEMONSTRATION PROJECT FOR

CERTAIN MEDICARE AND MEDICAID BENEFICIARIES

Section 424 of Pub. L. 100-360, which directed Secretary of

Health and Human Services to establish a demonstration project to

demonstrate that its volunteers were adequately trained and

competent to render effective benefits counseling and assistance to

the elderly, was repealed by Pub. L. 101-234, title III, Sec.

301(a), Dec. 13, 1989, 103 Stat. 1985.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395w-21, 1395ff of this

title.

-End-

-CITE-

42 USC Sec. 1395b-3 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

Sec. 1395b-3. Health insurance advisory service for medicare

beneficiaries

-STATUTE-

(a) In general

The Secretary of Health and Human Services shall establish a

health insurance advisory service program (in this section referred

to as the "beneficiary assistance program") to assist

medicare-eligible individuals with the receipt of services under

the medicare and medicaid programs and other health insurance

programs.

(b) Outreach elements

The beneficiary assistance program shall provide assistance -

(1) through operation using local Federal offices that provide

information on the medicare program,

(2) using community outreach programs, and

(3) using a toll-free telephone information service.

(c) Assistance provided

The beneficiary assistance program shall provide for information,

counseling, and assistance for medicare-eligible individuals with

respect to at least the following:

(1) With respect to the medicare program -

(A) eligibility,

(B) benefits (both covered and not covered),

(C) the process of payment for services,

(D) rights and process for appeals of determinations,

(E) other medicare-related entities (such as peer review

organizations, fiscal intermediaries, and carriers), and

(F) recent legislative and administrative changes in the

medicare program.

(2) With respect to the medicaid program -

(A) eligibility, benefits, and the application process,

(B) linkages between the medicaid and medicare programs, and

(C) referral to appropriate State and local agencies involved

in the medicaid program.

(3) With respect to medicare supplemental policies -

(A) the program under section 1395ss of this title and

standards required under such program,

(B) how to make informed decisions on whether to purchase

such policies and on what criteria to use in evaluating

different policies,

(C) appropriate Federal, State, and private agencies that

provide information and assistance in obtaining benefits under

such policies, and

(D) other issues deemed appropriate by the Secretary.

The beneficiary assistance program also shall provide such other

services as the Secretary deems appropriate to increase beneficiary

understanding of, and confidence in, the medicare program and to

improve the relationship between beneficiaries and the program.

(d) Educational material

The Secretary, through the Administrator of the Health Care

Financing Administration, shall develop appropriate educational

materials and other appropriate techniques to assist employees in

carrying out this section.

(e) Notice to beneficiaries

The Secretary shall take such steps as are necessary to assure

that medicare-eligible beneficiaries and the general public are

made aware of the beneficiary assistance program.

(f) Report

The Secretary shall include, in an annual report transmitted to

the Congress, a report on the beneficiary assistance program and on

other health insurance informational and counseling services made

available to medicare-eligible individuals. The Secretary shall

include in the report recommendations for such changes as may be

desirable to improve the relationship between the medicare program

and medicare-eligible individuals.

-SOURCE-

(Pub. L. 101-508, title IV, Sec. 4359, Nov. 5, 1990, 104 Stat.

1388-137.)

-COD-

CODIFICATION

Section was enacted as part of the Omnibus Budget Reconciliation

Act of 1990, and not as part of the Social Security Act which

comprises this chapter.

-MISC1-

QUALIFIED MEDICARE BENEFICIARY OUTREACH

Pub. L. 103-432, title I, Sec. 154, Oct. 31, 1994, 108 Stat.

4437, provided that: "Not later than 1 year after the date of the

enactment of this Act [Oct. 31, 1994], the Secretary of Health and

Human Services shall establish and implement a method for obtaining

information from newly eligible medicare beneficiaries that may be

used to determine whether such beneficiaries may be eligible for

medical assistance for medicare cost-sharing under State medicaid

plans as qualified medicare beneficiaries, and for transmitting

such information to the State in which such a beneficiary resides."

-End-

-CITE-

42 USC Sec. 1395b-4 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

Sec. 1395b-4. Health insurance information, counseling, and

assistance grants

-STATUTE-

(a) Grants

The Secretary of Health and Human Services (in this section

referred to as the "Secretary") shall make grants to States, with

approved State regulatory programs under section 1395ss of this

title, that submit applications to the Secretary that meet the

requirements of this section for the purpose of providing

information, counseling, and assistance relating to the procurement

of adequate and appropriate health insurance coverage to

individuals who are eligible to receive benefits under this

subchapter (in this section referred to as "eligible individuals").

The Secretary shall prescribe regulations to establish a minimum

level of funding for a grant issued under this section.

(b) Grant applications

(1) In submitting an application under this section, a State may

consolidate and coordinate an application that consists of parts

prepared by more than one agency or department of such State.

(2) As part of an application for a grant under this section, a

State shall submit a plan for a State-wide health insurance

information, counseling, and assistance program. Such program shall

-

(A) establish or improve upon a health insurance information,

counseling, and assistance program that provides counseling and

assistance to eligible individuals in need of health insurance

information, including -

(i) information that may assist individuals in obtaining

benefits and filing claims under this subchapter and subchapter

XIX of this chapter;

(ii) policy comparison information for medicare supplemental

policies (as described in section 1395ss(g)(1) of this title)

and information that may assist individuals in filing claims

under such medicare supplemental policies;

(iii) information regarding long-term care insurance; and

(iv) information regarding other types of health insurance

benefits that the Secretary determines to be appropriate;

(B) in conjunction with the health insurance information,

counseling, and assistance program described in subparagraph (A),

establish a system of referral to appropriate Federal or State

departments or agencies for assistance with problems related to

health insurance coverage (including legal problems), as

determined by the Secretary;

(C) provide for a sufficient number of staff positions

(including volunteer positions) necessary to provide the services

of the health insurance information, counseling, and assistance

program;

(D) provide assurances that staff members (including volunteer

staff members) of the health insurance information, counseling,

and assistance program have no conflict of interest in providing

the counseling described in subparagraph (A);

(E) provide for the collection and dissemination of timely and

accurate health care information to staff members;

(F) provide for training programs for staff members (including

volunteer staff members);

(G) provide for the coordination of the exchange of health

insurance information between the staff of departments and

agencies of the State government and the staff of the health

insurance information, counseling, and assistance program;

(H) make recommendations concerning consumer issues and

complaints related to the provision of health care to agencies

and departments of the State government and the Federal

Government responsible for providing or regulating health

insurance;

(I) establish an outreach program to provide the health

insurance information and counseling described in subparagraph

(A) and the referrals described in subparagraph (B) to eligible

individuals; and

(J) demonstrate, to the satisfaction of the Secretary, an

ability to provide the counseling and assistance required under

this section.

(c) Special grants

(1) A State that is conducting a health insurance information,

counseling, and assistance program that is substantially similar to

a program described in subsection (b)(2) of this section shall, as

a requirement for eligibility for a grant under this section,

demonstrate, to the satisfaction of the Secretary, that such State

shall maintain the activities of such program at least at the level

that such activities were conducted immediately preceding the date

of the issuance of any grant during the period of time covered by

such grant under this section.

(2) If the Secretary determines that the existing health

insurance information, counseling, and assistance program is

substantially similar to a program described in subsection (b)(2)

of this section, the Secretary may waive some or all of the

requirements described in such subsection and issue a grant to the

State for the purpose of increasing the number of services offered

by the health insurance information, counseling, and assistance

program, experimenting with new methods of outreach in conducting

such program, or expanding such program to geographic areas of the

State not previously served by the program.

(d) Criteria for issuing grants

In issuing a grant under this section, the Secretary shall

consider -

(1) the commitment of the State to carrying out the health

insurance information, counseling, and assistance program

described in subsection (b)(2) of this section, including the

level of cooperation demonstrated -

(A) by the office of the chief insurance regulator of the

State, or the equivalent State entity;

(B) other officials of the State responsible for overseeing

insurance plans issued by nonprofit hospital and medical

service associations; and

(C) departments and agencies of such State responsible for -

(i) administering funds under subchapter XIX of this

chapter, and

(ii) administering funds appropriated under the Older

Americans Act [42 U.S.C. 3001 et seq.];

(2) the population of eligible individuals in such State as a

percentage of the population of such State; and

(3) in order to ensure the needs of rural areas in such State,

the relative costs and special problems associated with

addressing the special problems of providing health care

information, counseling, and assistance eligible (!1) individuals

residing in rural areas of such State.

(e) Annual State report

A State that receives a grant under this section shall, not later

than 180 days after receiving such grant, and annually thereafter

during the period of the grant, issue a report to the Secretary

that includes information concerning -

(1) the number of individuals served by the health insurance

information, counseling and assistance program of such State;

(2) an estimate of the amount of funds saved by the State, and

by eligible individuals in the State, in the implementation of

such program; and

(3) the problems that eligible individuals in such State

encounter in procuring adequate and appropriate health care

coverage.

(f) Report to Congress

Beginning with 1992, and annually thereafter, the Secretary shall

issue a report to the Committee on Finance of the Senate, the

Special Committee on Aging of the Senate, the Committee on Ways and

Means of the House of Representatives, and the Committee on Energy

and Commerce of the House of Representatives that -

(1) summarizes the allocation of funds authorized for grants

under this section and the expenditure of such funds;

(2) outlines the problems that eligible individuals encounter

in procuring adequate and appropriate health care coverage;

(3) makes recommendations that the Secretary determines to be

appropriate to address the problems described in paragraph (3);

(!2) and

(4) in the case of the report issued 2 years after November 5,

1990, evaluates the effectiveness of counseling programs

established under this program, and makes recommendations

regarding continued authorization of funds for these purposes.

(g) Authorization of appropriations for grants

There are authorized to be appropriated, in equal parts from the

Federal Hospital Insurance Trust Fund and from the Federal

Supplementary Medical Insurance Trust Fund, $10,000,000 for each of

fiscal years 1991, 1992, 1993, 1994, 1995, and 1996, to fund the

grant programs described in this section.

-SOURCE-

(Pub. L. 101-508, title IV, Sec. 4360, Nov. 5, 1990, 104 Stat.

1388-138; Pub. L. 103-432, title I, Sec. 171(i), Oct. 31, 1994, 108

Stat. 4450; Pub. L. 103-437, Sec. 15(b), Nov. 2, 1994, 108 Stat.

4591; Pub. L. 105-362, title VI, Sec. 602(b)(2), Nov. 10, 1998, 112

Stat. 3286.)

-REFTEXT-

REFERENCES IN TEXT

The Older Americans Act, referred to in subsec. (d)(1)(C)(ii),

probably means the Older Americans Act of 1965, which is Pub. L.

89-73, July 14, 1965, 79 Stat. 218, as amended, and is classified

generally to chapter 35 (Sec. 3001 et seq.) of this title. For

complete classification of this Act to the Code, see Short Title

note set out under section 3001 of this title and Tables.

-COD-

CODIFICATION

Section was enacted as part of the Omnibus Budget Reconciliation

Act of 1990, and not as part of the Social Security Act which

comprises this chapter.

-MISC1-

AMENDMENTS

1998 - Subsec. (f). Pub. L. 105-362 substituted "Beginning with

1992" for "Not later than 180 days after November 5, 1990".

1994 - Subsec. (b)(2)(A)(ii). Pub. L. 103-432, Sec. 171(i)(1),

inserted closing parenthesis after "of this title".

Subsec. (b)(2)(D). Pub. L. 103-432, Sec. 171(i)(2), substituted

"counseling" for "services" before "described in subparagraph (A)".

Subsec. (b)(2)(I). Pub. L. 103-432, Sec. 171(i)(3), substituted

"referrals" for "assistance".

Subsec. (c)(1). Pub. L. 103-432, Sec. 171(i)(4), struck out "and

that such activities will continue to be maintained at such level"

after "covered by such grant under this section".

Subsec. (d)(3). Pub. L. 103-432, Sec. 171(i)(5), substituted

"eligible individuals residing in rural areas" for "to the rural

areas".

Subsec. (e). Pub. L. 103-432, Sec. 171(i)(6)(A), (B), in

introductory provisions, substituted "this section" for "subsection

(c) or (d) of this section" and "and annually thereafter during the

period of the grant, issue a report" for "and annually thereafter,

issue an annual report".

Subsec. (e)(1). Pub. L. 103-432, Sec. 171(i)(6)(C), struck out

"State-wide" before "health insurance information".

Subsec. (f). Pub. L. 103-437, Sec. 15(b)(1), in introductory

provisions, substituted "and the Committee on Energy and Commerce"

for "the Committee on Energy and Commerce of the House of

Representatives, and the Select Committee on Aging".

Pub. L. 103-432, Sec. 171(i)(8)(B), and Pub. L. 103-437, Sec.

15(b)(2), made identical amendments, redesignating subsec. (f),

relating to authorization of appropriations for grants, as (g).

Pub. L. 103-432, Sec. 171(i)(8)(A), in subsec. (f), relating to

authorization of appropriations for grants, substituted "1993,

1994, 1995, and 1996" for "and 1993".

Subsec. (f)(2) to (5). Pub. L. 103-432, Sec. 171(i)(7), in

subsec. (f), relating to report to Congress, redesignated pars. (3)

to (5) as (2) to (4), respectively, and struck out former par. (2)

which read as follows: "summarizes the scope and content of

training conferences convened under this section;".

Subsec. (g). Pub. L. 103-432, Sec. 171(i)(8)(B), and Pub. L.

103-437, Sec. 15(b)(2), made identical amendments, redesignating

subsec. (f), relating to authorization of appropriations for

grants, as (g).

-CHANGE-

CHANGE OF NAME

Committee on Energy and Commerce of House of Representatives

treated as referring to Committee on Commerce of House of

Representatives by section 1(a) of Pub. L. 104-14, set out as a

note preceding section 21 of Title 2, The Congress. Committee on

Commerce of House of Representatives changed to Committee on Energy

and Commerce of House of Representatives, and jurisdiction over

matters relating to securities and exchanges and insurance

generally transferred to Committee on Financial Services of House

of Representatives by House Resolution No. 5, One Hundred Seventh

Congress, Jan. 3, 2001.

-MISC2-

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by Pub. L. 103-432 effective as if included in the

enactment of Pub. L. 101-508, see section 171(l) of Pub. L.

103-432, set out as a note under section 1395ss of this title.

STATE REGULATORY PROGRAMS

For provisions relating to changes required to conform State

regulatory programs to amendments by section 171 of Pub. L.

103-432, see section 171(m) of Pub. L. 103-432, set out as a note

under section 1395ss of this title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1395w-27 of this title.

-FOOTNOTE-

(!1) So in original. Probably should be preceded by "to".

(!2) So in original. Probably should be paragraph "(2)".

-End-

-CITE-

42 USC Sec. 1395b-5 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

Sec. 1395b-5. Beneficiary incentive programs

-STATUTE-

(a) Repealed. Pub. L. 105-33, title IV, Sec. 4311(b)(2), Aug. 5,

1997, 111 Stat. 386

(b) Program to collect information on fraud and abuse

(1) Establishment of program

Not later than 3 months after August 21, 1996, the Secretary

shall establish a program under which the Secretary shall

encourage individuals to report to the Secretary information on

individuals and entities who are engaging in or who have engaged

in acts or omissions which constitute grounds for the imposition

of a sanction under section 1320a-7, 1320a-7a, or 1320a-7b of

this title, or who have otherwise engaged in fraud and abuse

against the Medicare program under this subchapter for which

there is a sanction provided under law. The program shall

discourage provision of, and not consider, information which is

frivolous or otherwise not relevant or material to the imposition

of such a sanction.

(2) Payment of portion of amounts collected

If an individual reports information to the Secretary under the

program established under paragraph (1) which serves as the basis

for the collection by the Secretary or the Attorney General of

any amount of at least $100 (other than any amount paid as a

penalty under section 1320a-7b of this title), the Secretary may

pay a portion of the amount collected to the individual (under

procedures similar to those applicable under section 7623 of the

Internal Revenue Code of 1986 to payments to individuals

providing information on violations of such Code).

(c) Program to collect information on program efficiency

(1) Establishment of program

Not later than 3 months after August 21, 1996, the Secretary

shall establish a program under which the Secretary shall

encourage individuals to submit to the Secretary suggestions on

methods to improve the efficiency of the Medicare program.

(2) Payment of portion of program savings

If an individual submits a suggestion to the Secretary under

the program established under paragraph (1) which is adopted by

the Secretary and which results in savings to the program, the

Secretary may make a payment to the individual of such amount as

the Secretary considers appropriate.

-SOURCE-

(Pub. L. 104-191, title II, Sec. 203, Aug. 21, 1996, 110 Stat.

1998; Pub. L. 105-33, title IV, Sec. 4311(b)(2), Aug. 5, 1997, 111

Stat. 386.)

-REFTEXT-

REFERENCES IN TEXT

The Internal Revenue Code of 1986, referred to in subsec. (b)(2),

is classified generally to Title 26, Internal Revenue Code.

-COD-

CODIFICATION

Section was enacted as part of the Health Insurance Portability

and Accountability Act of 1996, and not as part of the Social

Security Act which comprises this chapter.

-MISC1-

AMENDMENTS

1997 - Subsec. (a). Pub. L. 105-33 struck out heading and text of

subsec. (a). Text read as follows: "The Secretary of Health and

Human Services (in this section referred to as the 'Secretary')

shall provide an explanation of benefits under the Medicare program

under this subchapter with respect to each item or service for

which payment may be made under the program which is furnished to

an individual, without regard to whether or not a deductible or

coinsurance may be imposed against the individual with respect to

the item or service."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1395b-2 of this title.

-End-

-CITE-

42 USC Sec. 1395b-6 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

Sec. 1395b-6. Medicare Payment Advisory Commission

-STATUTE-

(a) Establishment

There is hereby established the Medicare Payment Advisory

Commission (in this section referred to as the "Commission").

(b) Duties

(1) Review of payment policies and annual reports

The Commission shall -

(A) review payment policies under this subchapter, including

the topics described in paragraph (2);

(B) make recommendations to Congress concerning such payment

policies;

(C) by not later than March 1 of each year (beginning with

1998), submit a report to Congress containing the results of

such reviews and its recommendations concerning such policies;

and

(D) by not later than June 15 of each year, submit a report

to Congress containing an examination of issues affecting the

medicare program, including the implications of changes in

health care delivery in the United States and in the market for

health care services on the medicare program and including a

review of the estimate of the conversion factor submitted under

section 1395w-4(d)(1)(E)(ii) of this title.

(2) Specific topics to be reviewed

(A) Medicare+Choice program

Specifically, the Commission shall review, with respect to

the Medicare+Choice program under part C of this subchapter,

the following:

(i) The methodology for making payment to plans under such

program, including the making of differential payments and

the distribution of differential updates among different

payment areas.

(ii) The mechanisms used to adjust payments for risk and

the need to adjust such mechanisms to take into account

health status of beneficiaries.

(iii) The implications of risk selection both among

Medicare+Choice organizations and between the Medicare+Choice

option and the original medicare fee-for-service option.

(iv) The development and implementation of mechanisms to

assure the quality of care for those enrolled with

Medicare+ÐChoice organizations.

(v) The impact of the Medicare+Choice program on access to

care for medicare beneficiaries.

(vi) Other major issues in implementation and further

development of the Medicare+Choice program.

(B) Original medicare fee-for-service system

Specifically, the Commission shall review payment policies

under parts A and B of this subchapter, including -

(i) the factors affecting expenditures for services in

different sectors, including the process for updating

hospital, skilled nursing facility, physician, and other

fees,

(ii) payment methodologies, and

(iii) their relationship to access and quality of care for

medicare beneficiaries.

(C) Interaction of medicare payment policies with health care

delivery generally

Specifically, the Commission shall review the effect of

payment policies under this subchapter on the delivery of

health care services other than under this subchapter and

assess the implications of changes in health care delivery in

the United States and in the general market for health care

services on the medicare program.

(3) Comments on certain secretarial reports

If the Secretary submits to Congress (or a committee of

Congress) a report that is required by law and that relates to

payment policies under this subchapter, the Secretary shall

transmit a copy of the report to the Commission. The Commission

shall review the report and, not later than 6 months after the

date of submittal of the Secretary's report to Congress, shall

submit to the appropriate committees of Congress written comments

on such report. Such comments may include such recommendations as

the Commission deems appropriate.

(4) Agenda and additional reviews

The Commission shall consult periodically with the chairmen and

ranking minority members of the appropriate committees of

Congress regarding the Commission's agenda and progress towards

achieving the agenda. The Commission may conduct additional

reviews, and submit additional reports to the appropriate

committees of Congress, from time to time on such topics relating

to the program under this subchapter as may be requested by such

chairmen and members and as the Commission deems appropriate.

(5) Availability of reports

The Commission shall transmit to the Secretary a copy of each

report submitted under this subsection and shall make such

reports available to the public.

(6) Appropriate committees of Congress

For purposes of this section, the term "appropriate committees

of Congress" means the Committees on Ways and Means and Commerce

of the House of Representatives and the Committee on Finance of

the Senate.

(7) Voting and reporting requirements

With respect to each recommendation contained in a report

submitted under paragraph (1), each member of the Commission

shall vote on the recommendation, and the Commission shall

include, by member, the results of that vote in the report

containing the recommendation.

(c) Membership

(1) Number and appointment

The Commission shall be composed of 17 members appointed by the

Comptroller General.

(2) Qualifications

(A) In general

The membership of the Commission shall include individuals

with national recognition for their expertise in health finance

and economics, actuarial science, health facility management,

health plans and integrated delivery systems, reimbursement of

health facilities, allopathic and osteopathic physicians, and

other providers of health services, and other related fields,

who provide a mix of different professionals, broad geographic

representation, and a balance between urban and rural

representatives.

(B) Inclusion

The membership of the Commission shall include (but not be

limited to) physicians and other health professionals,

employers, third-party payers, individuals skilled in the

conduct and interpretation of biomedical, health services, and

health economics research and expertise in outcomes and

effectiveness research and technology assessment. Such

membership shall also include representatives of consumers and

the elderly.

(C) Majority nonproviders

Individuals who are directly involved in the provision, or

management of the delivery, of items and services covered under

this subchapter shall not constitute a majority of the

membership of the Commission.

(D) Ethical disclosure

The Comptroller General shall establish a system for public

disclosure by members of the Commission of financial and other

potential conflicts of interest relating to such members.

(3) Terms

(A) In general

The terms of members of the Commission shall be for 3 years

except that the Comptroller General shall designate staggered

terms for the members first appointed.

(B) Vacancies

Any member appointed to fill a vacancy occurring before the

expiration of the term for which the member's predecessor was

appointed shall be appointed only for the remainder of that

term. A member may serve after the expiration of that member's

term until a successor has taken office. A vacancy in the

Commission shall be filled in the manner in which the original

appointment was made.

(4) Compensation

While serving on the business of the Commission (including

traveltime), a member of the Commission shall be entitled to

compensation at the per diem equivalent of the rate provided for

level IV of the Executive Schedule under section 5315 of title 5;

and while so serving away from home and the member's regular

place of business, a member may be allowed travel expenses, as

authorized by the Chairman of the Commission. Physicians serving

as personnel of the Commission may be provided a physician

comparability allowance by the Commission in the same manner as

Government physicians may be provided such an allowance by an

agency under section 5948 of title 5, and for such purpose

subsection (i) of such section shall apply to the Commission in

the same manner as it applies to the Tennessee Valley Authority.

For purposes of pay (other than pay of members of the Commission)

and employment benefits, rights, and privileges, all personnel of

the Commission shall be treated as if they were employees of the

United States Senate.

(5) Chairman; Vice Chairman

The Comptroller General shall designate a member of the

Commission, at the time of appointment of the member as Chairman

and a member as Vice Chairman for that term of appointment,

except that in the case of vacancy of the Chairmanship or Vice

Chairmanship, the Comptroller General may designate another

member for the remainder of that member's term.

(6) Meetings

The Commission shall meet at the call of the Chairman.

(d) Director and staff; experts and consultants

Subject to such review as the Comptroller General deems necessary

to assure the efficient administration of the Commission, the

Commission may -

(1) employ and fix the compensation of an Executive Director

(subject to the approval of the Comptroller General) and such

other personnel as may be necessary to carry out its duties

(without regard to the provisions of title 5 governing

appointments in the competitive service);

(2) seek such assistance and support as may be required in the

performance of its duties from appropriate Federal departments

and agencies;

(3) enter into contracts or make other arrangements, as may be

necessary for the conduct of the work of the Commission (without

regard to section 5 of title 41);

(4) make advance, progress, and other payments which relate to

the work of the Commission;

(5) provide transportation and subsistence for persons serving

without compensation; and

(6) prescribe such rules and regulations as it deems necessary

with respect to the internal organization and operation of the

Commission.

(e) Powers

(1) Obtaining official data

The Commission may secure directly from any department or

agency of the United States information necessary to enable it to

carry out this section. Upon request of the Chairman, the head of

that department or agency shall furnish that information to the

Commission on an agreed upon schedule.

(2) Data collection

In order to carry out its functions, the Commission shall -

(A) utilize existing information, both published and

unpublished, where possible, collected and assessed either by

its own staff or under other arrangements made in accordance

with this section,

(B) carry out, or award grants or contracts for, original

research and experimentation, where existing information is

inadequate, and

(C) adopt procedures allowing any interested party to submit

information for the Commission's use in making reports and

recommendations.

(3) Access of GAO to information

The Comptroller General shall have unrestricted access to all

deliberations, records, and nonproprietary data of the

Commission, immediately upon request.

(4) Periodic audit

The Commission shall be subject to periodic audit by the

Comptroller General.

(f) Authorization of appropriations

(1) Request for appropriations

The Commission shall submit requests for appropriations in the

same manner as the Comptroller General submits requests for

appropriations, but amounts appropriated for the Commission shall

be separate from amounts appropriated for the Comptroller

General.

(2) Authorization

There are authorized to be appropriated such sums as may be

necessary to carry out the provisions of this section. Sixty

percent of such appropriation shall be payable from the Federal

Hospital Insurance Trust Fund, and 40 percent of such

appropriation shall be payable from the Federal Supplementary

Medical Insurance Trust Fund.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1805, as added Pub. L.

105-33, title IV, Sec. 4022(a), Aug. 5, 1997, 111 Stat. 350;

amended Pub. L. 105-277, div. J, title V, Sec. 5202(a), Oct. 21,

1998, 112 Stat. 2681-917; Pub. L. 106-113, div. B, Sec. 1000(a)(6)

[title II, Sec. 211(a)(2)(B)], Nov. 29, 1999, 113 Stat. 1536,

1501A-347; Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 544(a)(1),

(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A-551.)

-REFTEXT-

REFERENCES IN TEXT

Parts A, B, and C of this subchapter, referred to in subsec.

(b)(2)(A), (B), are classified to sections 1395c et seq., 1395j et

seq., and 1395w-21 et seq., respectively, of this title.

The provisions of title 5 governing appointments in the

competitive service, referred to in subsec. (d)(1), are classified

generally to section 3301 et seq. of Title 5, Government

Organization and Employees.

-MISC1-

AMENDMENTS

2000 - Subsec. (b)(1)(D). Pub. L. 106-554, Sec. 1(a)(6) [title V,

Sec. 544(a)(1)], substituted "June 15 of each year," for "June 1 of

each year (beginning with 1998),".

Subsec. (b)(7). Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec.

544(b)], added par. (7).

1999 - Subsec. (b)(1)(D). Pub. L. 106-113 inserted "and including

a review of the estimate of the conversion factor submitted under

section 1395w-4(d)(1)(E)(ii) of this title" before period at end.

1998 - Subsec. (c)(1). Pub. L. 105-277 substituted "17" for "15".

EFFECTIVE DATE OF 2000 AMENDMENT

Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 544(a)(2)], Dec. 21,

2000, 114 Stat. 2763, 2763A-551, provided that: "The amendment made

by paragraph (1) [amending this section] shall apply beginning with

2001."

EFFECTIVE DATE OF 1999 AMENDMENT

Amendment by Pub. L. 106-113 effective in determining conversion

factor under section 1395w-4(d) of this title for years beginning

with 2001 and not applicable to or affecting any update (or any

update adjustment factor) for any year before 2001, see section

1000(a)(6) [title II, Sec. 211(d)] of Pub. L. 106-113, set out as a

note under section 1395w-4 of this title.

EFFECTIVE DATE; TRANSITION; TRANSFER OF FUNCTIONS

Section 4022(c) of Pub. L. 105-33 provided that:

"(1) In general. - The Comptroller General shall first provide

for appointment of members to the Medicare Payment Advisory

Commission (in this subsection referred to as 'MedPAC') by not

later than September 30, 1997.

"(2) Transition. - As quickly as possible after the date a

majority of members of MedPAC are first appointed [Oct. 1, 1997,

see 62 FR 52131], the Comptroller General, in consultation with the

Prospective Payment Assessment Commission (in this subsection

referred to as 'ProPAC') and the Physician Payment Review

Commission (in this subsection referred to as 'PPRC'), shall

provide for the termination of the ProPAC and the PPRC. As of the

date of termination of the respective Commissions [Nov. 1, 1997,

see 62 FR 59356], the amendments made by paragraphs (1) and (2),

respectively, of subsection (b) [amending sections 1395w-4, 1395y,

and 1395ww of this title and repealing section 1395w-1 of this

title] become effective. The Comptroller General, to the extent

feasible, shall provide for the transfer to the MedPAC of assets

and staff of the ProPAC and the PPRC, without any loss of benefits

or seniority by virtue of such transfers. Fund balances available

to the ProPAC or the PPRC for any period shall be available to the

MedPAC for such period for like purposes.

"(3) Continuing responsibility for reports. - The MedPAC shall be

responsible for the preparation and submission of reports required

by law to be submitted (and which have not been submitted by the

date of establishment of the MedPAC) by the ProPAC and the PPRC,

and, for this purpose, any reference in law to either such

Commission is deemed, after the appointment of the MedPAC, to refer

to the MedPAC."

MEDPAC ANALYSIS OF IMPACT OF VOLUME ON PER UNIT COST OF RURAL

HOSPITALS WITH PSYCHIATRIC UNITS

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 214], Dec. 21,

2000, 114 Stat. 2763, 2763A-486, provided that: "The Medicare

Payment Advisory Commission, in its study conducted pursuant to

subsection (a) of section 411 of BBRA [Pub. L. 106-113, Sec.

1000(a)(6) [title IV, Sec. 411], set out as a note below] (113

Stat. 1501A-377), shall include -

"(1) in such study an analysis of the impact of volume on the

per unit cost of rural hospitals with psychiatric units; and

"(2) in its report under subsection (b) of such section a

recommendation on whether special treatment for such hospitals

may be warranted."

MEDPAC STUDY ON COMPLEXITY OF MEDICARE PROGRAM AND LEVELS OF

BURDENS PLACED ON PROVIDERS THROUGH FEDERAL REGULATIONS

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 229(c)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-357, provided that:

"(1) Study. - The Medicare Payment Advisory Commission shall

undertake a comprehensive study to review the regulatory burdens

placed on all classes of health care providers under parts A and B

of the medicare program under title XVIII of the Social Security

Act [this subchapter] and to determine the costs these burdens

impose on the nation's health care system. The study shall also

examine the complexity of the current regulatory system and its

impact on providers.

"(2) Report. - Not later than December 31, 2001, the Commission

shall submit to Congress one or more reports on the study conducted

under paragraph (1). The report shall include recommendations

regarding -

"(A) how the Health Care Financing Administration can reduce

the regulatory burdens placed on patients and providers; and

"(B) legislation that may be appropriate to reduce the

complexity of the medicare program, including improvement of the

rules regarding billing, compliance, and fraud and abuse."

MEDPAC REPORT

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec.

312(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A-365, provided that:

"The Medicare Payment Advisory Commission shall include in its

report submitted to Congress in March of 2001 recommendations

regarding the appropriateness of the initial residency period used

under section 1886(h)(5)(F) of the Social Security Act (42 U.S.C.

1395ww(h)(5)(F)) for other residency training programs in a

specialty that require preliminary years of study in another

specialty."

MEDPAC STUDY OF RURAL PROVIDERS

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title IV, Sec. 411],

Nov. 29, 1999, 113 Stat. 1536, 1501A-377, provided that:

"(a) Study. - The Medicare Payment Advisory Commission shall

conduct a study of rural providers furnishing items and services

for which payment is made under title XVIII of the Social Security

Act [this subchapter]. Such study shall examine and evaluate the

adequacy and appropriateness of the categories of special payments

(and payment methodologies) established for rural hospitals under

the medicare program, and the impact of such categories on

beneficiary access and quality of health care services.

"(b) Report. - Not later than 18 months after the date of the

enactment of this Act [Nov. 29, 1999], the Medicare Payment

Advisory Commission shall submit to Congress a report on the study

conducted under subsection (a)."

QUALITY IMPROVEMENT STANDARDS

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 520(c)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-386, provided that:

"(1) Study. - The Medicare Payment Advisory Commission shall

conduct a study on the appropriate quality improvement standards

that should apply to -

"(A) each type of Medicare+Choice plan described in section

1851(a)(2) of the Social Security Act (42 U.S.C. 1395w-21(a)(2)),

including each type of Medicare+Choice plan that is a coordinated

care plan (as described in subparagraph (A) of such section); and

"(B) the original medicare fee-for-service program under parts

A and B [sic] title XVIII of such Act (42 U.S.C. 1395 et seq.)

[parts A and B of this subchapter].

"(2) Considerations. - Such study shall specifically examine the

effects, costs, and feasibility of requiring entities, physicians,

and other health care providers that provide items and services

under the original medicare fee-for-service program to comply with

quality standards and related reporting requirements that are

comparable to the quality standards and related reporting

requirements that are applicable to Medicare+Choice organizations.

"(3) Report. - Not later than 2 years after the date of the

enactment of this Act [Nov. 29, 1999], such Commission shall submit

a report to Congress on the study conducted under this subsection,

together with any recommendations for legislation that it

determines to be appropriate as a result of such study."

INITIAL TERMS OF ADDITIONAL MEMBERS

Pub. L. 105-277, div. J, title V, Sec. 5202(b), Oct. 21, 1998,

112 Stat. 2681-917, provided that:

"(1) In general. - For purposes of staggering the initial terms

of members of the Medicare Payment Advisory Commission (under

section 1805(c)(3) of such Act (42 U.S.C. 1395b-6(c)(3))[)], the

initial terms of the two additional members of the Commission

provided for by the amendment under subsection (a) [amending this

section] are as follows:

"(A) One member shall be appointed for one year.

"(B) One member shall be appointed for two years.

"(2) Commencement of terms. - Such terms shall begin on May 1,

1999."

INFORMATION INCLUDED IN ANNUAL RECOMMENDATIONS

Section 4804(c) of Pub. L. 105-33 provided that: "The Medicare

Payment Advisory Commission shall include in its annual report

under section 1805(b)(1)(B) of the Social Security Act [subsec.

(b)(1)(B) of this section] recommendations on the methodology and

level of payments made to PACE providers under sections 1894(d) and

1934(d) of such Act [sections 1395eee(d) and 1396u-4(d) of this

title] and on the treatment of private, for-profit entities as PACE

providers."

-End-

-CITE-

42 USC Sec. 1395b-7 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

-HEAD-

Sec. 1395b-7. Explanation of medicare benefits

-STATUTE-

(a) In general

The Secretary shall furnish to each individual for whom payment

has been made under this subchapter (or would be made without

regard to any deductible) a statement which -

(1) lists the item or service for which payment has been made

and the amount of such payment for each item or service; and

(2) includes a notice of the individual's right to request an

itemized statement (as provided in subsection (b) of this

section).

(b) Request for itemized statement for medicare items and services

(1) In general

An individual may submit a written request to any physician,

provider, supplier, or any other person (including an

organization, agency, or other entity) for an itemized statement

for any item or service provided to such individual by such

person with respect to which payment has been made under this

subchapter.

(2) 30-day period to furnish statement

(A) In general

Not later than 30 days after the date on which a request

under paragraph (1) has been made, a person described in such

paragraph shall furnish an itemized statement describing each

item or service provided to the individual requesting the

itemized statement.

(B) Penalty

Whoever knowingly fails to furnish an itemized statement in

accordance with subparagraph (A) shall be subject to a civil

money penalty of not more than $100 for each such failure. Such

penalty shall be imposed and collected in the same manner as

civil money penalties under subsection (a) of section 1320a-7a

of this title are imposed and collected under that section.

(3) Review of itemized statement

(A) In general

Not later than 90 days after the receipt of an itemized

statement furnished under paragraph (1), an individual may

submit a written request for a review of the itemized statement

to the Secretary.

(B) Specific allegations

A request for a review of the itemized statement shall

identify -

(i) specific items or services that the individual believes

were not provided as claimed, or

(ii) any other billing irregularity (including duplicate

billing).

(4) Findings of Secretary

The Secretary shall, with respect to each written request

submitted under paragraph (3), determine whether the itemized

statement identifies specific items or services that were not

provided as claimed or any other billing irregularity (including

duplicate billing) that has resulted in unnecessary payments

under this subchapter.

(5) Recovery of amounts

The Secretary shall take all appropriate measures to recover

amounts unnecessarily paid under this subchapter with respect to

a statement described in paragraph (4).

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1806, as added Pub. L.

105-33, title IV, Sec. 4311(b)(1), Aug. 5, 1997, 111 Stat. 385.)

-MISC1-

EFFECTIVE DATE

Section 4311(b)(3) of Pub. L. 105-33 provided that:

"(A) Statement by secretary. - Paragraph (1) of section 1806(a)

of the Social Security Act [subsec. (a)(1) of this section], as

added by paragraph (1), and the repeal made by paragraph (2)

[amending section 1395b-5 of this title] shall take effect on the

date of the enactment of this Act [Aug. 5, 1997].

"(B) Itemized statement. - Paragraph (2) of section 1806(a) and

section 1806(b) of the Social Security Act [subsecs. (a)(2) and (b)

of this section], as so added, shall take effect not later than

January 1, 1999."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1395b-2 of this title.

-End-

-CITE-

42 USC Part A - Hospital Insurance Benefits for Aged and

Disabled 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

PART A - HOSPITAL INSURANCE BENEFITS FOR AGED AND DISABLED

-SECREF-

PART REFERRED TO IN OTHER SECTIONS

This part is referred to in sections 300dd-3, 300gg, 300gg-41,

402, 426, 426-1, 426a, 1320a-3, 1320a-7a, 1320b-1, 1320d, 1383c,

1395a, 1395b-2, 1395b-6, 1395l, 1395m, 1395o, 1395p, 1395q, 1395u,

1395v, 1395w-21, 1395w-22, 1395w-23, 1395w-24, 1395w-27, 1395w-28,

1395x, 1395y, 1395aa, 1395cc, 1395cc-1, 1395cc-2, 1395ff, 1395ll,

1395mm, 1395pp, 1395rr, 1395ss, 1395vv, 1395ww, 1395yy, 1395eee,

1395ggg, 1396a, 1396b, 1396d, 1396n, 1396u-4 of this title; title 5

sections 8904, 8910; title 8 sections 1182, 1611; title 10 sections

1079, 1086, 1087, 1108, 1111; title 26 sections 35, 6103, 9801;

title 29 sections 1181, 2918; title 31 section 3806; title 45

section 231f.

-End-

-CITE-

42 USC Sec. 1395c 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395c. Description of program

-STATUTE-

The insurance program for which entitlement is established by

sections 426 and 426-1 of this title provides basic protection

against the costs of hospital, related post-hospital, home health

services, and hospice care in accordance with this part for (1)

individuals who are age 65 or over and are eligible for retirement

benefits under subchapter II of this chapter (or would be eligible

for such benefits if certain government employment were covered

employment under such subchapter) or under the railroad retirement

system, (2) individuals under age 65 who have been entitled for not

less than 24 months to benefits under subchapter II of this chapter

(or would have been so entitled to such benefits if certain

government employment were covered employment under such

subchapter) or under the railroad retirement system on the basis of

a disability, and (3) certain individuals who do not meet the

conditions specified in either clause (1) or (2) but who are

medically determined to have end stage renal disease.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1811, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 291; amended

Pub. L. 92-603, title II, Sec. 201(a)(2), Oct. 30, 1972, 86 Stat.

1371; Pub. L. 95-292, Sec. 4(a), June 13, 1978, 92 Stat. 315; Pub.

L. 96-265, title I, Sec. 103(a)(2), June 9, 1980, 94 Stat. 444;

Pub. L. 96-473, Sec. 2(b), Oct. 19, 1980, 94 Stat. 2263; Pub. L.

96-499, title IX, Sec. 930(a), Dec. 5, 1980, 94 Stat. 2631; Pub. L.

97-248, title I, Sec. 122(a)(1), title II, Sec. 278(b)(3), Sept. 3,

1982, 96 Stat. 356, 561; Pub. L. 99-272, title XIII, Sec.

13205(b)(2)(C)(i), Apr. 7, 1986, 100 Stat. 317; Pub. L. 100-360,

title I, Sec. 104(d)(1), July 1, 1988, 102 Stat. 688; Pub. L.

101-234, title I, Sec. 101(a), Dec. 13, 1989, 103 Stat. 1979.)

-MISC1-

AMENDMENTS

1989 - Pub. L. 101-234 repealed Pub. L. 100-360, Sec. 104(d)(1),

and provided that the provisions of law amended or repealed by such

section are restored or revived as if such section had not been

enacted, see 1988 Amendment note below.

1988 - Pub. L. 100-360 substituted "inpatient hospital services,

extended care services" for "hospital, related post-hospital".

1986 - Pub. L. 99-272 substituted "government employment" for

"Federal employment" in cls. (1) and (2).

1982 - Pub. L. 97-248, Sec. 122(a)(1), substituted "home health

services, and hospice care" for "and home health services".

Pub. L. 97-248, Sec. 278(b)(3), inserted "(or would be eligible

for such benefits if certain Federal employment were covered

employment under such subchapter)" after "subchapter II of this

chapter" in cl. (1), and inserted "(or would have been so entitled

to such benefits if certain Federal employment were covered

employment under such subchapter)" after "subchapter II of this

chapter" in cl. (2).

1980 - Pub. L. 96-499 substituted ", related post-hospital, and

home health services" for "and related post-hospital services".

Pub. L. 96-473 substituted "are eligible for" for "are entitled

to".

Pub. L. 96-265 substituted "not less than 24 months" for "not

less than 24 consecutive months".

1978 - Pub. L. 95-292 inserted references to section 426-1 of

this title and to individuals who do not meet the conditions

specified in either clause (1) or (2) but who are medically

determined to have end stage renal disease.

1972 - Pub. L. 92-603 designated existing provisions as cl. (1)

and added cl. (2).

EFFECTIVE DATE OF 1989 AMENDMENT

Section 101(d) of Pub. L. 101-234 provided that: "The provisions

of this section [amending this section and sections 1395d, 1395e,

1395f, 1395k, 1395x, 1395cc, and 1395tt of this title, enacting

provisions set out as notes under sections 1395e and 1395ww of this

title, and amending provisions set out as notes under sections

1395e and 1395ww of this title] shall take effect January 1, 1990,

except that the amendments made by subsection (c) [amending

provisions set out as a note under section 1395ww of this title]

shall be effective as if included in the enactment of MCCA [Pub. L.

100-360]."

EFFECTIVE DATE OF 1988 AMENDMENT

Amendment by Pub. L. 100-360 effective Jan. 1, 1989, except as

otherwise provided, and applicable to inpatient hospital deductible

for 1989 and succeeding years, to care and services furnished on or

after Jan. 1, 1989, to premiums for January 1989 and succeeding

months, and to blood or blood cells furnished on or after Jan. 1,

1989, see section 104(a) of Pub. L. 100-360, set out as a note

under section 1395d of this title.

EFFECTIVE DATE OF 1986 AMENDMENT

Amendment by Pub. L. 99-272 effective after Mar. 31, 1986, with

no individual to be considered under disability for any period

beginning before Apr. 1, 1986, for purposes of hospital insurance

benefits, see section 13205(d)(2) of Pub. L. 99-272, set out as a

note under section 410 of this title.

EFFECTIVE DATE OF 1982 AMENDMENT

Section 122(h)(1) of Pub. L. 97-248, as amended by Pub. L.

99-272, title IX, Sec. 9123(a), Apr. 7, 1986, 100 Stat. 168,

provided that: "The amendments made by this section [amending this

section and sections 1395d to 1395f, 1395h, and 1395x to 1395cc of

this title and section 231f of Title 45, Railroads, and enacting

provisions set out as notes under sections 1395b-1 and 1395f of

this title] apply to hospice care provided on or after November 1,

1983."

Amendment by section 278(b)(3) of Pub. L. 97-248 effective on and

after Jan. 1, 1983, and applicable to remuneration (for medicare

qualified Federal employment) paid after Dec. 31, 1982, see section

278(c)(2)(A) of Pub. L. 97-248, set out as a note under section 426

of this title.

EFFECTIVE DATE OF 1980 AMENDMENTS

Amendment by Pub. L. 96-499 effective with respect to services

furnished on or after July 1, 1981, see section 930(s)(1) of Pub.

L. 96-499, set out as a note under section 1395x of this title.

Amendment by Pub. L. 96-473 effective after second month

beginning after Oct. 19, 1980, see section 2(d) of Pub. L. 96-473,

set out as a note under section 426 of this title.

Amendment by Pub. L. 96-265 applicable with respect to hospital

insurance or supplementary medical insurance benefits for services

provided on or after first day of sixth month which begins after

June 9, 1980, see section 103(c) of Pub. L. 96-265, set out as a

note under section 426 of this title.

EFFECTIVE DATE OF 1978 AMENDMENT

Amendment by Pub. L. 95-292 effective with respect to services,

supplies, and equipment furnished after the third calendar month

beginning after June 13, 1978, except that provisions for the

implementation of an incentive reimbursement system for dialysis

services furnished in facilities and providers to become effective

with respect to a facility's or provider's first accounting period

beginning after the last day of the twelfth month following the

month of June 1978, and except that provisions for reimbursement

rates for home dialysis to become effective on Apr. 1, 1979, see

section 6 of Pub. L. 95-292, set out as a note under section 426 of

this title.

ADVISORY COUNCIL TO STUDY COVERAGE OF DISABLED UNDER THIS

SUBCHAPTER

Pub. L. 90-248, title I, Sec. 140, Jan. 2, 1968, 81 Stat. 854,

directed Secretary of Health, Education, and Welfare to appoint an

Advisory Council to study need for coverage of disabled under the

health insurance programs of this subchapter, directed Council to

submit a report on such study to Secretary by Jan. 1, 1969, and

directed Secretary in turn to transmit such report to Congress,

resulting in termination of Council's existence.

REIMBURSEMENT OF CHARGES UNDER PART A FOR SERVICES TO PATIENTS

ADMITTED PRIOR TO 1968 TO CERTAIN HOSPITALS

Pub. L. 90-248, title I, Sec. 142, Jan. 2, 1968, 81 Stat. 855,

provided that:

"(a) Notwithstanding any provision of title XVIII of the Social

Security Act [this subchapter] an individual who is entitled to

hospital insurance benefits under section 226 of such Act [section

426 of this title] may, subject to subsections (b) and (c),

receive, on the basis of an itemized bill, reimbursement for

charges to him for inpatient hospital services (as defined in

section 1861 of such Act [section 1395x of this title], but without

regard to subsection (e) of such section) furnished by, or under

arrangements (as defined in section 1861(w) of such Act [section

1395x(w) of this title] with, a hospital if -

"(1) the hospital did not have an agreement in effect under

section 1866 of such Act [section 1395cc of this title] but would

have been eligible for payment under part A of title XVIII of

such Act [this part] with respect to such services if at the time

such services were furnished the hospital had such an agreement

in effect;

"(2) the hospital (A) meets the requirements of paragraphs (5)

and (7) of section 1861(e) of such Act [section 1395x(e) of this

title], (B) is not primarily engaged in providing the services

described in section 1961(j)(1)(A) of such Act [section

1395x(j)(1)(A) of this title], and (C) is primarily engaged in

providing, by or under the supervision of individuals referred to

in paragraph (1) of section 1861(r) of such Act [section 1395x(r)

of this title], to inpatients (i) diagnostic services and

therapeutic services for medical diagnosis, treatment, and care

of injured, disabled, or sick persons, or (ii) rehabilitation

services for the rehabilitation of injured, disabled, or sick

persons;

"(3) the hospital did not meet the requirements that must be

met to permit payment to the hospital under part A of title XVIII

of such Act [this part]; and

"(4) an application is filed (submitted in such form and manner

and by such person, and containing and supported by such

information, as the Secretary shall by regulations prescribe) for

reimbursement before January 1, 1969.

"(b) Payments under this section may not be made for inpatient

hospital services (as described in subsection (a)) furnished to an

individual -

"(1) prior to July 1, 1966,

"(2) after December 31, 1967, unless furnished with respect to

an admission to the hospital prior to January 1, 1968, and

"(3) for more than -

"(A) 90 days in any spell of illness, but only if (i) prior

to January 1, 1969, the hospital furnishing such services

entered into an agreement under section 1866 of the Social

Security Act [section 1395cc of this title] and (ii) the

hospital's plan for utilization review, as provided for in

section 1861(k) of such Act [section 1395x(k) of this title],

has, in accordance with section 1814 of such Act [section 1395f

of this title], been applied to the services furnished such

individual, or

"(B) 20 days in any spell of illness, if the hospital did not

meet the conditions of clauses (i) and (ii) of subparagraph

(A).

"(c)(1) The amounts payable in accordance with subsection (a)

with respect to inpatient hospital services shall, subject to

paragraph (2) of this subsection, be paid from the Federal Hospital

Insurance Trust Fund in amounts equal to 60 percent of the

hospital's reasonable charges for routine services furnished in the

accommodations occupied by the individual or in semi-private

accommodations (as defined in section 1861(v)(4) of the Social

Security Act [section 1395x(v)(4) of this title]) whichever is

less, plus 80 percent of the hospital's reasonable charges for

ancillary services. If separate charges for routine and ancillary

services are not made by the hospital, reimbursement may be based

on two-thirds of the hospital's reasonable charges for the services

received but not to exceed the charges which would have been made

if the patient had occupied semi-private accommodations (as so

defined). For purposes of the preceding provisions of this

paragraph, the term 'routine services' shall mean the regular room,

dietary, and nursing services, minor medical and surgical supplies

and the use of equipment and facilities for which a separate charge

is not customarily made; the term 'ancillary services' shall mean

those special services for which charges are customarily made in

addition to routine services.

"(2) Before applying paragraph (1), payments made under this

section shall be reduced to the extent provided for under section

1813 of the Social Security Act [section 1395e of this title] in

the case of benefits payable to providers of services under part A

of title XVIII of such Act [this part].

"(d) For the purposes of this section -

"(1) the 90-day period, referred to in subsection (b)(3)(A),

shall be reduced by the number of days of inpatient hospital

services furnished to such individual during the spell of

illness, referred to therein, and with respect to which he was

entitled to have payment made under part A of title XVIII of the

Social Security Act [this part];

"(2) the 20-day period, referred to in subsection (b)(3)(B)

shall be reduced by the number of days in excess of 70 days of

inpatient hospital services furnished during the spell of

illness, referred to therein, and with respect to which such

individual was entitled to have payment made under such part A

[this part];

"(3) the term 'spell of illness' shall have the meaning

assigned to it by subsection (a) of section 1861 of such Act

[section 1395x(a) of this title] except that the term 'inpatient

hospital services' as it appears in such subsection shall have

the meaning assigned to it by subsection (a) of this section."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in title 26 section 220; title 38

sections 1725, 1729.

-End-

-CITE-

42 USC Sec. 1395d 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395d. Scope of benefits

-STATUTE-

(a) Entitlement to payment for inpatient hospital services,

post-hospital extended care services, home health services, and

hospice care

The benefits provided to an individual by the insurance program

under this part shall consist of entitlement to have payment made

on his behalf or, in the case of payments referred to in section

1395f(d)(2) of this title to him (subject to the provisions of this

part) for -

(1) inpatient hospital services or inpatient critical access

hospital services for up to 150 days during any spell of illness

minus 1 day for each day of such services in excess of 90

received during any preceding spell of illness (if such

individual was entitled to have payment for such services made

under this part unless he specifies in accordance with

regulations of the Secretary that he does not desire to have such

payment made);

(2)(A) post-hospital extended care services for up to 100 days

during any spell of illness, and (B) to the extent provided in

subsection (f) of this section, extended care services that are

not post-hospital extended care services;

(3) for individuals not enrolled in part B of this subchapter,

home health services, and for individuals so enrolled,

post-institutional home health services furnished during a home

health spell of illness for up to 100 visits during such spell of

illness; and

(4) in lieu of certain other benefits, hospice care with

respect to the individual during up to two periods of 90 days

each and an unlimited number of subsequent periods of 60 days

each with respect to which the individual makes an election under

subsection (d)(1) of this section.

(b) Services not covered

Payment under this part for services furnished an individual

during a spell of illness may not (subject to subsection (c) of

this section) be made for -

(1) inpatient hospital services furnished to him during such

spell after such services have been furnished to him for 150 days

during such spell minus 1 day for each day of inpatient hospital

services in excess of 90 received during any preceding spell of

illness (if such individual was entitled to have payment for such

services made under this part unless he specifies in accordance

with regulations of the Secretary that he does not desire to have

such payment made);

(2) post-hospital extended care services furnished to him

during such spell after such services have been furnished to him

for 100 days during such spell; or

(3) inpatient psychiatric hospital services furnished to him

after such services have been furnished to him for a total of 190

days during his lifetime.

Payment under this part for post-institutional home health services

furnished an individual during a home health spell of illness may

not be made for such services beginning after such services have

been furnished for a total of 100 visits during such spell.

(c) Inpatients of psychiatric hospitals

If an individual is an inpatient of a psychiatric hospital on the

first day of the first month for which he is entitled to benefits

under this part, the days on which he was an inpatient of such a

hospital in the 150-day period immediately before such first day

shall be included in determining the number of days limit under

subsection (b)(1) of this section insofar as such limit applies to

(1) inpatient psychiatric hospital services, or (2) inpatient

hospital services for an individual who is an inpatient primarily

for the diagnosis or treatment of mental illness (but shall not be

included in determining such number of days limit insofar as it

applies to other inpatient hospital services or in determining the

190-day limit under subsection (b)(3) of this section).

(d) Hospice care; election; waiver of rights; revocation; change of

election

(1) Payment under this part may be made for hospice care provided

with respect to an individual only during two periods of 90 days

each and an unlimited number of subsequent periods of 60 days each

during the individual's lifetime and only, with respect to each

such period, if the individual makes an election under this

paragraph to receive hospice care under this part provided by, or

under arrangements made by, a particular hospice program instead of

certain other benefits under this subchapter.

(2)(A) Except as provided in subparagraphs (B) and (C) and except

in such exceptional and unusual circumstances as the Secretary may

provide, if an individual makes such an election for a period with

respect to a particular hospice program, the individual shall be

deemed to have waived all rights to have payment made under this

subchapter with respect to -

(i) hospice care provided by another hospice program (other

than under arrangements made by the particular hospice program)

during the period, and

(ii) services furnished during the period that are determined

(in accordance with guidelines of the Secretary) to be -

(I) related to the treatment of the individual's condition

with respect to which a diagnosis of terminal illness has been

made or

(II) equivalent to (or duplicative of) hospice care;

except that clause (ii) shall not apply to physicians' services

furnished by the individual's attending physician (if not an

employee of the hospice program) or to services provided by (or

under arrangements made by) the hospice program.

(B) After an individual makes such an election with respect to a

90-day period or a subsequent 60-day period, the individual may

revoke the election during the period, in which case -

(i) the revocation shall act as a waiver of the right to have

payment made under this part for any hospice care benefits for

the remaining time in such period and (for purposes of subsection

(a)(4) of this section and subparagraph (A)) the individual shall

be deemed to have been provided such benefits during such entire

period, and

(ii) the individual may at any time after the revocation

execute a new election for a subsequent period, if the individual

otherwise is entitled to hospice care benefits with respect to

such a period.

(C) An individual may, once in each such period, change the

hospice program with respect to which the election is made and such

change shall not be considered a revocation of an election under

subparagraph (B).

(D) For purposes of this subchapter, an individual's election

with respect to a hospice program shall no longer be considered to

be in effect with respect to that hospice program after the date

the individual's revocation or change of election with respect to

that election takes effect.

(e) Services taken into account

For purposes of subsections (b) and (c) of this section,

inpatient hospital services, inpatient psychiatric hospital

services, and post-hospital extended care services shall be taken

into account only if payment is or would be, except for this

section or the failure to comply with the request and certification

requirements of or under section 1395f(a) of this title, made with

respect to such services under this part.

(f) Coverage of extended care services without regard to three-day

prior hospitalization requirement

(1) The Secretary shall provide for coverage, under clause (B) of

subsection (a)(2) of this section, of extended care services which

are not post-hospital extended care services at such time and for

so long as the Secretary determines, and under such terms and

conditions (described in paragraph (2)) as the Secretary finds

appropriate, that the inclusion of such services will not result in

any increase in the total of payments made under this subchapter

and will not alter the acute care nature of the benefit described

in subsection (a)(2) of this section.

(2) The Secretary may provide -

(A) for such limitations on the scope and extent of services

described in subsection (a)(2)(B) of this section and on the

categories of individuals who may be eligible to receive such

services, and

(B) notwithstanding sections 1395f, 1395x(v), and 1395ww of

this title, for such restrictions and alternatives on the amounts

and methods of payment for services described in such subsection,

as may be necessary to carry out paragraph (1).

(g) "Spell of illness" defined

For definitions of "spell of illness", and for definitions of

other terms used in this part, see section 1395x of this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1812, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 291; amended

Pub. L. 90-248, title I, Secs. 129(c)(2), 137(a), 138(a), 143(b),

146(a), Jan. 2, 1968, 81 Stat. 847, 853, 854, 857, 859; Pub. L.

96-499, title IX, Secs. 930(b)-(d), 931(a), Dec. 5, 1980, 94 Stat.

2631, 2633; Pub. L. 97-35, title XXI, Sec. 2121(a), Aug. 13, 1981,

95 Stat. 796; Pub. L. 97-248, title I, Secs. 122(b), 123, Sept. 3,

1982, 96 Stat. 356, 364; Pub. L. 97-448, title III, Sec. 309(b)(5),

Jan. 12, 1983, 96 Stat. 2409; Pub. L. 100-360, title I, Sec. 101,

July 1, 1988, 102 Stat. 684; Pub. L. 101-234, title I, Sec. 101(a),

Dec. 13, 1989, 103 Stat. 1979; Pub. L. 101-239, title VI, Sec.

6003(g)(3)(B)(i), Dec. 19, 1989, 103 Stat. 2152; Pub. L. 101-508,

title IV, Sec. 4006(a), Nov. 5, 1990, 104 Stat. 1388-43; Pub. L.

103-432, title I, Sec. 102(g)(1), Oct. 31, 1994, 108 Stat. 4404;

Pub. L. 105-33, title IV, Secs. 4201(c)(1), 4443(a), (b)(1),

4611(a), Aug. 5, 1997, 111 Stat. 373, 423, 472; Pub. L. 106-113,

div. B, Sec. 1000(a)(6) [title III, Sec. 321(k)(1)], Nov. 29, 1999,

113 Stat. 1536, 1501A-366.)

-REFTEXT-

REFERENCES IN TEXT

Part B of this subchapter, referred to in subsec. (a)(3), is

classified to section 1395j et seq. of this title.

-MISC1-

AMENDMENTS

1999 - Subsec. (b). Pub. L. 106-113 inserted "during" after "100

visits" in concluding provisions.

1997 - Subsec. (a)(1). Pub. L. 105-33, Sec. 4201(c)(1),

substituted "critical access" for "rural primary care".

Subsec. (a)(3). Pub. L. 105-33, Sec. 4611(a)(1), substituted "for

individuals not enrolled in part B of this subchapter, home health

services, and for individuals so enrolled, post-institutional home

health services furnished during a home health spell of illness for

up to 100 visits during such spell of illness" for "home health

services".

Subsec. (a)(4). Pub. L. 105-33, Sec. 4443(a), substituted "and an

unlimited number of subsequent periods of 60 days each" for ", a

subsequent period of 30 days, and a subsequent extension period".

Subsec. (b). Pub. L. 105-33, Sec. 4611(a)(2), inserted closing

provisions.

Subsec. (d)(1). Pub. L. 105-33, Sec. 4443(a), substituted "and an

unlimited number of subsequent periods of 60 days each" for ", a

subsequent period of 30 days, and a subsequent extension period".

Subsec. (d)(2)(B). Pub. L. 105-33, Sec. 4443(b)(1), substituted

"90-day period or a subsequent 60-day period" for "90- or 30-day

period or a subsequent extension period".

1994 - Subsec. (a)(1). Pub. L. 103-432 substituted "inpatient

hospital services or inpatient rural primary care hospital

services" for "inpatient hospital services" before "for up to 150

days" and "such services" for "inpatient hospital services" before

"in excess of 90" and struck out "and inpatient rural primary care

hospital services" after "such payment made)".

1990 - Subsec. (a)(4). Pub. L. 101-508, Sec. 4006(a)(1),

substituted "90 days each, a subsequent period of 30 days, and a

subsequent extension period" for "90 days each and one subsequent

period of 30 days".

Subsec. (d)(1). Pub. L. 101-508, Sec. 4006(a)(2)(A), substituted

"90 days each, a subsequent period of 30 days, and a subsequent

extension period during the individual's lifetime" for "90 days

each and one subsequent period of 30 days during the individual's

lifetime".

Subsec. (d)(2)(B). Pub. L. 101-508, Sec. 4006(a)(2)(B),

substituted "a 90- or 30-day period or a subsequent extension

period" for "a 90- or 30-day period".

1989 - Subsec. (a). Pub. L. 101-234 repealed Pub. L. 100-360,

Sec. 101(1), and provided that the provisions of law amended or

repealed by such section are restored or revived as if such section

had not been enacted, see 1988 Amendment note below.

Subsec. (a)(1). Pub. L. 101-239 inserted "and inpatient rural

primary care hospital services" before semicolon at end.

Subsecs. (b) to (d)(1), (2)(B), (e) to (g). Pub. L. 101-234

repealed Pub. L. 100-360, Sec. 101(2)-(6), and provided that the

provisions of law amended or repealed by such section are restored

or revived as if such section had not been enacted, see 1988

Amendment notes below.

1988 - Subsec. (a). Pub. L. 100-360, Sec. 101(1), struck out

former pars. (1) to (4) and added new pars. (1) to (4) which read

as follows:

"(1) inpatient hospital services;

"(2) extended care services for up to 150 days during any

calendar year;

"(3) home health services; and

"(4) in lieu of certain other benefits, hospice care with respect

to the individual during up to two periods of 90 days each, a

subsequent period of 30 days, and a subsequent extension period

with respect to which the individual makes an election under

subsection (d)(1) of this section."

Subsec. (b). Pub. L. 100-360, Sec. 101(2), amended subsec. (b)

generally, striking out par. (1) and renumbering and amending pars.

(2) and (3) as (1) and (2), respectively.

Subsec. (c). Pub. L. 100-360, Sec. 101(3), amended subsec. (c)

generally, substituting pars. (1) to (4) limiting periods for

inpatients of psychiatric hospitals for former single paragraph.

Subsec. (d)(1). Pub. L. 100-360, Sec. 101(4)(A), substituted ", a

subsequent period of 30 days, and a subsequent extension period"

for "and one subsequent period of 30 days".

Subsec. (d)(2)(B). Pub. L. 100-360, Sec. 101(4)(B), inserted "or

a subsequent extension period" after "30-day period" in

introductory provisions.

Subsec. (e). Pub. L. 100-360, Sec. 101(5), struck out

"post-hospital" before "extended care services".

Subsec. (f). Pub. L. 100-360, Sec. 101(6), struck out subsec. (f)

which provided coverage of extended care services without regard to

three-day prior hospitalization requirement.

Subsec. (g). Pub. L. 100-360, Sec. 101(6), struck out subsec. (g)

which cross-referenced section 1395x of this title for definitions

of "spell of illness" and other terms used in this part.

1983 - Subsec. (d)(2)(A). Pub. L. 97-448 substituted "or to

services" for "or to other than services" after "(if not an

employee of the hospice program)".

1982 - Subsec. (a)(2). Pub. L. 97-248, Sec. 123(a), redesignated

existing provisions as subpar. (A) and added subpar. (B).

Subsec. (a)(4). Pub. L. 97-248, Sec. 122(b)(1), added par. (4).

Subsec. (d). Pub. L. 97-248, Sec. 122(b)(2), added subsec. (d).

Subsecs. (f), (g). Pub. L. 97-248, Sec. 123(b), added subsec. (f)

and redesignated former subsec. (f) as (g).

1981 - Subsec. (a). Pub. L. 97-35 struck out par. (4) which

related to alcohol detoxification facility services.

1980 - Subsec. (a)(3). Pub. L. 96-499, Sec. 930(b), substituted

"home health services" for "post-hospital home health services for

up to 100 visits (during the one-year period described in section

1395x(n) of this title) after the beginning of one spell of illness

and before the beginning of the next".

Subsec. (a)(4). Pub. L. 96-499, Sec. 931(a), added par. (4).

Subsec. (d). Pub. L. 96-499, Sec. 930(c), struck out subsec. (d)

which authorized payment for post-hospital home health services

furnished an individual only during the one year period described

in section 1395x(n) of this title following his most recent

hospital discharge which met the requirements of such section and

only for the first 100 visits in such period.

Subsec. (e). Pub. L. 96-499, Sec. 930(d), substituted

"subsections (b) and (c)" for "subsections (b), (c), and (d)" and

"and post-hospital extended care services" for "post-hospital

extended care services, and post-hospital home health services".

1968 - Subsec. (a). Pub. L. 90-248, Sec. 143(b), inserted "or, in

the case of payments referred to in section 1395f(d)(2) of this

title to him" after "on his behalf" in text preceding par. (1).

Subsec. (a)(1). Pub. L. 90-248, Sec. 137(a)(1), increased the

maximum duration of benefits from 90 to 150 days minus 1 day for

each day of inpatient hospital services in excess of 90 received

during any preceding spell of illness (if such individual was

entitled to have payment for such services made under this part

unless he specifies that he does not desire to have such payment

made).

Subsec. (a)(4). Pub. L. 90-248, Sec. 129(c)(2), struck out par.

(4) which provided for payment for outpatient hospital diagnostic

services.

Subsec. (b)(1). Pub. L. 90-248, Sec. 137(a)(2), changed the

limitation on payments from 90 to 150 days minus 1 day for each day

of inpatient hospital services in excess of 90 received during any

preceding spell of illness (if such individual was entitled to have

payment for such services made under this part unless he specifies

that he does not desire to have such payment made).

Subsec. (c). Pub. L. 90-248, Sec. 138(a), increased the limit

from 90 to 150 days so that if an individual was an inpatient of a

psychiatric or tuberculosis hospital on the first day of the first

month for which he is entitled to benefits, the days he was an

inpatient in the 150-day period immediately before such first day

are included in determining the limit under subsec. (b)(1) insofar

as such limit applies to (1) inpatient psychiatric hospital

services and inpatient tuberculosis hospital services, or (2)

inpatient hospital services for an individual who is an inpatient

primarily for the diagnosis or treatment of mental illness or

tuberculosis (but are not included in determining such limit as it

applies to other inpatient hospital services or in determining the

190-day limit under subsec. (b)(3)).

Pub. L. 90-248, Sec. 146(a), provided that the limitation of

allowable days of inpatient hospital services will not apply to

services provided to an inpatient of a tuberculosis hospital.

EFFECTIVE DATE OF 1999 AMENDMENT

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec.

321(m)], Nov. 29, 1999, 113 Stat. 1536, 1501A-368, provided that:

"Except as otherwise provided, the amendments made by this section

[amending this section and sections 1395i, 1395i-4, 1395l, 1395m,

1395u, 1395w-3, 1395w-4, 1395w-21, 1395w-22, 1395w-24, 1395x,

1395y, 1395cc, 1395ss, 1395ww, 1395yy, and 1395fff of this title,

repealing section 1320b-5 of this title, and amending provisions

set out as notes under sections 1395f and 1395ww of this title]

shall take effect as if included in the enactment of BBA [Balanced

Budget Act of 1997, Pub. L. 105-33]."

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by section 4201(c)(1) of Pub. L. 105-33 applicable to

services furnished on or after Oct. 1, 1997, see section 4201(d) of

Pub. L. 105-33, set out as a note under section 1395f of this

title.

Section 4449 of title IV of Pub. L. 105-33 provided that: "Except

as otherwise provided in this chapter [chapter 4 (Secs. 4441-4449)

of subtitle E of title IV of Pub. L. 105-33, amending this section

and sections 1395f, 1395x, and 1395pp of this title and enacting

provisions set out as notes under section 1395f and 1395x of this

title], the amendments made by this chapter apply to benefits

provided on or after the date of the enactment of this chapter

[Aug. 5, 1997], regardless of whether or not an individual has made

an election under section 1812(d) of the Social Security Act (42

U.S.C. 1395d(d)) before such date."

Section 4611(f) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and sections 1395u,

1395x, and 1395ff of this title] apply to services furnished on or

after January 1, 1998. For purpose of applying such amendments, any

home health spell of illness that began, but not [sic] did not end,

before such date shall be considered to have begun as of such

date."

EFFECTIVE DATE OF 1994 AMENDMENT

Section 102(i) of Pub. L. 103-432 provided that: "The amendments

made by this section [amending this section and sections 1395e,

1395f, 1395i-4, 1395m, 1395x, and 1395ww of this title] shall take

effect on the date of the enactment of this Act [Oct. 31, 1994]."

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4006(c) of Pub. L. 101-508 provided that: "The amendments

made by this section [amending this section and section 1395f of

this title] shall apply with respect to care and services furnished

on or after January 1, 1990."

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section

101(d) of Pub. L. 101-234, set out as a note under section 1395c of

this title.

EFFECTIVE DATE OF 1988 AMENDMENT

Section 104(a) of Pub. L. 100-360, as amended by Pub. L. 100-485,

title VI, Sec. 608(d)(3)(A), Oct. 13, 1988, 102 Stat. 2413,

provided that:

"(1) In general. - Except as provided in paragraph (2) and

subsection (b), the amendments made by this subtitle [subtitle A

(Secs. 101-104) of title I of Pub. L. 100-360, amending this

section and sections 1395c, 1395e, 1395f, 1395i-2, 1395k, 1395x,

1395cc, and 1395tt of this title] shall take effect on January 1,

1989, and shall apply -

"(A) to the inpatient hospital deductible for 1989 and

succeeding years,

"(B) to care and services furnished on or after January 1,

1989,

"(C) to premiums for January 1989 and succeeding months, and

"(D) to blood or blood cells furnished on or after January 1,

1989.

"(2) Elimination of post-hospital requirement for extended care

services. - The amendments made by this subtitle, insofar as they

eliminate the requirement (under section 1812(a)(2) of the Social

Security Act [subsec. (a)(2) of this section]) that extended care

services are only covered under title XVIII of such Act [this

subchapter] if they are post-hospital extended care services, shall

only apply to extended care services furnished pursuant to an

admission to a skilled nursing facility occurring on or after

January 1, 1989."

EFFECTIVE DATE OF 1983 AMENDMENT

Amendment by Pub. L. 97-448 effective as if originally included

as a part of this section as this section was amended by the Tax

Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248, see

section 309(c)(2) of Pub. L. 97-448, set out as a note under

section 426-1 of this title.

EFFECTIVE DATE OF 1982 AMENDMENT

Amendment by section 122(b) of Pub. L. 97-248 applicable to

hospice care provided on or after Nov. 1, 1983, see section

122(h)(1) of Pub. L. 97-248, as amended, set out as a note under

section 1395c of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Section 2121(i) of Pub. L. 97-35 provided that: "The amendments

made by this section [amending this section and sections 1320c-3,

1320c-4, 1320c-7, 1395f, and 1395x of this title] (other than by

subsection (h) [repealing provisions set out as a note under

section 1395ll of this title]) shall apply to services furnished in

detoxification facilities for inpatient stays beginning on or after

the tenth day after the date of the enactment of this Act [Aug. 13,

1981]."

EFFECTIVE DATE OF 1980 AMENDMENT

Amendment by section 930(b)-(d) of Pub. L. 96-499 effective with

respect to services furnished on or after July 1, 1981, see section

930(s)(1) of Pub. L. 96-499, set out as a note under section 1395x

of this title.

Section 931(e) of Pub. L. 96-499 provided that: "The amendments

made by subsections (a) through (d) of this section [amending this

section and sections 1395f and 1395x of this title] shall become

effective on April 1, 1981."

EFFECTIVE DATE OF 1968 AMENDMENT

Section 129(d) of Pub. L. 90-248 provided that: "The amendments

made by this section [amending this section and sections 426,

1395e, 1395f, 1395k, 1395l, 1395n, 1395x, and 1395cc of this title

and section 228s-2 of Title 45, Railroads] shall apply with respect

to services furnished after March 31, 1968, except that subsection

(c)(5) of such section [amending section 1395f of this title] shall

become effective with respect to services furnished after the date

of enactment of this Act [Jan. 2, 1968]."

Section 137(c) of Pub. L. 90-248 provided that: "The amendments

made by subsections (a) and (b) [amending this section and section

1395e of this title] shall apply with respect to services furnished

after December 31, 1967."

Section 138(b) of Pub. L. 90-248 provided that: "The amendments

made by subsection (a) [amending this section] shall apply with

respect to payment for services furnished after December 31, 1967."

Section 143(d) of Pub. L. 90-248 provided that: "The provisions

made by subsection (a) of this section [amending section 1395x of

this title] shall become effective as of July 1, 1966, and the

provisions made by subsections (b) and (c) of this section

[amending this section and section 1395f of this title] shall apply

to services furnished with respect to admissions occurring after

December 31, 1967, and to outpatient hospital diagnostic services

furnished after December 31, 1967, and before April 1, 1968."

Section 146(b) of Pub. L. 90-248 provided that: "The amendment

made by subsection (a) [amending this section] shall apply with

respect to payment for services furnished after December 31, 1967."

MEDPAC REPORT ON ACCESS TO, AND USE OF, HOSPICE BENEFIT

Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 323], Dec. 21,

2000, 114 Stat. 2763, 2763A-501, provided that:

"(a) In General. - The Medicare Payment Advisory Commission shall

conduct a study to examine the factors affecting the use of hospice

benefits under the medicare program under title XVIII of the Social

Security Act [this subchapter], including a delay in the time

(relative to death) of entry into a hospice program, and

differences in such use between urban and rural hospice programs

and based upon the presenting condition of the patient.

"(b) Report. - Not later than 18 months after the date of the

enactment of this Act [Dec. 21, 2000], the Commission shall submit

to Congress a report on the study conducted under subsection (a),

together with any recommendations for legislation that the

Commission deems appropriate."

TRANSITION

Section 4611(e) of Pub. L. 105-33 provided that:

"(1) In general. - Notwithstanding any provision of title XVIII

of the Social Security Act [this subchapter], the Secretary of

Health and Human Services shall establish a transition for the

aggregate amount of expenditures that are transferred from part A,

to part B, of title XVIII of the Social Security Act [this part and

part B of this subchapter], as a result of the amendments made by

this section [amending this section and sections 1395u, 1395x, and

1395ff of this title], during each of the years during the period

beginning with 1998 and ending with 2002 according to this

subsection. Under the transition for each such year, the Secretary

shall effect such transfer, between the trust funds under such

parts, as will result in only the proportion (specified in

paragraph (2)) of such aggregate expenditures for the year being

transferred from such part A to such part B.

"(2) Proportion specified. - The proportion specified in this

paragraph for -

"(A) 1998 is 1/6 ,

"(B) 1999 is 1/3 ,

"(C) 2000 is 1/2 ,

"(D) 2001 is 2/3 , and

"(E) 2002 is 5/6 .

"(3) Application in establishing monthly premiums for 1998

through 2003. -

"(A) In general. - For purposes only of computing the monthly

premium under section 1839 of the Social Security Act (42 U.S.C.

1395r), the monthly actuarial rate for enrollees age 65 and over

shall be computed as though any reference in paragraph (1) of

this subsection to 2002 were a reference to 2003 and as if the

following proportions were substituted for the proportions

specified in paragraph (2):

"(i) For 1998, 1/7 .

"(ii) For 1999, 2/7 .

"(iii) For 2000, 3/7 .

"(iv) For 2001, 4/7 .

"(v) For 2002, 5/7 .

"(vi) For 2003, 6/7 .

"(B) No impact on government contribution. - Subparagraph (A)

does not apply in determining the amount of the Government

contribution under section 1844 of the Social Security Act (42

U.S.C. 1395w)."

REPEAL OF 1988 EXPANSION OF MEDICARE PART A BENEFITS

For provisions repealing amendment by section 101 of Pub. L.

100-360, restoring or reviving this section as if section 101 of

Pub. L. 100-360 had not been enacted, and providing a transition

period for medicare beneficiaries with respect to inpatient

hospital services and extended care services provided on or after

Jan. 1, 1990, and providing an exception to such restoration for

certain hospice care, see section 101(a)-(b)(2) of Pub. L. 101-234,

set out as a note under section 1395e of this title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395e, 1395f, 1395w-23,

1395x, 1395eee, 1396b, 1396d, 1396r-8 of this title; title 10

section 1074j.

-End-

-CITE-

42 USC Sec. 1395e 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395e. Deductibles and coinsurance

-STATUTE-

(a) Inpatient hospital services; outpatient hospital diagnostic

services; blood; post-hospital extended care services

(1) The amount payable for inpatient hospital services or

inpatient critical access hospital services furnished an individual

during any spell of illness shall be reduced by a deduction equal

to the inpatient hospital deductible or, if less, the charges

imposed with respect to such individual for such services, except

that, if the customary charges for such services are greater than

the charges so imposed, such customary charges shall be considered

to be the charges so imposed. Such amount shall be further reduced

by a coinsurance amount equal to -

(A) one-fourth of the inpatient hospital deductible for each

day (before the 91st day) on which such individual is furnished

such services during such spell of illness after such services

have been furnished to him for 60 days during such spell; and

(B) one-half of the inpatient hospital deductible for each day

(before the day following the last day for which such individual

is entitled under section 1395d(a)(1) of this title to have

payment made on his behalf for inpatient hospital services or

inpatient critical access hospital services during such spell of

illness) on which such individual is furnished such services

during such spell of illness after such services have been

furnished to him for 90 days during such spell;

except that the reduction under this sentence for any day shall not

exceed the charges imposed for that day with respect to such

individual for such services (and for this purpose, if the

customary charges for such services are greater than the charges so

imposed, such customary charges shall be considered to be the

charges so imposed).

(2)(A) The amount payable to any provider of services under this

part for services furnished an individual shall be further reduced

by a deduction equal to the expenses incurred for the first three

pints of whole blood (or equivalent quantities of packed red blood

cells, as defined under regulations) furnished to the individual

during each calendar year, except that such deductible for such

blood shall in accordance with regulations be appropriately reduced

to the extent that there has been a replacement of such blood (or

equivalent quantities of packed red blood cells, as so defined);

and for such purposes blood (or equivalent quantities of packed red

blood cells, as so defined) furnished such individual shall be

deemed replaced when the institution or other person furnishing

such blood (or such equivalent quantities of packed red blood

cells, as so defined) is given one pint of blood for each pint of

blood (or equivalent quantities of packed red blood cells, as so

defined) furnished such individual with respect to which a

deduction is made under this sentence.

(B) The deductible under subparagraph (A) for blood or blood

cells furnished an individual in a year shall be reduced to the

extent that a deductible has been imposed under section 1395l(b) of

this title to blood or blood cells furnished the individual in the

year.

(3) The amount payable for post-hospital extended care services

furnished an individual during any spell of illness shall be

reduced by a coinsurance amount equal to one-eighth of the

inpatient hospital deductible for each day (before the 101st day)

on which he is furnished such services after such services have

been furnished to him for 20 days during such spell.

(4)(A) The amount payable for hospice care shall be reduced -

(i) in the case of drugs and biologicals provided on an

outpatient basis by (or under arrangements made by) the hospice

program, by a coinsurance amount equal to an amount (not to

exceed $5 per prescription) determined in accordance with a drug

copayment schedule (established by the hospice program) which is

related to, and approximates 5 percent of, the cost of the drug

or biological to the program, and

(ii) in the case of respite care provided by (or under

arrangements made by) the hospice program, by a coinsurance

amount equal to 5 percent of the amount estimated by the hospice

program (in accordance with regulations of the Secretary) to be

equal to the amount of payment under section 1395f(i) of this

title to that program for respite care;

except that the total of the coinsurance required under clause (ii)

for an individual may not exceed for a hospice coinsurance period

the inpatient hospital deductible applicable for the year in which

the period began. For purposes of this subparagraph, the term

"hospice coinsurance period" means, for an individual, a period of

consecutive days beginning with the first day for which an election

under section 1395d(d) of this title is in effect for the

individual and ending with the close of the first period of 14

consecutive days on each of which such an election is not in effect

for the individual.

(B) During the period of an election by an individual under

section 1395d(d)(1) of this title, no copayments or deductibles

other than those under subparagraph (A) shall apply with respect to

services furnished to such individual which constitute hospice

care, regardless of the setting in which such services are

furnished.

(b) Inpatient hospital deductible; application

(1) The inpatient hospital deductible for 1987 shall be $520. The

inpatient hospital deductible for any succeeding year shall be an

amount equal to the inpatient hospital deductible for the preceding

calendar year, changed by the Secretary's best estimate of the

payment-weighted average of the applicable percentage increases (as

defined in section 1395ww(b)(3)(B) of this title) which are applied

under section 1395ww(d)(3)(A) of this title for discharges in the

fiscal year that begins on October 1 of such preceding calendar

year, and adjusted to reflect changes in real case mix (determined

on the basis of the most recent case mix data available). Any

amount determined under the preceding sentence which is not a

multiple of $4 shall be rounded to the nearest multiple of $4 (or,

if it is midway between two multiples of $4, to the next higher

multiple of $4).

(2) The Secretary shall promulgate the inpatient hospital

deductible and all coinsurance amounts under this section between

September 1 and September 15 of the year preceding the year to

which they will apply.

(3) The inpatient hospital deductible for a year shall apply to -

(A) the deduction under the first sentence of subsection (a)(1)

of this section for the year in which the first day of inpatient

hospital services or inpatient critical access hospital services

occurs in a spell of illness, and

(B) to the coinsurance amounts under subsection (a) of this

section for inpatient hospital services, inpatient critical

access hospital services and post-hospital extended care services

furnished in that year.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1813, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 292; amended

Pub. L. 90-248, title I, Secs. 129(c)(3), (4), 135(a), 137(b), Jan.

2, 1968, 81 Stat. 847, 848, 852, 854; Pub. L. 97-35, title XXI,

Secs. 2131(a), 2132(a), Aug. 13, 1981, 95 Stat. 797; Pub. L.

97-248, title I, Sec. 122(e), Sept. 3, 1982, 96 Stat. 361; Pub. L.

99-272, title IX, Sec. 9125(a), Apr. 7, 1986, 100 Stat. 168; Pub.

L. 99-509, title IX, Sec. 9301(a), Oct. 21, 1986, 100 Stat. 1981;

Pub. L. 100-203, title IV, Sec. 4002(f)(3), Dec. 22, 1987, as added

Pub. L. 100-360, title IV, Sec. 411(b)(1)(H)(ii), July 1, 1988, 102

Stat. 769; Pub. L. 100-360, title I, Sec. 102, July 1, 1988, 102

Stat. 685; Pub. L. 101-234, title I, Sec. 101(a), Dec. 13, 1989,

103 Stat. 1979; Pub. L. 103-432, title I, Sec. 102(g)(2), (3), Oct.

31, 1994, 108 Stat. 4404; Pub. L. 105-33, title IV, Sec.

4201(c)(1), Aug. 5, 1997, 111 Stat. 373.)

-MISC1-

AMENDMENTS

1997 - Pub. L. 105-33 substituted "critical access" for "rural

primary care" wherever appearing.

1994 - Subsec. (a)(1). Pub. L. 103-432, Sec. 102(g)(2),

substituted "inpatient hospital services or inpatient rural primary

care hospital services" for "inpatient hospital services" in

introductory provisions and in subpar. (B).

Subsec. (b)(3)(A). Pub. L. 103-432, Sec. 102(g)(2), substituted

"inpatient hospital services or inpatient rural primary care

hospital services" for "inpatient hospital services".

Subsec. (b)(3)(B). Pub. L. 103-432, Sec. 102(g)(3), substituted

"inpatient hospital services, inpatient rural primary care hospital

services" for "inpatient hospital services".

1989 - Subsecs. (a)(1) to (3), (b)(3). Pub. L. 101-234 repealed

Pub. L. 100-360, Sec. 102, subject to an exception for blood

deduction, and provided that the provisions of law amended or

repealed by such section are restored or revived as if such section

had not been enacted, see 1988 Amendment notes below.

1988 - Subsec. (a)(1) to (3). Pub. L. 100-360, Sec. 102(1),

amended pars. (1) to (3) generally, revising and reorganizing

former pars. (1)(A), (B), (2), and (3), as par. (1), consisting of

subpars. (A) to (D), and pars. (2) and (3), each consisting of

subpars. (A) and (B).

Subsec. (b)(1). Pub. L. 100-360, Sec. 411(b)(1)(H)(ii), added

Pub. L. 100-203, Sec. 4002(f)(3), see 1987 Amendment note below.

Subsec. (b)(3). Pub. L. 100-360, Sec. 102(2), struck out par. (3)

which related to application of deductible.

1987 - Subsec. (b)(1). Pub. L. 100-203, Sec. 4002(f)(3), as added

by Pub. L. 100-360, Sec. 411(b)(1)(H)(ii), substituted "Secretary's

best estimate of the payment-weighted average of the applicable

percentage increases (as defined in section 1395ww(b)(3)(B) of this

title) which are applied" for "applicable percentage increase (as

defined in section 1395ww(b)(3)(B) of this title) which is

applied".

1986 - Subsec. (b). Pub. L. 99-509 amended subsec. (b) generally.

Prior to amendment, subsec. (b) read as follows:

"(1) The inpatient hospital deductible which shall be applicable

for the purposes of subsection (a) of this section shall be $40 in

the case of any spell of illness beginning before 1969.

"(2) The Secretary shall, between July 1 and September 15 of

1968, and of each year thereafter, determine and promulgate the

inpatient hospital deductible which shall be applicable for the

purposes of subsection (a) of this section in the case of any

inpatient hospital services or post-hospital extended care services

furnished during the succeeding calendar year. Such inpatient

hospital deductible shall be equal to $45 multiplied by the ratio

of (A) the current average per diem rate for inpatient hospital

services for the calendar year preceding the promulgation, to (B)

the current average per diem rate for such services for 1966. Any

amount determined under the preceding sentence which is not a

multiple of $4 shall be rounded to the nearest multiple of $4 (or,

if it is midway between two multiplies of $4, to the next higher

multiple of $4). The current average per diem rate for any year

shall be determined by the Secretary on the basis of the best

information available to him (at the time the determination is

made) as to the amounts paid under this part on account of

inpatient hospital services furnished during such year, by

hospitals which have agreements in effect under section 1395cc of

this title, to individuals who are entitled to hospital insurance

benefits under section 426 of this title, plus the amount which

would have been so paid but for subsection (a)(1) of this section."

Subsec. (b)(2). Pub. L. 99-272 substituted "September 15" for

"October 1".

1982 - Subsec. (a)(4). Pub. L. 97-248 added par. (4).

1981 - Subsec. (b)(2). Pub. L. 97-35 substituted "any inpatient

hospital services or post-hospital extended care services furnished

during the succeeding calendar year. Such inpatient hospital

deductible shall be equal to $45" for "any spell of illness

beginning during the succeeding calendar year. Such inpatient

hospital deductible shall be equal to $40".

1968 - Subsec. (a)(1). Pub. L. 90-248, Sec. 137(b), designated

existing provisions as subpar. (A) and added subpar. (B) and the

exception provision that the reduction for any day shall not exceed

the charges for that day.

Subsec. (a)(2). Pub. L. 90-248, Sec. 135(a), made the three pint

deductible applicable also to equivalent quantities of packed red

blood cells, as defined by the Secretary under regulations.

Subsec. (a)(2) to (4). Pub. L. 90-248, Sec. 129(c)(3), struck out

par. (2) which provided for reduction of amount payable for

outpatient hospital diagnostic services furnished an individual

during a diagnostic study, and redesignated pars. (3) and (4) as

(2) and (3), respectively.

Subsec. (b)(1), (2). Pub. L. 90-248, Sec. 129(c)(4)(A), (B),

struck out diagnostic studies from application of inpatient

hospital deductible.

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by Pub. L. 105-33 applicable to services furnished on

or after Oct. 1, 1997, see section 4201(d) of Pub. L. 105-33, set

out as a note under section 1395f of this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section

101(d) of Pub. L. 101-234, set out as a note under section 1395c of

this title.

EFFECTIVE DATE OF 1988 AMENDMENT

Amendment by section 102 of Pub. L. 100-360 effective Jan. 1,

1989, except as otherwise provided, and applicable to inpatient

hospital deductible for 1989 and succeeding years, to care and

services furnished on or after Jan. 1, 1989, to premiums for

January 1989 and succeeding months, and to blood or blood cells

furnished on or after Jan. 1, 1989, see section 104(a) of Pub. L.

100-360, set out as a note under section 1395d of this title.

Section 411(b)(1)(H)(iii) of Pub. L. 100-360 provided that: "The

amendment made by clause (ii) [amending Pub. L. 100-203] shall

apply to the inpatient hospital deductible for years beginning with

1989."

EFFECTIVE DATE OF 1986 AMENDMENTS

Section 9301(b) of Pub. L. 99-509 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

inpatient hospital services and post-hospital extended care

services furnished on or after January 1, 1987, and to the monthly

premium (under part A of title XVIII of the Social Security Act

[this part]) for months beginning with January 1987."

Section 9125(b) of Pub. L. 99-272 provided that: "The amendment

made by this section [amending this section] shall apply to

calendar years after 1985."

EFFECTIVE DATE OF 1982 AMENDMENT

Amendment by Pub. L. 97-248 applicable to hospice care provided

on or after Nov. 1, 1983, see section 122(h)(1) of Pub. L. 97-248,

as amended, set out as a note under section 1395c of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Section 2131(b) of Pub. L. 97-35 provided that: "The amendment

made by subsection (a) [amending this section] is effective for

inpatient hospital services or post-hospital extended care services

furnished on or after January 1, 1982."

Section 2132(b) of Pub. L. 97-35 provided that: "The amendments

made by subsection (a) [amending this section] shall apply to

inpatient hospital services and post-hospital extended care

services furnished in calendar years beginning with calendar year

1982."

EFFECTIVE DATE OF 1968 AMENDMENT

Amendment by section 129(c)(3), (4) of Pub. L. 90-248 applicable

with respect to services furnished after Mar. 31, 1968, see section

129(d) of Pub. L. 90-248, set out as a note under section 1395d of

this title.

Section 135(d) of Pub. L. 90-248 provided that: "The amendments

made by this section [amending this section and sections 1395l and

1395cc of this title] shall apply with respect to payment for blood

(or packed red blood cells) furnished an individual after December

31, 1967."

Amendment by section 137(b) of Pub. L. 90-248 applicable with

respect to services furnished after Dec. 31, 1967, see section

137(c) of Pub. L. 90-248, set out as a note under section 1395d of

this title.

REPEAL OF 1988 EXPANSION OF MEDICARE PART A BENEFITS

Section 101(a)-(b)(2) of Pub. L. 101-234, as amended by Pub. L.

101-508, title IV, Sec. 4008(m)(1), Nov. 5, 1990, 104 Stat.

1388-53, provided that:

"(a) In General. -

"(1) General rule. - Except as provided in paragraph (2),

sections 101, 102, and 104(d) (other than paragraph (7)) of the

Medicare Catastrophic Coverage Act of 1988 (Public Law 100-360)

[amending this section and sections 1395c, 1395d, 1395f, 1395k,

1395x, 1395cc, and 1395tt of this title] (in this Act referred to

as 'MCCA') are repealed, and the provisions of law amended or

repealed by such sections are restored or revived as if such

section had not been enacted.

"(2) Exception for blood deduction. - The repeal of section

102(1) of MCCA [amending this section] (relating to deductibles

and coinsurance under part A) shall not apply, but only insofar

as such section amended paragraph (2) of section 1813(a) of the

Social Security Act [subsec. (a)(2) of this section] (relating to

a deduction for blood).

"(b) Transition Provisions for Medicare Beneficiaries. -

"(1) Inpatient hospital services and post-hospital extended

care services. - In applying sections 1812 and 1813 of the Social

Security Act [section 1395d of this title and this section], as

restored by subsection (a)(1), with respect to inpatient hospital

services and extended care services provided on or after January

1, 1990 -

"(A) no day before January 1, 1990, shall be counted in

determining the beginning (or period) of a spell of illness;

"(B) with respect to the limitation (other than the

limitation under section 1812(c) of such Act [section 1395d(c)

of this title]) on such services provided in a spell of

illness, days of such services before January 1, 1990, shall

not be counted, except that days of inpatient hospital services

before January 1, 1989, which were applied with respect to an

individual after receiving 90 days of services in a spell of

illness (commonly known as 'lifetime reserve days') shall be

counted;

"(C) the limitation of coverage of extended care services to

post-hospital extended care services shall not apply to an

individual receiving such services from a skilled nursing

facility during a continuous period beginning before (and

including) January 1, 1990, until the end of the period of 30

consecutive days in which the individual is not provided

inpatient hospital services or extended care services; and

"(D) the inpatient hospital deductible under section

1813(a)(1) of such Act [subsec. (a)(1) of this section] shall

not apply -

"(i) in the case of an individual who is receiving

inpatient hospital services during a continuous period

beginning before (and including) January 1, 1990, with

respect to the spell of illness beginning on such date, if

such a deductible was imposed on the individual for a period

of hospitalization during 1989;

"(ii) for a spell of illness beginning during January 1990,

if such a deductible was imposed on the individual for a

period of hospitalization that began in December 1989; and

"(iii) in the case of a spell of illness of an individual

that began before January 1, 1990.

"(2) Hospice care. - The restoration of section 1812(a)(4) of

the Social Security Act [section 1395d(a)(4) of this title],

effected by subsection (a)(1), shall not apply to hospice care

provided during the subsequent period (described in such section

as in effect on December 31, 1989) with respect to which an

election has been made before January 1, 1990."

[Section 4008(m)(1) of Pub. L. 101-508 provided that amendment by

that section to section 101(b)(1)(B) of Pub. L. 101-234, set out

above, is effective as if included in enactment of Medicare

Catastrophic Coverage Repeal Act of 1989, Pub. L. 101-234.]

HOLD HARMLESS PROVISIONS; APPLICATION OF SUBSECTION (A)(1) AND (2)

Section 104(b) of Pub. L. 100-360, as amended by Pub. L. 100-485,

title VI, Sec. 608(d)(3)(B), Oct. 13, 1988, 102 Stat. 2413; Pub. L.

101-234, title I, Sec. 101(b)(3), Dec. 13, 1989, 103 Stat. 1980,

provided that: "In the case of an individual for whom a spell of

illness (as defined in section 1861(a) of the Social Security Act

[section 1395x(a) of this title], as in effect on December 31,

1988) began before January 1, 1989, and had not yet ended as of

such date -

"(1)(A) section 1813(a)(1) of such Act [subsec. (a)(1) of this

section] (as amended by this subtitle [subtitle A (Secs. 101-104)

of title I of Pub. L. 100-360]) shall not apply to services

furnished during that spell of illness during 1989, and

"(B) if that individual begins a period of hospitalization (as

defined in such section) during 1989 after the end of that spell

of illness, the first period of hospitalization during 1989 that

begins after that spell of illness shall be considered to be (for

purposes of such section) the first period of hospitalization

that begins during that year; and

"(2) the amount of any deductible under section 1813(a)(2) of

such Act (as amended by this subtitle) shall be reduced during

that spell of illness during 1989 to the extent the deductible

under such section was applied during the spell of illness."

PROMULGATION OF NEW DEDUCTIBLE

Section 9301(c) of Pub. L. 99-509 directed Secretary of Health

and Human Services to provide, within 30 days after Oct. 21, 1986,

for publication of inpatient hospital deductible, coinsurance

amounts for inpatient hospital services and post-hospital extended

care services, and monthly part A premiums for 1987, as modified

under the amendment of this section made by subsection (a).

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395f, 1395l, 1395x,

1395cc, 1395ww, 1395eee, 1396d of this title; title 5 section 8904;

title 38 section 1710.

-End-

-CITE-

42 USC Sec. 1395f 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395f. Conditions of and limitations on payment for services

-STATUTE-

(a) Requirement of requests and certifications

Except as provided in subsections (d) and (g) of this section and

in section 1395mm of this title, payment for services furnished an

individual may be made only to providers of services which are

eligible therefor under section 1395cc of this title and only if -

(1) written request, signed by such individual, except in cases

in which the Secretary finds it impracticable for the individual

to do so, is filed for such payment in such form, in such manner,

and by such person or persons as the Secretary may by regulation

prescribe, no later than the close of the period of 3 calendar

years following the year in which such services are furnished

(deeming any services furnished in the last 3 calendar months of

any calendar year to have been furnished in the succeeding

calendar year) except that where the Secretary deems that

efficient administration so requires, such period may be reduced

to not less than 1 calendar year;

(2) a physician, or, in the case of services described in

subparagraph (B), a physician, or a nurse practitioner or

clinical nurse specialist who does not have a direct or indirect

employment relationship with the facility but is working in

collaboration with a physician, certifies (and recertifies, where

such services are furnished over a period of time, in such cases,

with such frequency, and accompanied by such supporting material,

appropriate to the case involved, as may be provided by

regulations, except that the first of such recertifications shall

be required in each case of inpatient hospital services not later

than the 20th day of such period) that -

(A) in the case of inpatient psychiatric hospital services,

such services are or were required to be given on an inpatient

basis, by or under the supervision of a physician, for the

psychiatric treatment of an individual; and (i) such treatment

can or could reasonably be expected to improve the condition

for which such treatment is or was necessary or (ii) inpatient

diagnostic study is or was medically required and such services

are or were necessary for such purposes;

(B) in the case of post-hospital extended care services, such

services are or were required to be given because the

individual needs or needed on a daily basis skilled nursing

care (provided directly by or requiring the supervision of

skilled nursing personnel) or other skilled rehabilitation

services, which as a practical matter can only be provided in a

skilled nursing facility on an inpatient basis, for any of the

conditions with respect to which he was receiving inpatient

hospital services (or services which would constitute inpatient

hospital services if the institution met the requirements of

paragraphs (6) and (9) of section 1395x(e) of this title) prior

to transfer to the skilled nursing facility or for a condition

requiring such extended care services which arose after such

transfer and while he was still in the facility for treatment

of the condition or conditions for which he was receiving such

inpatient hospital services;

(C) in the case of home health services, such services are or

were required because the individual is or was confined to his

home (except when receiving items and services referred to in

section 1395x(m)(7) of this title) and needs or needed skilled

nursing care (other than solely venipuncture for the purpose of

obtaining a blood sample) on an intermittent basis or physical

or speech therapy or, in the case of an individual who has been

furnished home health services based on such a need and who no

longer has such a need for such care or therapy, continues or

continued to need occupational therapy; a plan for furnishing

such services to such individual has been established and is

periodically reviewed by a physician; and such services are or

were furnished while the individual was under the care of a

physician; or

(D) in the case of inpatient hospital services in connection

with the care, treatment, filling, removal, or replacement of

teeth or structures directly supporting teeth, the individual,

because of his underlying medical condition and clinical status

or because of the severity of the dental procedure, requires

hospitalization in connection with the provision of such

services;

(3) with respect to inpatient hospital services (other than

inpatient psychiatric hospital services) which are furnished over

a period of time, a physician certifies that such services are

required to be given on an inpatient basis for such individual's

medical treatment, or that inpatient diagnostic study is

medically required and such services are necessary for such

purpose, except that (A) such certification shall be furnished

only in such cases, with such frequency, and accompanied by such

supporting material, appropriate to the cases involved, as may be

provided by regulations, and (B) the first such certification

required in accordance with clause (A) shall be furnished no

later than the 20th day of such period;

(4) in the case of inpatient psychiatric hospital services, the

services are those which the records of the hospital indicate

were furnished to the individual during periods when he was

receiving (A) intensive treatment services, (B) admission and

related services necessary for a diagnostic study, or (C)

equivalent services;

(5) with respect to inpatient hospital services furnished such

individual after the 20th day of a continuous period of such

services, there was not in effect, at the time of admission of

such individual to the hospital, a decision under section

1395cc(d) of this title (based on a finding that utilization

review of long-stay cases is not being made in such hospital);

(6) with respect to inpatient hospital services or

post-hospital extended care services furnished such individual

during a continuous period, a finding has not been made (by the

physician members of the committee or group, as described in

section 1395x(k)(4) of this title, including any finding made in

the course of a sample or other review of admissions to the

institution) pursuant to the system of utilization review that

further inpatient hospital services or further post-hospital

extended care services, as the case may be, are not medically

necessary; except that, if such a finding has been made, payment

may be made for such services furnished before the 4th day after

the day on which the hospital or skilled nursing facility, as the

case may be, received notice of such finding;

(7) in the case of hospice care provided an individual -

(A)(i) in the first 90-day period -

(I) the individual's attending physician (as defined in

section 1395x(dd)(3)(B) of this title), and

(II) the medical director (or physician member of the

interdisciplinary group described in section 1395x(dd)(2)(B)

of this title) of the hospice program providing (or arranging

for) the care,

each certify in writing at the beginning of the period, that

the individual is terminally ill (as defined in section

1395x(dd)(3)(A) of this title), and

(ii) in a subsequent 90- or 60-day period, the medical

director or physician described in clause (i)(II) recertifies

at the beginning of the period that the individual is

terminally ill;

(B) a written plan for providing hospice care with respect to

such individual has been established (before such care is

provided by, or under arrangements made by, that hospice

program) and is periodically reviewed by the individual's

attending physician and by the medical director (and the

interdisciplinary group described in section 1395x(dd)(2)(B) of

this title) of the hospice program; and

(C) such care is being or was provided pursuant to such plan

of care; and

(8) in the case of inpatient critical access hospital services,

a physician certifies that the individual may reasonably be

expected to be discharged or transferred to a hospital within 96

hours after admission to the critical access hospital.

To the extent provided by regulations, the certification and

recertification requirements of paragraph (2) shall be deemed

satisfied where, at a later date, a physician, nurse practitioner,

or clinical nurse specialist (as the case may be) makes

certification of the kind provided in subparagraph (A), (B), (C),

or (D) of paragraph (2) (whichever would have applied), but only

where such certification is accompanied by such medical and other

evidence as may be required by such regulations. With respect to

the physician certification required by paragraph (2) for home

health services furnished to any individual by a home health agency

(other than an agency which is a governmental entity) and with

respect to the establishment and review of a plan for such

services, the Secretary shall prescribe regulations which shall

become effective no later than July 1, 1981, and which prohibit a

physician who has a significant ownership interest in, or a

significant financial or contractual relationship with, such home

health agency from performing such certification and from

establishing or reviewing such plan, except that such prohibition

shall not apply with respect to a home health agency which is a

sole community home health agency (as determined by the Secretary).

For purposes of the preceding sentence, service by a physician as

an uncompensated officer or director of a home health agency shall

not constitute having a significant ownership interest in, or a

significant financial or contractual relationship with, such

agency. For purposes of paragraph (2)(C), an individual shall be

considered to be "confined to his home" if the individual has a

condition, due to an illness or injury, that restricts the ability

of the individual to leave his or her home except with the

assistance of another individual or the aid of a supportive device

(such as crutches, a cane, a wheelchair, or a walker), or if the

individual has a condition such that leaving his or her home is

medically contraindicated. While an individual does not have to be

bedridden to be considered "confined to his home", the condition of

the individual should be such that there exists a normal inability

to leave home, that leaving home requires a considerable and taxing

effort by the individual. The certification regarding terminal

illness of an individual under paragraph (7) shall be based on the

physician's or medical director's clinical judgment regarding the

normal course of the individual's illness. Any absence of an

individual from the home attributable to the need to receive health

care treatment, including regular absences for the purpose of

participating in therapeutic, psychosocial, or medical treatment in

an adult day-care program that is licensed or certified by a State,

or accredited, to furnish adult day-care services in the State

shall not disqualify an individual from being considered to be

"confined to his home". Any other absence of an individual from the

home shall not so disqualify an individual if the absence is of

infrequent or of relatively short duration. For purposes of the

preceding sentence, any absence for the purpose of attending a

religious service shall be deemed to be an absence of infrequent or

short duration.

(b) Amount paid to provider of services

The amount paid to any provider of services (other than a hospice

program providing hospice care, other than a critical access

hospital providing inpatient critical access hospital services, and

other than a home health agency with respect to durable medical

equipment) with respect to services for which payment may be made

under this part shall, subject to the provisions of sections 1395e

(!1) 1395ww, and 1395fff of this title, be -

(1) except as provided in paragraph (3), the lesser of (A) the

reasonable cost of such services, as determined under section

1395x(v) of this title and as further limited by section

1395rr(b)(2)(B) of this title, or (B) the customary charges with

respect to such services;

(2) if such services are furnished by a public provider of

services, or by another provider which demonstrates to the

satisfaction of the Secretary that a significant portion of its

patients are low-income (and requests that payment be made under

this paragraph), free of charge or at nominal charges to the

public, the amount determined on the basis of those items

(specified in regulations prescribed by the Secretary) included

in the determination of such reasonable cost which the Secretary

finds will provide fair compensation to such provider for such

services; or

(3) if some or all of the hospitals in a State have been

reimbursed for services (for which payment may be made under this

part) pursuant to a reimbursement system approved as a

demonstration project under section 402 of the Social Security

Amendments of 1967 or section 222 of the Social Security

Amendments of 1972, if the rate of increase in such hospitals in

their costs per hospital inpatient admission of individuals

entitled to benefits under this part over the duration of such

project was equal to or less than such rate of increase for

admissions of such individuals with respect to all hospitals in

the United States during such period, and if either the State has

legislative authority to operate such system and the State elects

to have reimbursement to such hospitals made in accordance with

this paragraph or the system is operated through a voluntary

agreement of hospitals and such hospitals elect to have

reimbursement to those hospitals made in accordance with this

paragraph, then the Secretary may provide for continuation of

reimbursement to such hospitals under such system until the

Secretary determines that -

(A) a third-party payor reimburses such a hospital on a basis

other than under such system, or

(B) the aggregate rate of increase from January 1, 1981, to

the most recent date for which annual data are available in

such hospitals in costs per hospital inpatient admission of

individuals entitled to benefits under this part is greater

than such rate of increase for admissions of such individuals

with respect to all hospitals in the United States for such

period.

In the case of any State which has had such a demonstration project

reimbursement system in continuous operation since July 1, 1977,

the Secretary shall provide under paragraph (3) for continuation of

reimbursement to hospitals in the State under such system until the

first day of the 37th month beginning after the date the Secretary

determines and notifies the Governor of the State that either of

the conditions described in subparagraph (A) or (B) of such

paragraph has occurred. If, by the end of such 36-month period, the

Secretary determines, based on evidence submitted by the Governor

of the State, that neither of the conditions described in

subparagraph (A) or (B) of paragraph (3) continues to apply, the

Secretary shall continue without interruption payment to hospitals

in the State under the State's system. If, by the end of such

36-month period, the Secretary determines, based on such evidence,

that either of the conditions described in subparagraph (A) or (B)

of such paragraph continues to apply, the Secretary shall (i)

collect any net excess reimbursement to hospitals in the State

during such 36-month period (basing such net excess reimbursement

on the net difference, if any, in the rate of increase in costs per

hospital inpatient admission under the State system compared to the

rate of increase in such costs with respect to all hospitals in the

United States over the 36-month period, as measured by including

the cumulative savings under the State system based on the

difference in the rate of increase in costs per hospital inpatient

admission under the State system as compared to the rate of

increase in such costs with respect to all hospitals in the United

States between January 1, 1981, and the date of the Secretary's

initial notice), and (ii) provide a reasonable period, not to

exceed 2 years, for transition from the State system to the

national payment system.

(c) No payments to Federal providers of services

Subject to section 1395qq of this title, no payment may be made

under this part (except under subsection (d) or subsection (h) of

this section) to any Federal provider of services, except a

provider of services which the Secretary determines is providing

services to the public generally as a community institution or

agency; and no such payment may be made to any provider of services

for any item or service which such provider is obligated by a law

of, or a contract with, the United States to render at public

expense.

(d) Payments for emergency hospital services

(1) Payments shall also be made to any hospital for inpatient

hospital services furnished in a calendar year, by the hospital or

under arrangements (as defined in section 1395x(w) of this title)

with it, to an individual entitled to hospital insurance benefits

under section 426 of this title even though such hospital does not

have an agreement in effect under this subchapter if (A) such

services were emergency services, (B) the Secretary would be

required to make such payment if the hospital had such an agreement

in effect and otherwise met the conditions of payment hereunder,

and (C) such hospital has elected to claim payments for all such

inpatient emergency services and for the emergency outpatient

services referred to in section 1395n(b) of this title furnished

during such year. Such payments shall be made only in the amounts

provided under subsection (b) of this section and then only if such

hospital agrees to comply, with respect to the emergency services

provided, with the provisions of section 1395cc(a) of this title.

(2) Payment may be made on the basis of an itemized bill to an

individual entitled to hospital insurance benefits under section

426 of this title for services described in paragraph (1) which are

emergency services if (A) payment cannot be made under paragraph

(1) solely because the hospital does not elect to claim such

payment, and (B) such individual files application (submitted

within such time and in such form and manner and by such person,

and containing and supported by such information as the Secretary

shall by regulations prescribe) for reimbursement.

(3) The amounts payable under the preceding paragraph with

respect to services described therein shall, subject to the

provisions of section 1395e of this title, be equal to 60 percent

of the hospital's reasonable charges for routine services furnished

in the accommodations occupied by the individual or in semiprivate

accommodations (as defined in section 1395x(v)(4) of this title),

whichever is less, plus 80 percent of the hospital's reasonable

charges for ancillary services. If separate charges for routine and

ancillary services are not made by the hospital, reimbursement may

be based on two-thirds of the hospital's reasonable charges for the

services received but not to exceed the charges which would have

been made if the patient had occupied semiprivate accommodations.

For purposes of the preceding provisions of this paragraph, the

term "routine services" shall mean the regular room, dietary, and

nursing services, minor medical and surgical supplies and the use

of equipment and facilities for which a separate charge is not

customarily made; the term "ancillary services" shall mean those

special services for which charges are customarily made in addition

to routine services.

(e) Payment for inpatient hospital services prior to notification

of noneligibility

Notwithstanding that an individual is not entitled to have

payment made under this part for inpatient hospital services

furnished by any hospital, payment shall be made to such hospital

(unless it elects not to receive such payment or, if payment has

already been made by or on behalf of such individual, fails to

refund such payment within the time specified by the Secretary) for

such services which are furnished to the individual prior to

notification to such hospital from the Secretary of his lack of

entitlement, if such payments are precluded only by reason of

section 1395d of this title and if such hospital complies with the

requirements of and regulations under this subchapter with respect

to such payments, has acted in good faith and without knowledge of

such lack of entitlement, and has acted reasonably in assuming

entitlement existed. Payment under the preceding sentence may not

be made for services furnished an individual pursuant to any

admission after the 6th elapsed day (not including as an elapsed

day Saturday, Sunday, or a legal holiday) after the day on which

such admission occurred.

(f) Payment for certain inpatient hospital services furnished

outside United States

(1) Payment shall be made for inpatient hospital services

furnished to an individual entitled to hospital insurance benefits

under section 426 of this title by a hospital located outside the

United States, or under arrangements (as defined in section

1395x(w) of this title) with it, if -

(A) such individual is a resident of the United States, and

(B) such hospital was closer to, or substantially more

accessible from, the residence of such individual than the

nearest hospital within the United States which was adequately

equipped to deal with, and was available for the treatment of,

such individual's illness or injury.

(2) Payment may also be made for emergency inpatient hospital

services furnished to an individual entitled to hospital insurance

benefits under section 426 of this title by a hospital located

outside the United States if -

(A) such individual was physically present -

(i) in a place within the United States; or

(ii) at a place within Canada while traveling without

unreasonable delay by the most direct route (as determined by

the Secretary) between Alaska and another State;

at the time the emergency which necessitated such inpatient

hospital services occurred, and

(B) such hospital was closer to, or substantially more

accessible from, such place than the nearest hospital within the

United States which was adequately equipped to deal with, and was

available for the treatment of, such individual's illness or

injury.

(3) Payment shall be made in the amount provided under subsection

(b) of this section to any hospital for the inpatient hospital

services described in paragraph (1) or (2) furnished to an

individual by the hospital or under arrangements (as defined in

section 1395x(w) of this title) with it if (A) the Secretary would

be required to make such payment if the hospital had an agreement

in effect under this subchapter and otherwise met the conditions of

payment hereunder, (B) such hospital elects to claim such payment,

and (C) such hospital agrees to comply, with respect to such

services, with the provisions of section 1395cc(a) of this title.

(4) Payment for the inpatient hospital services described in

paragraph (1) or (2) furnished to an individual entitled to

hospital insurance benefits under section 426 of this title may be

made on the basis of an itemized bill to such individual if (A)

payment for such services cannot be made under paragraph (3) solely

because the hospital does not elect to claim such payment, and (B)

such individual files application (submitted within such time and

in such form and manner and by such person, and continuing and

supported by such information as the Secretary shall by regulations

prescribe) for reimbursement. The amount payable with respect to

such services shall, subject to the provisions of section 1395e of

this title, be equal to the amount which would be payable under

subsection (d)(3) of this section.

(g) Payments to physicians for services rendered in teaching

hospitals

For purposes of services for which the reasonable cost thereof is

determined under section 1395x(v)(1)(D) of this title (or would be

if section 1395ww of this title did not apply), payment under this

part shall be made to such fund as may be designated by the

organized medical staff of the hospital in which such services were

furnished or, if such services were furnished in such hospital by

the faculty of a medical school, to such fund as may be designated

by such faculty, but only if -

(1) such hospital has an agreement with the Secretary under

section 1395cc of this title, and

(2) the Secretary has received written assurances that (A) such

payment will be used by such fund solely for the improvement of

care of hospital patients or for educational or charitable

purposes and (B) the individuals who were furnished such services

or any other persons will not be charged for such services (or if

charged, provision will be made for return of any moneys

incorrectly collected).

(h) Payment for specified hospital services provided in Department

of Veterans Affairs hospitals; amount of payment

(1) Payments shall also be made to any hospital operated by the

Department of Veterans Affairs for inpatient hospital services

furnished in a calendar year by the hospital, or under arrangements

(as defined in section 1395x(w) of this title) with it, to an

individual entitled to hospital benefits under section 426 of this

title even though the hospital is a Federal provider of services if

(A) the individual was not entitled to have the services furnished

to him free of charge by the hospital, (B) the individual was

admitted to the hospital in the reasonable belief on the part of

the admitting authorities that the individual was a person who was

entitled to have the services furnished to him free of charge, (C)

the authorities of the hospital, in admitting the individual, and

the individual, acted in good faith, and (D) the services were

furnished during a period ending with the close of the day on which

the authorities operating the hospital first became aware of the

fact that the individual was not entitled to have the services

furnished to him by the hospital free of charge, or (if later)

ending with the first day on which it was medically feasible to

remove the individual from the hospital by discharging him

therefrom or transferring him to a hospital which has in effect an

agreement under this subchapter.

(2) Payment for services described in paragraph (1) shall be in

an amount equal to the charge imposed by the Secretary of Veterans

Affairs for such services, or (if less) the amount that would be

payable for such services under subsection (b) of this section and

section 1395ww of this title (as estimated by the Secretary). Any

such payment shall be made to the entity to which payment for the

services involved would have been payable, if payment for such

services had been made by the individual receiving the services

involved (or by another private person acting on behalf of such

individual).

(i) Payment for hospice care

(1)(A) Subject to the limitation under paragraph (2) and the

provisions of section 1395e(a)(4) of this title and except as

otherwise provided in this paragraph, the amount paid to a hospice

program with respect to hospice care for which payment may be made

under this part shall be an amount equal to the costs which are

reasonable and related to the cost of providing hospice care or

which are based on such other tests of reasonableness as the

Secretary may prescribe in regulations (including those authorized

under section 1395x(v)(1)(A) of this title), except that no payment

may be made for bereavement counseling and no reimbursement may be

made for other counseling services (including nutritional and

dietary counseling) as separate services.

(B) Notwithstanding subparagraph (A), for hospice care furnished

on or after April 1, 1986, the daily rate of payment per day for

routine home care shall be $63.17 and the daily rate of payment for

other services included in hospice care shall be the daily rate of

payment recognized under subparagraph (A) as of July 1, 1985,

increased by $10.

(C)(i) With respect to routine home care and other services

included in hospice care furnished on or after January 1, 1990, and

on or before September 30, 1990, the payment rates for such care

and services shall be 120 percent of such rates in effect as of

September 30, 1989.

(ii) With respect to routine home care and other services

included in hospice care furnished during a subsequent fiscal year,

the payment rates for such care and services shall be the payment

rates in effect under this subparagraph during the previous fiscal

year increased by -

(I) for a fiscal year ending on or before September 30, 1993,

the market basket percentage increase (as defined in section

1395ww(b)(3)(B)(iii) of this title) for the fiscal year;

(II) for fiscal year 1994, the market basket percentage

increase for the fiscal year minus 2.0 percentage points;

(III) for fiscal year 1995, the market basket percentage

increase for the fiscal year minus 1.5 percentage points;

(IV) for fiscal year 1996, the market basket percentage

increase for the fiscal year minus 1.5 percentage points;

(V) for fiscal year 1997, the market basket percentage increase

for the fiscal year minus 0.5 percentage point;

(VI) for each of fiscal years 1998 through 2002, the market

basket percentage increase for the fiscal year involved minus 1.0

percentage points, plus, in the case of fiscal year 2001, 5.0

percentage points; and

(VII) for a subsequent fiscal year, the market basket

percentage increase for the fiscal year.

(2)(A) The amount of payment made under this part for hospice

care provided by (or under arrangements made by) a hospice program

for an accounting year may not exceed the "cap amount" for the year

(computed under subparagraph (B)) multiplied by the number of

medicare beneficiaries in the hospice program in that year

(determined under subparagraph (C)).

(B) For purposes of subparagraph (A), the "cap amount" for a year

is $6,500, increased or decreased, for accounting years that end

after October 1, 1984, by the same percentage as the percentage

increase or decrease, respectively, in the medical care expenditure

category of the Consumer Price Index for All Urban Consumers

(United States city average), published by the Bureau of Labor

Statistics, from March 1984 to the fifth month of the accounting

year.

(C) For purposes of subparagraph (A), the "number of medicare

beneficiaries" in a hospice program in an accounting year is equal

to the number of individuals who have made an election under

subsection (d) of this section with respect to the hospice program

and have been provided hospice care by (or under arrangements made

by) the hospice program under this part in the accounting year,

such number reduced to reflect the proportion of hospice care that

each such individual was provided in a previous or subsequent

accounting year or under a plan of care established by another

hospice program.

(D) A hospice program shall submit claims for payment for hospice

care furnished in an individual's home under this subchapter only

on the basis of the geographic location at which the service is

furnished, as determined by the Secretary.

(3) Hospice programs providing hospice care for which payment is

made under this subsection shall submit to the Secretary such data

with respect to the costs for providing such care for each fiscal

year, beginning with fiscal year 1999, as the Secretary determines

necessary.

(j) Elimination of lesser-of-cost-or-charges provision

(1) The lesser-of-cost-or-charges provisions (described in

paragraph (2)) will not apply in the case of services provided by a

class of provider of services if the Secretary determines and

certifies to Congress that the failure of such provisions to apply

to the services provided by that class of providers will not result

in any increase in the amount of payments made for those services

under this subchapter. Such change will take effect with respect to

services furnished, or cost reporting periods of providers, on or

after such date as the Secretary shall provide in the

certification. Such change for a class of provider shall be

discontinued if the Secretary determines and notifies Congress that

such change has resulted in an increase in the amount of payments

made under this subchapter for services provided by that class of

provider.

(2) The lesser-of-cost-or-charges provisions referred to in

paragraph (1) are as follows:

(A) Clause (B) of paragraph (1) and paragraph (2) of subsection

(b) of this section.

(B) Section 1395m(a)(1)(B) of this title.

(C) So much of subparagraph (A) of section 1395l(a)(2) of this

title as provides for payment other than of the reasonable cost

of such services, as determined under section 1395x(v) of this

title.

(D) Subclause (II) of clause (i) and clause (ii) of section

1395l(a)(2)(B) of this title.

(k) Payments to home health agencies for durable medical equipment

The amount paid to any home health agency with respect to durable

medical equipment for which payment may be made under this part

shall be the amount described in section 1395m(a)(1) of this title.

(l) Payment for inpatient critical access hospital services

The amount of payment under this part for inpatient critical

access hospital services is the reasonable costs of the critical

access hospital in providing such services.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1814, as added Pub. L.

89-87, title I, Sec. 102(a), July 30, 1965, 79 Stat. 294; amended

Pub. L. 90-248, title I, Secs. 126(a), 129(c)(5), (6)(A), 143(c),

Jan. 2, 1968, 81 Stat. 846, 848, 857; Pub. L. 92-603, title II,

Secs. 211(a), 226(c)(1), 227(b), 228(a), 233(a), 234(g)(1), 238(a),

247(a), 256(a), 278(a)(1)-(3), (b)(4), (17), 281(e), Oct. 30, 1972,

86 Stat. 1382, 1404, 1405, 1407, 1411, 1413, 1416, 1425, 1447,

1453, 1454, 1456; Pub. L. 93-233, Sec. 18(k)(1), (2), Dec. 31,

1973, 87 Stat. 970; Pub. L. 94-437, title IV, Sec. 401(a), Sept.

30, 1976, 90 Stat. 1408; Pub. L. 95-142, Sec. 23(a), (b), Oct. 25,

1977, 91 Stat. 1208; Pub. L. 95-292, Sec. 4(f), June 13, 1978, 92

Stat. 315; Pub. L. 96-499, title IX, Secs. 903(a), 930(e), (f),

931(b), 936(b), 941(a), (b), Dec. 5, 1980, 94 Stat. 2614, 2631,

2633, 2640, 2641; Pub. L. 97-35, title XXI, Secs. 2121(b),

2122(a)(1), Aug. 13, 1981, 95 Stat. 796; Pub. L. 97-248, title I,

Secs. 101(c)(1), 122(c)(1), (2), Sept. 3, 1982, 96 Stat. 335, 357,

358; Pub. L. 97-448, title III, Sec. 309(b)(7), Jan. 12, 1983, 96

Stat. 2409; Pub. L. 98-21, title VI, Secs. 601(d), 602(b), (c),

Apr. 20, 1983, 97 Stat. 152, 163; Pub. L. 98-90, Aug. 29, 1983, 97

Stat. 606; Pub. L. 98-369, div. B, title III, Secs. 2308(b)(2)(A),

2321(a), (f), 2335(a), 2336(a), (b), 2354(b)(1), (c)(1)(A), July

18, 1984, 98 Stat. 1074, 1084, 1085, 1090, 1091, 1100, 1102; Pub.

L. 98-617, Secs. 1(a), 3(a)(3), (b)(1), Nov. 8, 1984, 98 Stat.

3294, 3295; Pub. L. 99-272, title IX, Sec. 9123(b), Apr. 7, 1986,

100 Stat. 168; Pub. L. 100-203, title IV, Secs. 4008(b)(1),

4024(a), 4062(d)(1), Dec. 22, 1987, 101 Stat. 1330-55, 1330-73,

1330-108; Pub. L. 100-360, title I, Sec. 104(d)(2), 102 Stat. 688;

Pub. L. 101-234, title I, Sec. 101(a), Dec. 13, 1989, 103 Stat.

1979; Pub. L. 101-239, title VI, Secs. 6003(g)(3)(B)(ii), (iii),

6005(a), (b), 6028, Dec. 19, 1989, 103 Stat. 2152, 2160, 2161,

2168; Pub. L. 101-508, title IV, Secs. 4006(b), 4008(i)(3),

(m)(3)(A), Nov. 5, 1990, 104 Stat. 1388-43, 1388-51, 1388-53; Pub.

L. 102-54, Sec. 13(q)(3)(A)(iii), (iv), (B)(iv), June 13, 1991, 105

Stat. 279; Pub. L. 103-66, title XIII, Sec. 13504, Aug. 10, 1993,

107 Stat. 579; Pub. L. 103-432, title I, Secs. 102(a)(3), (d),

106(b)(1)(A), 110(d)(1), Oct. 31, 1994, 108 Stat. 4402, 4403, 4405,

4408; Pub. L. 105-33, title IV, Secs. 4201(c)(1), (3), 4441,

4442(a), 4443(b)(2), 4448, 4603(c)(1), 4615(a), Aug. 5, 1997, 111

Stat. 373, 422-424, 470, 475; Pub. L. 106-554, Sec. 1(a)(6) [title

III, Secs. 321(a), (e), 322(a)(1), title V, Sec. 507(a)(1)], Dec.

21, 2000, 114 Stat. 2763, 2763A-500, 2763A-501, 2763A-532.)

-REFTEXT-

REFERENCES IN TEXT

Section 402 of the Social Security Amendments of 1967, referred

to in subsec. (b)(3), means section 402 of Pub. L. 90-248, which

amended sections 1395b-1 and 1395ll of this title.

Section 222 of the Social Security Amendments of 1972, referred

to in subsec. (b)(3), means section 222 of Pub. L. 92-603, which

amended sections 1395b-1 and 1395ll of this title and enacted a

provision set out as a note under section 1395b-1 of this title.

-MISC1-

AMENDMENTS

2000 - Subsec. (a). Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec.

507(a)(1)(B)], inserted at end "Any absence of an individual from

the home attributable to the need to receive health care treatment,

including regular absences for the purpose of participating in

therapeutic, psychosocial, or medical treatment in an adult

day-care program that is licensed or certified by a State, or

accredited, to furnish adult day-care services in the State shall

not disqualify an individual from being considered to be 'confined

to his home'. Any other absence of an individual from the home

shall not so disqualify an individual if the absence is of

infrequent or of relatively short duration. For purposes of the

preceding sentence, any absence for the purpose of attending a

religious service shall be deemed to be an absence of infrequent or

short duration."

Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 507(a)(1)(A)], which

directed amendment of subsec. (a) by striking out in the last

sentence ", and that absences of the individual from home are

infrequent or of relatively short duration, or are attributable to

the need to receive medical treatment", was executed by striking

out that language after "taxing effort by the individual" in the

penultimate sentence, to reflect the probable intent of Congress

and the amendment by Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec.

322(a)(1)]. See note below.

Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 322(a)(1)],

inserted at end "The certification regarding terminal illness of an

individual under paragraph (7) shall be based on the physician's or

medical director's clinical judgment regarding the normal course of

the individual's illness."

Subsec. (a)(7)(A)(ii). Pub. L. 106-554, Sec. 1(a)(6) [title III,

Sec. 321(e)], substituted a semicolon for period at end.

Subsec. (i)(1)(C)(ii)(VI). Pub. L. 106-554, Sec. 1(a)(6) [title

III, Sec. 321(a)], inserted ", plus, in the case of fiscal year

2001, 5.0 percentage points" before semicolon.

1997 - Subsec. (a)(2)(C). Pub. L. 105-33, Sec. 4615(a), inserted

"(other than solely venipuncture for the purpose of obtaining a

blood sample)" after "skilled nursing care".

Subsec. (a)(7)(A)(i). Pub. L. 105-33, Secs. 4443(b)(2)(A), 4448,

in concluding provisions, substituted "at the beginning of the

period" for " not later than 2 days after hospice care is initiated

(or, if each certify verbally not later than 2 days after hospice

care is initiated, not later than 8 days after such care is

initiated)" and inserted "and" at end.

Subsec. (a)(7)(A)(ii). Pub. L. 105-33, Sec. 4443(b)(2)(B),

substituted "60-day" for "30-day" and substituted a period for ",

and" at end.

Subsec. (a)(7)(A)(iii). Pub. L. 105-33, Sec. 4443(b)(2)(C),

struck out cl. (iii) which read as follows: "in a subsequent

extension period, the medical director or physician described in

clause (i)(II) recertifies at the beginning of the period that the

individual is terminally ill;".

Subsec. (a)(8). Pub. L. 105-33, Sec. 4201(c)(1), (3)(A),

substituted "critical access" for "rural primary care" in two

places and "96 hours" for "72 hours".

Subsec. (b). Pub. L. 105-33, Sec. 4603(c)(1), substituted

"1395ww, and 1395fff of this title" for "and 1395ww of this title"

in introductory provisions.

Pub. L. 105-33, Sec. 4201(c)(1), substituted "critical access"

for "rural primary care" in two places in introductory provisions.

Subsec. (i)(1)(C)(ii)(V) to (VII). Pub. L. 105-33, Sec. 4441(a),

struck out "and" at end of subcl. (V), added subcl. (VI), and

redesignated former subcl. (VI) as (VII).

Subsec. (i)(2)(D). Pub. L. 105-33, Sec. 4442(a), added subpar.

(D).

Subsec. (i)(3). Pub. L. 105-33, Sec. 4441(b), added par. (3).

Subsec. (l). Pub. L. 105-33, Sec. 4201(c)(3)(B), amended heading

and text of subsec. (l) generally. Prior to amendment, text read as

follows:

"(1) The amount of payment under this part for inpatient rural

primary care hospital services -

"(A) in the case of the first 12-month cost reporting period

for which the facility operates as such a hospital, is the

reasonable costs of the facility in providing inpatient rural

primary care hospital services during such period, as such costs

are determined on a per diem basis, and

"(B) in the case of a later reporting period, is the per diem

payment amount established under this paragraph for the preceding

12-month cost reporting period, increased by the applicable

percentage increase under section 1395ww(b)(3)(B)(i) of this

title for that particular cost reporting period applicable to

hospitals located in a rural area.

The payment amounts otherwise determined under this paragraph shall

be reduced, to the extent necessary, to avoid duplication of any

payment made under section 1395i-4(a)(2) of this title (or under

section 4005(e) of the Omnibus Budget Reconciliation Act of 1987)

to cover the provision of inpatient rural primary care hospital

services.

"(2) The Secretary shall develop a prospective payment system for

determining payment amounts for inpatient rural primary care

hospital services under this part furnished on or after January 1,

1996."

1994 - Subsec. (a)(5). Pub. L. 103-432, Sec. 106(b)(1)(A), struck

out "and with respect to post-hospital extended care services

furnished after such day of a continuous period of such services as

may be prescribed in or pursuant to regulations" after "continuous

period of such services", "or skilled nursing facility, as the case

may be" after "such individual to the hospital", and "or facility"

after "made in such hospital".

Subsec. (a)(8). Pub. L. 103-432, Sec. 102(a)(3), substituted "the

individual may reasonably be expected to be discharged or

transferred to a hospital within 72 hours after admission to the

rural primary care hospital." for "such services were required to

be immediately furnished on a temporary, inpatient basis."

Subsec. (i)(1)(C)(i). Pub. L. 103-432, Sec. 110(d)(1),

substituted "September 30, 1990," for "September 30, 1990,,".

Subsec. (l)(2). Pub. L. 103-432, Sec. 102(d), substituted

"January 1, 1996" for "January 1, 1993".

1993 - Subsec. (i)(1)(C)(ii). Pub. L. 103-66 substituted

"increased by - " and subcls. (I) to (VI) for "increased by the

market basket percentage increase (as defined in section

1395ww(b)(3)(B)(iii) of this title) otherwise applicable to

discharges occurring in the fiscal year."

1991 - Subsec. (h). Pub. L. 102-54 substituted "Department of

Veterans Affairs" for "Veterans' Administration" in heading and

par. (1) and "Secretary of Veterans Affairs" for "Veterans'

Administration" in par. (2).

1990 - Subsec. (a)(7)(A)(iii). Pub. L. 101-508, Sec. 4006(b),

added cl. (iii).

Subsec. (b)(3). Pub. L. 101-508, Sec. 4008(i)(3), substituted

"January 1, 1981" for "October 1, 1983" in subpar. (B) substituted

"37th month" for "seventh month" in sentence following subpar. (B),

and inserted at end provisions setting forth procedures to be

followed by Secretary at end of 36-month period.

Subsec. (i)(1)(C)(i). Pub. L. 101-508, Sec. 4008(m)(3)(A),

substituted "on or after January 1, 1990, and on or before

September 30, 1990," for "during fiscal year 1990".

1989 - Subsec. (a). Pub. L. 101-239, Sec. 6028(2), substituted "a

physician, nurse practitioner, or clinical nurse specialist (as the

case may be) makes" for "a physician makes" in first sentence of

concluding provisions.

Subsec. (a)(2). Pub. L. 101-239, Sec. 6028(1), substituted "a

physician, or, in the case of services described in subparagraph

(B), a physician, or a nurse practitioner or clinical nurse

specialist who does not have a direct or indirect employment

relationship with the facility but is working in collaboration with

a physician," for "a physician" after "(2)".

Subsec. (a)(2)(B), (6). Pub. L. 101-234 repealed Pub. L. 100-360,

Sec. 104(d)(2)(A), (B), and provided that the provisions of law

amended or repealed by such section are restored or revived as if

such section had not been enacted, see 1988 Amendment notes below.

Subsec. (a)(7)(A)(i). Pub. L. 101-239, Sec. 6005(b), substituted

"certify in writing, not later than 2 days after hospice care is

initiated (or, if each certify verbally not later than 2 days after

hospice care is initiated, not later than 8 days after such care is

initiated)," for "certify, not later than two days after hospice

care is initiated," in concluding provisions.

Subsec. (a)(7)(A)(iii). Pub. L. 101-234 repealed Pub. L. 100-360,

Sec. 104(d)(2)(C), and provided that the provisions of law amended

or repealed by such section are restored or revived as if such

section had not been enacted, see 1988 Amendment note below.

Subsec. (a)(8). Pub. L. 101-239, Sec. 6003(g)(3)(B)(ii), added

par. (8).

Subsec. (b). Pub. L. 101-239, Sec. 6003(g)(3)(B)(iii)(I),

inserted ", other than a rural primary care hospital providing

inpatient rural primary care hospital services," after "providing

hospice care" in introductory provisions.

Subsec. (d)(3). Pub. L. 101-234 repealed Pub. L. 100-360, Sec.

104(d)(2)(D), and provided that the provisions of law amended or

repealed by such section are restored or revived as if such section

had not been enacted, see 1988 Amendment note below.

Subsec. (i)(1)(A). Pub. L. 101-239, Sec. 6005(a)(1), inserted

"and except as otherwise provided in this paragraph" after "section

1395e(a)(4) of this title".

Subsec. (i)(1)(C). Pub. L. 101-239, Sec. 6005(a)(2), added

subpar. (C) and struck out former subpar. (C) which read as

follows: "With respect to care and services furnished on or after

October 1, 1986, the Secretary shall, not less often than annually,

review and make appropriate adjustments to the payment rate for

routine home care and the payment rates for other services included

in hospice care based on the costs that are reasonable and related

to the costs of furnishing such care and services. The Secretary

shall report to Congress on October 1 each year on such review and

such adjustments and on the adequacy of the rates under this

paragraph to ensure participation by an adequate number of hospice

programs under this subchapter."

Subsec. (l). Pub. L. 101-239, Sec. 6003(g)(3)(B)(iii)(II), added

subsec. (l).

1988 - Subsec. (a)(2)(B). Pub. L. 100-360, Sec. 104(d)(2)(A),

(B), struck out "post-hospital" after "in the case of" and ", for

any of the conditions with respect to which he was receiving

inpatient hospital services (or services which would constitute

inpatient hospital services if the institution met the requirements

of paragraphs (6) and (9) of section 1395x(e) of this title) prior

to transfer to the skilled nursing facility or for a condition

requiring such extended care services which arose after such

transfer and while he was still in the facility for treatment of

the condition or conditions for which he was receiving such

inpatient hospital services" before semicolon at end.

Subsec. (a)(6). Pub. L. 100-360, Sec. 104(d)(2)(A), struck out

"post-hospital" before "extended care services" in two places.

Subsec. (a)(7)(A)(iii). Pub. L. 100-360, Sec. 104(d)(2)(C), added

cl. (iii) which read as follows: "in a subsequent extension period,

the medical director or physician described in clause (i)(II)

recertifies at the beginning of the period that the individual is

terminally ill;".

Subsec. (d)(3). Pub. L. 100-360, Sec. 104(d)(2)(D), substituted

"equal to 100 percent" for "equal to 60 percent" and "plus 100

percent" for "plus 80 percent" and struck out "two-thirds of" after

"based on".

1987 - Subsec. (a). Pub. L. 100-203, Sec. 4024(a), inserted two

sentences at end clarifying "confined to his home" for purposes of

par. (2)(C).

Subsec. (b)(3)(B). Pub. L. 100-203, Sec. 4008(b)(1), substituted

"aggregate rate of increase from October 1, 1983, to the most

recent date for which annual data are available" for "rate of

increase for the previous three-year period".

Subsec. (j)(2)(B). Pub. L. 100-203, Sec. 4062(d)(1)(A),

substituted "Section 1395m(a)(1)(B) of this title" for "Subsection

(k)(1)(B) of this section".

Subsec. (k). Pub. L. 100-203, Sec. 4062(d)(1)(B), substituted

"the amount described in section 1395m(a)(1) of this title." for a

dash and former pars. (1) and (2) which read as follows:

"(1) the lesser of -

"(A) the reasonable cost of such equipment, as determined under

section 1395x(v) of this title, or

"(B) the customary charges with respect to such equipment,

less the amount the home health agency may charge as described in

section 1395cc(a)(2)(A)(ii) of this title, but in no case may the

payment for such equipment exceed 80 percent of such reasonable

cost, or

"(2) if such equipment is furnished by a public home health

agency, or by another home health agency which demonstrates to the

satisfaction of the Secretary that a significant portion of its

patients are low-income (and requests that payment be made under

this paragraph), free of charge or at nominal charge to the public,

80 percent of the amount which the Secretary finds will provide

fair compensation to the home health agency."

1986 - Subsec. (i)(1)(B). Pub. L. 99-272, Sec. 9123(b)(1),

amended subpar. (B) generally. Prior to amendment, subpar. (B) read

as follows: "Notwithstanding subparagraph (A), the rate of payment

per day for routine home care furnished during fiscal year 1985

shall be $53.17."

Subsec. (i)(1)(C). Pub. L. 99-272, Sec. 9123(b)(2), substituted

"1986" for "1985".

1984 - Subsec. (a). Pub. L. 98-369, Sec. 2354(b)(1), as amended

by Pub. L. 98-617, Sec. 3(a)(3), in concluding provisions,

substituted "contractual" for "contractural".

Pub. L. 98-369, Sec. 2336(b), inserted before period at end of

third sentence ", except that such prohibition shall not apply with

respect to a home health agency which is a sole community home

health agency (as determined by the Secretary)".

Pub. L. 98-369, Sec. 2336(a), inserted sentence at end that for

purposes of the preceding sentence, service by a physician as an

uncompensated officer or director of a home health agency shall not

constitute having a significant ownership interest in, or a

significant financial or contractual relationship with, such

agency.

Pub. L. 98-369, Sec. 2335(a)(4), in concluding provisions,

substituted "or (D)" for "(D), or (E)".

Subsec. (a)(2)(B) to (E). Pub. L. 98-369, Sec. 2335(a)(1),

redesignated subpars. (C) to (E) as (B) to (D), respectively, and

struck out former subpar. (B) which provided that payment could be

made only if a physician certified, in the case of inpatient

tuberculosis hospital services, that such services were required to

be given on an inpatient basis, by or under the supervision of a

physician, for the treatment of an individual for tuberculosis; and

that such treatment could reasonably be expected to improve the

condition for which such treatment was necessary or render the

condition noncommunicable.

Subsec. (a)(3). Pub. L. 98-369, Sec. 2335(a)(2), struck out "and

inpatient tuberculosis hospital services" after "psychiatric

hospital services".

Subsec. (a)(5) to (8). Pub. L. 98-369, Sec. 2335(a)(3),

redesignated pars. (6) to (8) as (5) to (7), respectively, and

struck out former par. (5) which had provided that payment would be

made only if, in the case of inpatient tuberculosis hospital

services, the services were those which the records of the hospital

indicate were furnished to the individual during periods when he

was receiving treatment which could reasonably be expected to

improve his condition or render it noncommunicable.

Subsec. (b). Pub. L. 98-369, Sec. 2321(a)(1), inserted in

provisions preceding par. (1) "and other than a home health agency

with respect to durable medical equipment" after "hospice care".

Subsec. (b)(2). Pub. L. 98-369, Sec. 2308(b)(2)(A), inserted ",

or by another provider which demonstrates to the satisfaction of

the Secretary that a significant portion of its patients are

low-income (and requests that payment be made under this

paragraph),".

Subsec. (b)(3). Pub. L. 98-369, Sec. 2354(c)(1)(A), amended

directory language of Pub. L. 96-449, Sec. 903(a)(4), resulting in

no change in text. See 1980 Amendment note below.

Subsec. (i)(1). Pub. L. 98-617, Sec. 1(a), designated existing

provisions as subpar. (A) and added subpars. (B) and (C).

Subsec. (j)(2)(B) to (D). Pub. L. 98-369, Sec. 2321(f), added

subpar. (B) and redesignated former subpars. (B) and (C) as (C) and

(D), respectively.

Subsec. (k). Pub. L. 98-369, Sec. 2321(a)(2), added subsec. (k).

Subsec. (k)(2). Pub. L. 98-617, Sec. 3(b)(1), inserted ", or by

another home health agency which demonstrates to the satisfaction

of the Secretary that a significant portion of its patients are

low-income (and requests that payment be made under this

paragraph)," after "public home health agency" and "80 percent of"

before "the amount".

1983 - Subsec. (g). Pub. L. 98-21, Sec. 602(b), inserted "(or

would be if section 1395ww of this title did not apply)" after

"section 1395x(v)(1)(D) of this title".

Subsec. (h)(2). Pub. L. 98-21, Sec. 602(c), substituted "the

amount that would be payable for such services under subsection (b)

of this section and section 1395ww of this title" for "the

reasonable costs for such services".

Subsec. (i)(1). Pub. L. 97-448 inserted "made" before "for

bereavement counseling".

Subsec. (i)(2)(A). Pub. L. 98-90, Sec. 1(1), struck out "located

in a region (as defined by the Secretary)" after "a hospice

program" and "for the region" after " 'the cap amount' ".

Subsec. (i)(2)(B). Pub. L. 98-90, Sec. 1(2), amended subpar. (B)

generally, substituting provisions establishing a hospice

reimbursement cap amount of $6,500, indexed by the medical care

component of the Consumer Price Index, for provisions which had

established a cap of 40% of the estimated regional average medicare

expenditure per beneficiary in the regular medicare program during

the six months of life for persons dying of cancer.

Subsec. (j). Pub. L. 98-21, Sec. 601(d)(2), added subsec. (j) by

transferring and redesignating provisions formerly classified to

subsec. (d) of section 1395ww of this title.

Subsec. (j)(2)(A). Pub. L. 98-21, Sec. 601(d)(1), substituted

"subsection (b) of this section" for "section 1395f(b) of this

title".

1982 - Subsec. (a)(8). Pub. L. 97-248, Sec. 122(c)(1), added par.

(8).

Subsec. (b). Pub. L. 97-248, Sec. 101(c)(1), substituted

"sections 1395e and 1395ww" for "section 1395e" in provisions

preceding par. (1), and substituted "until the first day of the

seventh month beginning after the date the Secretary determines and

notifies the Governor of the State" for "until the Secretary

determines" in provisions following par. (3).

Pub. L. 97-248, Sec. 122(c)(2)(A), inserted "(other than a

hospice program providing hospice care)" after "The amount paid to

any provider of services".

Subsec. (i). Pub. L. 97-248, Sec. 122(c)(2)(B), added subsec.

(i).

1981 - Subsec. (a)(2)(D). Pub. L. 97-35, Sec. 2122(a)(1),

substituted "needs or needed skilled nursing care on an

intermittent basis or physical or speech therapy or, in the case of

an individual who has been furnished home health services based on

such a need and who no longer has such a need for such care or

therapy, continues or continued to need occupational therapy" for

"needed skilled nursing care on an intermittent basis, or physical,

occupational, or speech therapy".

Subsec. (a)(2)(F). Pub. L. 97-35, Sec. 2121(b), struck out

subpar. (F) which provided that in the case of alcohol

detoxification facility services, such services were required on an

inpatient basis (based upon an examination by such certifying

physician made prior to initiation of alcohol detoxification).

1980 - Subsec. (a). Pub. L. 96-499, Sec. 930(e), inserted

provision at end of subsec. (a) authorizing the Secretary to

prescribe regulations to prohibit significantly interested

physicians from performing the physician certification required by

par. (2) for home health services.

Subsec. (a)(2)(D). Pub. L. 96-499, Sec. 930(f), substituted "home

health services" for "post-hospital home health services" and

"physical, occupational, or speech" for "physical or speech" and

deleted ", for any of the conditions with respect to which he was

receiving inpatient hospital services (or services which would

constitute inpatient hospital services if the institution met the

requirements of paragraphs (6) and (9) of section 1395x(e) of this

title) or post-hospital extended care services" after "therapy".

Subsec. (a)(2)(E). Pub. L. 96-499, Sec. 936(b), inserted "or

because of the severity of the dental procedure" and substituted

"such services" for "such dental services".

Subsec. (a)(2)(F). Pub. L. 96-499, Sec. 931(b), added subpar.

(F).

Subsec. (b)(1). Pub. L. 96-499, Sec. 903(a)(1), inserted "except

as provided in paragraph (3),".

Subsec. (b)(3). Pub. L. 96-499, Sec. 903(a)(4), as amended by

Pub. L. 98-369, Sec. 2354(c)(1)(A), added par. (3).

Subsec. (c). Pub. L. 96-499, Sec. 941(b), substituted "subsection

(h)" for "subsection (j)".

Subsecs. (h) to (j). Pub. L. 96-499, Sec. 941(a), struck out

subsecs. (h) and (i) and redesignated subsec. (j) as (h).

1978 - Subsec. (b)(1). Pub. L. 95-292 inserted "and as further

limited by section 1395rr(b)(2)(B) of this title" after "section

1395x(v) of this title".

1977 - Subsec. (c). Pub. L. 95-142, Sec. 23(a), inserted

reference to subsec. (j) of this section.

Subsec. (j). Pub. L. 95-142, Sec. 23(b), added subsec. (j).

1976 - Subsec. (c). Pub. L. 94-437 substituted "Subject to

section 1395qq of this title, no payment" for "No payment".

1973 - Subsec. (a)(2)(E). Pub. L. 93-233, Sec. 18(k)(1),

substituted "the care, treatment, filling, removal, or replacement

of teeth or structures directly supporting teeth, the individual,

because of his underlying medical condition and clinical status,

requires hospitalization in connection with the provision of such

dental services" for "a dental procedure, the individual suffers

from impairments of such severity as to require hospitalization".

Subsec. (a), last sentence. Pub. L. 93-233, Sec. 18(k)(2),

inserted reference to subpar. (E) of par. (2).

1972 - Subsec. (a). Pub. L. 92-603, Secs. 226(c)(1), 227(b)(1),

inserted reference to subsec. (g) of this section and section

1395mm of this title in provisions preceding par. (1).

Subsec. (a)(1). Pub. L. 92-603, Sec. 281(e), placed a 3-year time

limitation on the time within which a written request for payment

is filed, with provision for reduction of the limit to 1 year.

Subsec. (a)(2)(C). Pub. L. 92-603, Secs. 234(g)(1), 247(a),

278(a)(1), substituted "because the individual needs or needed on a

daily basis skilled nursing care (provided directly by or requiring

the supervision of skilled nursing personnel) or other skilled

rehabilitation services, which as a practical matter can only be

provided in a skilled nursing facility on an inpatient basis," for

"on an inpatient basis because the individual needs or needed

skilled nursing care on a continuing basis", "skilled nursing

facility" for "extended care facility", and "paragraphs (6) and (9)

of section 1395x(e) of this title" for "paragraphs (6) and (8) of

section 1395x(e) of this title".

Subsec. (a)(2)(D). Pub. L. 92-603, Sec. 234(g)(1), substituted

reference to par. (9) of section 1395x(e) of this title for

reference to par. (8) of section 1395x(e) of this title.

Subsec. (a)(2)(E). Pub. L. 92-603, Sec. 256(a), added subpar.

(E).

Subsec. (a)(6). Pub. L. 92-603, Sec. 278(a)(2), substituted

"skilled nursing facility" for "extended care facility".

Subsec. (a)(7). Pub. L. 92-603, Secs. 238(a), 278(a)(3), inserted

", including any finding made in the course of a sample or other

review of admissions to the institution" after "as described in

section 1395x(k)(4) of this title" in the parenthetical provisions

covering the finding not made by the committee or group, and

substituted "skilled nursing facility" for "extended care

facility".

Subsec. (b). Pub. L. 92-603, Sec. 233(a), substituted pars. (1)

and (2) for provisions describing the amount payable as the

reasonable cost determined under section 1395x(v) of this title.

Subsec. (f). Pub. L. 92-603, Sec. 211(a), designated existing

provisions as par. (2), added pars. (1) and (3), and in par. (2) as

so redesignated inserted provisions covering individuals physically

present at a place within Canada while traveling without

unreasonable delay by the most direct route between Alaska and

another State.

Subsec. (g). Pub. L. 92-603, Sec. 227(b)(2), added subsec. (g).

Subsec. (h). Pub. L. 92-603, Secs. 228(a), 278(b)(4), (17), added

subsec. (h) and substituted "skilled nursing facility" for

"extended care facility".

Subsec. (i). Pub. L. 92-603, Sec. 228(a), added subsec. (i).

1968 - Subsec. (a). Pub. L. 90-248, Secs. 126(a)(5),

129(c)(5)(B), struck out references to former subpars. (E) and (F)

in last sentence.

Subsec. (a)(2)(A) to (E). Pub. L. 90-248, Sec. 126(a)(1), (2),

struck out subpar. (A) which provided that there be a physician's

certification of medical necessity for admissions to hospitals

other than psychiatric or tuberculosis institutions, and

redesignated subpars. (B) to (E) as (A) to (D), respectively.

Subsec. (a)(2)(F). Pub. L. 90-248, Sec. 129(c)(5)(A), struck out

subpar. (F) which provided that there be a physician's

certification for services furnished to outpatients.

Subsec. (a)(3) to (7). Pub. L. 90-248, Sec. 126(a)(3), (4), added

par. (3) and redesignated former pars. (3) to (6) as (4) to (7),

respectively.

Subsec. (d). Pub. L. 90-248, Sec. 129(c)(6)(A), struck out

reference to outpatient hospital diagnostic services from

provisions requiring payment for emergency hospital services.

Subsec. (d)(1) to (3). Pub. L. 90-248, Sec. 143(c), designated

existing provisions as par. (1), inserted "in a calendar year"

after "furnished" in first sentence of par. (1), added subpar. (C)

to par. (1), and added pars. (2) and (3).

EFFECTIVE DATE OF 2000 AMENDMENT

Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 321(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-500, provided that: "The amendment made

by subsection (a) [amending this section] shall apply to hospice

care furnished on or after April 1, 2001. In applying clause (ii)

of section 1814(i)(1)(C) of the Social Security Act (42 U.S.C.

1395f(i)(1)(C)) beginning with fiscal year 2002, the payment rates

in effect under such section during the period beginning on April

1, 2001, and ending on September 30, shall be treated as the

payment rates in effect during fiscal year 2001."

Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 322(a)(2)], Dec.

21, 2000, 114 Stat. 2763, 2763A-501, provided that: "The amendment

made by paragraph (1) [amending this section] shall apply to

certifications made on or after the date of the enactment of this

Act [Dec. 21, 2000]."

Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 507(a)(2)], Dec. 21,

2000, 114 Stat. 2763, 2763A-532, provided that: "The amendments

made by paragraph (1) [amending this section and section 1395n of

this title] shall apply to home health services furnished on or

after the date of the enactment of this Act [Dec. 21, 2000]."

EFFECTIVE DATE OF 1997 AMENDMENT

Section 4201(d) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and sections 1320a-7a,

1320a-7b, 1320b-4, 1320b-8, 1395d, 1395e, 1395h, 1395i-4, 1395k to

1395n, 1395u, 1395x, 1395y, 1395aa, 1395cc, 1395dd, and 1395ww of

this title] shall apply to services furnished on or after October

1, 1997."

Pub. L. 105-33, title IV, Sec. 4442(b), Aug. 5, 1997, 111 Stat.

423, as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title

III, Sec. 321(i)], Nov. 29, 1999, 113 Stat. 1536, 1501A-366,

provided that: "The amendment made by subsection (a) [amending this

section] applies to items and services furnished on or after

October 1, 1997."

Amendment by sections 4441, 4443(b)(2), and 4448 of Pub. L.

105-33 applicable to benefits provided on or after Aug. 5, 1997,

except as otherwise provided, see section 4449 of Pub. L. 105-33,

set out as a note under section 1395d of this title.

Amendment by section 4603(c)(1) of Pub. L. 105-33 applicable to

cost reporting periods beginning on or after Oct. 1, 1999, except

as otherwise provided, see section 4603(d) of Pub. L. 105-33, set

out as an Effective Date note under section 1395fff of this title.

Section 4615(b) of Pub. L. 105-33 provided that: "The amendments

made by subsection (a) [amending this section and section 1395n of

this title] apply to home health services furnished after the

6-month period beginning after the date of enactment of this Act

[Aug. 5, 1997]."

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by section 106(b)(1)(A) of Pub. L. 103-432 effective as

if included in the enactment of Pub. L. 100-203, see section

106(b)(2) of Pub. L. 103-432, set out as a note under section

1395cc of this title.

EFFECTIVE DATE OF 1990 AMENDMENT

Amendment by section 4006(b) of Pub. L. 101-508 applicable with

respect to care and services furnished on or after Jan. 1, 1990,

see section 4006(c) of Pub. L. 101-508, set out as a note under

section 1395d of this title.

EFFECTIVE DATE OF 1989 AMENDMENTS

Section 6005(c) of Pub. L. 101-239, as amended by Pub. L.

101-508, title IV, Sec. 4008(m)(3)(B), Nov. 5, 1990, 104 Stat.

1388-54, provided that: "The amendments made by subsections (a) and

(b) [amending this section] shall become effective with respect to

care and services furnished on or after January 1, 1990."

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section

101(d) of Pub. L. 101-234, set out as a note under section 1395c of

this title.

EFFECTIVE DATE OF 1988 AMENDMENT

Amendment by Pub. L. 100-360 effective Jan. 1, 1989, except as

otherwise provided, and applicable to inpatient hospital deductible

for 1989 and succeeding years, to care and services furnished on or

after Jan. 1, 1989, to premiums for January 1989 and succeeding

months, and to blood or blood cells furnished on or after Jan. 1,

1989, see section 104(a) of Pub. L. 100-360, set out as a note

under section 1395d of this title.

EFFECTIVE DATE OF 1987 AMENDMENT

Section 4008(b)(2) of Pub. L. 100-203 provided that: "The

amendment made by paragraph (1) [amending this section] shall take

effect on the date of the enactment of this Act [Dec. 22, 1987]."

Section 4024(c) of Pub. L. 100-203 provided that: "The amendments

made by subsections (a) and (b) [amending this section and section

1395n of this title] shall apply to items and services provided on

or after January 1, 1988."

Section 4062(e) of Pub. L. 100-203, as amended by Pub. L.

101-508, title IV, Sec. 4152(h), Nov. 5, 1990, 104 Stat. 1388-80,

provided that: "The amendments made by this section [enacting

section 1395m of this title, amending this section and sections

1395k, 1395l, and 1395cc of this title, and repealing section

1395zz of this title] shall apply to covered items (other than

oxygen and oxygen equipment) furnished on or after January 1, 1989

and to oxygen and oxygen equipment furnished on or after June 1,

1989."

[Section 4152(h) of Pub. L. 101-508 provided that amendment by

that section to section 4062(e) of Pub. L. 100-203, set out above,

is effective as if included in enactment of Omnibus Budget

Reconciliation Act of 1987, Pub. L. 100-203.]

EFFECTIVE DATE OF 1984 AMENDMENTS

Section 1(b) of Pub. L. 98-617 provided that: "The amendments

made by this Act [probably means section 1 of Pub. L. 98-617,

amending this section] shall apply to routine home care and other

services included in hospice care furnished on or after October 1,

1984."

Section 3(c) of Pub. L. 98-617 provided that: "The amendments

made by this section [amending this section and sections 1395l,

1395n, 1395r, 1395u, 1395x, 1395rr, 1395ww, 1396a, and 1396b of

this title and amending provisions set out as notes under sections

1395h and 1395mm of this title] shall be effective as if they had

been originally included in the Deficit Reduction Act of 1984 [Pub.

L. 98-369]."

Section 2321(g) of Pub. L. 98-369 provided that: "The amendments

made by this section [enacting section 1395zz of this title and

amending this section and sections 1395l, 1395x, and 1395cc of this

title] shall apply to items and services furnished on or after the

date of the enactment of this Act [July 18, 1984]."

Section 2335(g) of Pub. L. 98-369 provided that: "The amendments

made by this section [amending this section and sections 1395x,

1395z, 1395cc, 1396a, and 1396d of this title] shall become

effective on the date of the enactment of this Act [July 18,

1984]."

Section 2336(c)(1) of Pub. L. 98-369 provided that: "The

amendments made by subsection (a) [amending this section and

section 1395n of this title] shall apply to certifications and

plans of care made or established on or after the date of the

enactment of this Act [July 18, 1984]."

Amendment by section 2354(b)(1) of Pub. L. 98-369 effective July

18, 1984, but not to be construed as changing or affecting any

right, liability, status, or interpretation which existed (under

the provisions of law involved) before that date, see section

2354(e)(1) of Pub. L. 98-369, set out as a note under section

1320a-1 of this title.

Amendment by section 2354(c)(1)(A) of Pub. L. 98-369 effective as

if originally included in Pub. L. 96-499, see section 2354(e)(2) of

Pub. L. 98-369, set out as a note under section 1320a-1 of this

title.

EFFECTIVE DATE OF 1983 AMENDMENTS

Amendment by Pub. L. 98-21 applicable to items and services

furnished by or under arrangement with a hospital beginning with

its first cost reporting period that begins on or after Oct. 1,

1983, any change in a hospital's cost reporting period made after

November 1982 to be recognized for such purposes only if the

Secretary finds good cause therefor, see section 604(a)(1) of Pub.

L. 98-21, set out as a note under section 1395ww of this title.

Amendment by Pub. L. 97-448 effective as if originally included

as a part of this section as this section was amended by the Tax

Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248, see

section 309(c)(2) of Pub. L. 97-448, set out as a note under

section 426-1 of this title.

EFFECTIVE DATE OF 1982 AMENDMENT

Amendment by section 122(c)(1), (2) of Pub. L. 97-248 applicable

to hospice care provided on or after Nov. 1, 1983, see section

122(h)(1) of Pub. L. 97-248, as amended, set out as a note under

section 1395c of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Amendment by section 2121(b) of Pub. L. 97-35 applicable to

services furnished in detoxification facilities for inpatient stays

beginning on or after the tenth day after Aug. 13, 1981, see

section 2121(i) of Pub. L. 97-35, set out as a note under section

1395d of this title.

Section 2122(b) of Pub. L. 97-35 provided that: "The amendments

made by this section [amending this section and section 1395n of

this title] shall apply to services furnished pursuant to plans of

treatment implemented after the third month beginning after the

date of the enactment of this Act [Aug. 13, 1981]."

EFFECTIVE DATE OF 1980 AMENDMENT

Amendment by section 930(e), (f) of Pub. L. 96-499 effective with

respect to services furnished on or after July 1, 1981, see section

930(s)(1) of Pub. L. 96-499, set out as a note under section 1395x

of this title.

Amendment by section 931(b) of Pub. L. 96-499 effective Apr. 1,

1981, see section 931(e) of Pub. L. 96-499, set out as a note under

section 1395d of this title.

Section 936(d) of Pub. L. 96-499 provided that: "The amendments

made by this section [amending this section and sections 1395x and

1395y of this title] shall apply with respect to services provided

on or after July 1, 1981."

Section 941(c) of Pub. L. 96-499 provided that: "The amendments

made by this section [amending this section] shall take effect on

January 1, 1981."

EFFECTIVE DATE OF 1978 AMENDMENT

Amendment by Pub. L. 95-292 effective with respect to services,

supplies, and equipment furnished after the third calendar month

beginning after June 13, 1978, except that provisions for the

implementation of an incentive reimbursement system for dialysis

services furnished in facilities and providers to become effective

with respect to a facility's or provider's first accounting period

beginning after the last day of the twelfth month following the

month of June 1978, and except that provisions for reimbursement

rates for home dialysis to become effective on Apr. 1, 1979, see

section 6 of Pub. L. 95-292, set out as a note under section 426 of

this title.

EFFECTIVE DATE OF 1977 AMENDMENT

Section 23(c) of Pub. L. 95-142 provided that: "The amendments

made by this section [amending this section] shall apply to

inpatient hospital services furnished on and after July 1, 1974."

EFFECTIVE DATE OF 1973 AMENDMENT

Section 18(z-3)(2) of Pub. L. 93-233 provided that: "The

amendments made by subsection (k) [amending this section and

section 1395y of this title] shall be effective with respect to

admissions subject to the provisions of section 1814(a)(2) of the

Social Security Act [subsec. (a)(2) of this section] which occur

after December 31, 1972."

EFFECTIVE DATE OF 1972 AMENDMENT

Section 211(d) of Pub. L. 92-603 provided that: "The amendments

made by this section [amending this section and sections 1395l,

1395u, 1395x, and 1395y of this title] shall apply to services

furnished with respect to admissions occurring after December 31,

1972."

Amendment by section 226(c)(1) of Pub. L. 92-603 effective with

respect to services provided on or after July 1, 1973, see section

226(f) of Pub. L. 92-603, set out as an Effective Date note under

section 1395mm of this title.

Amendment by section 227(b) of Pub. L. 92-603 applicable with

respect to accounting periods beginning after June 30, 1973, see

section 227(g) of Pub. L. 92-603, set out as a note under section

1395x of this title.

Section 228(b) of Pub. L. 92-603 provided that: "The amendment

made by subsection (a) [amending this section] and any regulations

adopted pursuant to such amendment shall apply with respect to

plans of care initiated on or after January 1, 1973, and with

respect to admission to skilled nursing facilities and home health

plans initiated on or after such date."

Section 233(f) of Pub. L. 92-603 provided that: "The amendments

made by subsections (a) and (b) [amending this section and section

1395l of this title] shall apply to services furnished by

hospitals, extended care facilities, and home health agencies in

accounting periods beginning after December 31, 1972. The

amendments made by subsections (c), (d), and (e) [amending sections

706, 709, and 1396b of this title] shall apply with respect to

services furnished by hospitals in accounting periods beginning

after December 31, 1972." See, also, section 16 of Pub. L. 93-233,

set out below.

Amendment by section 234(g)(1) of Pub. L. 92-603 applicable with

respect to providers of services for fiscal years beginning after

fifth month following October 1972, see section 234(i) of Pub. L.

92-603, set out as a note under section 1395x of this title.

Section 238(b) of Pub. L. 92-603 provided that: "The amendment

made by subsection (a) [amending this section] shall apply with

respect to services furnished after the second month following the

month in which this Act is enacted [October 1972]."

Section 247(c) of Pub. L. 92-603 provided that: "The amendments

made by this section [amending this section and section 1396d of

this title] shall be effective with respect to services furnished

after December 31, 1972."

Section 256(d) of Pub. L. 92-603 provided that: "The amendments

made by this section [amending this section and sections 1395x and

1395y of this title] shall apply with respect to admissions

occurring after the second month following the month in which this

Act is enacted [October 1972]."

Amendment by section 281(e) of Pub. L. 92-603 applicable in the

case of services furnished (or deemed to have been furnished) after

1970, see section 281(g) of Pub. L. 92-603, set out as a note under

section 1395gg of this title.

EFFECTIVE DATE OF 1968 AMENDMENT

Section 126(c) of Pub. L. 90-248 provided that: "The amendments

made by this section [amending this section and section 1395n of

this title] shall apply with respect to services furnished after

the date of the enactment of this Act [Jan. 2, 1968]."

Amendment by section 129(c)(5), (6)(A) of Pub. L. 90-248

applicable with respect to services furnished after Jan. 2, 1968,

see section 129(d) of Pub. L. 90-248, set out as a note under

section 1395d of this title.

Amendment by section 143(c) of Pub. L. 90-248 applicable with

respect to services furnished with respect to admissions occurring

after Dec. 31, 1967, and to outpatient hospital diagnostic services

furnished after Dec. 31, 1967, and before Apr. 1, 1968, see section

143(d) of Pub. L. 90-248, set out as a note under section 1395d of

this title.

STUDY AND REPORT ON EFFECT OF 2000 AMENDMENT

Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 507(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-532, provided that:

"(1) In general. - The Comptroller General of the United States

shall conduct an evaluation of the effect of the amendment

[amending this section and section 1395n of this title] on the cost

of and access to home health services under the medicare program

under title XVIII of the Social Security Act [this subchapter].

"(2) Report. - Not later than 1 year after the date of the

enactment of this Act [Dec. 21, 2000], the Comptroller General

shall submit to Congress a report on the study conducted under

paragraph (1)."

STUDY AND REPORT ON PHYSICIAN CERTIFICATION REQUIREMENT FOR HOSPICE

BENEFITS

Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 322(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-501, provided that:

"(1) Study. - The Secretary of Health and Human Services shall

conduct a study to examine the appropriateness of the certification

regarding terminal illness of an individual under section

1814(a)(7) of the Social Security Act (42 U.S.C. 1395f(a)(7)) that

is required in order for such individual to receive hospice

benefits under the medicare program under title XVIII of such Act

[this subchapter]. In conducting such study, the Secretary shall

take into account the effect of the amendment made by subsection

(a) [amending this section].

"(2) Report. - Not later than 2 years after the date of the

enactment of this Act [Dec. 21, 2000], the Secretary of Health and

Human Services shall submit to Congress a report on the study

conducted under paragraph (1), together with any recommendations

for legislation that the Secretary deems appropriate."

TEMPORARY INCREASE IN PAYMENT FOR HOSPICE CARE

Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 321(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-501, provided that: "The provisions of

this section [amending this section and enacting provisions set out

as a note under this section] shall have no effect on the

application of section 131 of BBRA [Pub. L. 106-113, Sec.

1000(a)(6) [title I, Sec. 131], set out as a note below]."

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title I, Sec. 131],

Nov. 29, 1999, 113 Stat. 1536, 1501A-333, provided that:

"(a) Increase for Fiscal Years 2001 and 2002. - For purposes of

payments under section 1814(i)(1)(C) of the Social Security Act (42

U.S.C. 1395f(i)(1)(C)) for hospice care furnished during fiscal

years 2001 and 2002, the Secretary of Health and Human Services

shall increase the payment rate in effect (but for this section)

for -

"(1) fiscal year 2001, by 0.5 percent, and

"(2) fiscal year 2002, by 0.75 percent.

"(b) Additional Payment Not Built Into the Base. - The Secretary

of Health and Human Services shall not include any additional

payment made under this subsection (a) in updating the payment

rate, as increased by the applicable market basket percentage

increase for the fiscal year involved under section

1814(i)(1)(C)(ii) of that Act (42 U.S.C. 1395f(i)(1)(C)(ii))."

STUDY AND REPORT TO CONGRESS REGARDING MODIFICATION OF PAYMENT

RATES FOR HOSPICE CARE

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title I, Sec. 132],

Nov. 29, 1999, 113 Stat. 1536, 1501A-333, provided that:

"(a) Study. - The Comptroller General of the United States shall

conduct a study to determine the feasibility and advisability of

updating the payment rates and the cap amount determined with

respect to a fiscal year under section 1814(i) of the Social

Security Act (42 U.S.C. 1395f(i)) for routine home care and other

services included in hospice care. Such study shall examine the

cost factors used to determine such rates and such amount and shall

evaluate whether such factors should be modified, eliminated, or

supplemented with additional cost factors.

"(b) Report. - Not later than one year after the date of

enactment of this Act [Nov. 29, 1999], the Comptroller General of

the United States shall submit to Congress a report on the study

conducted under subsection (a), together with any recommendations

for legislation that the Comptroller General determines to be

appropriate as a result of such study."

STUDY OF METHODS TO COMPENSATE HOSPICES FOR HIGH-COST CARE

Section 6016 of Pub. L. 101-239 directed Secretary of Health and

Human Services to conduct a study of high-cost hospice care

provided to medicare beneficiaries under the medicare program,

evaluate the ability of hospice programs participating in the

medicare program to provide such high-cost care to such patients,

develop methods to compensate such programs for providing such

high-cost care, and submit, not later than Apr. 1, 1991, a report

to the Committee on Ways and Means of the House of Representatives

and the Committee on Finance of the Senate on the study, including

in the report any recommendations developed by the Secretary to

compensate hospice programs for providing high-cost hospice care to

medicare beneficiaries.

CONTINUATION OF BAD DEBT RECOGNITION FOR HOSPITAL SERVICES

Section 4008(c) of Pub. L. 100-203, as amended by Pub. L.

100-647, title VIII, Sec. 8402, Nov. 10, 1987, 102 Stat. 3798; Pub.

L. 101-239, title VI, Sec. 6023(a), Dec. 19, 1989, 103 Stat. 2167,

provided that: "In making payments to hospitals under title XVIII

of the Social Security Act [this subchapter], the Secretary of

Health and Human Services shall not make any change in the policy

in effect on August 1, 1987, with respect to payment under title

XVIII of the Social Security Act to providers of service for

reasonable costs relating to unrecovered costs associated with

unpaid deductible and coinsurance amounts incurred under such title

(including criteria for what constitutes a reasonable collection

effort, including criteria for indigency determination procedures,

for record keeping, and for determining whether to refer a claim to

an external collection agency). The Secretary may not require a

hospital to change its bad debt collection policy if a fiscal

intermediary, in accordance with the rules in effect as of August

1, 1987, with respect to criteria for indigency determination

procedures, record keeping, and determining whether to refer a

claim to an external collection agency, has accepted such policy

before that date, and the Secretary may not collect from the

hospital on the basis of an expectation of a change in the

hospital's collection policy."

[Section 6023(b) of Pub. L. 101-239 provided that: "The amendment

made by subsection (a) [amending section 4008(c) of Pub. L.

100-203, set out above] shall take effect as if included in the

enactment of the Omnibus Budget Reconciliation Act of 1987 [Pub. L.

100-203]."]

[Pub. L. 100-647, title VIII, Sec. 8402, Nov. 10, 1988, 102 Stat.

3798, provided that amendment of section 4008(c) of Pub. L.

100-203, set out above, by section 8402 of Pub. L. 100-647 is

effective as of date of enactment of Omnibus Budget Reconciliation

Act of 1987, Pub. L. 100-203, which was approved Dec. 22, 1987.]

PROVIDERS OF SERVICES TO CALCULATE AND REPORT

LESSER-OF-COST-OR-CHARGES DETERMINATIONS SEPARATELY WITH RESPECT TO

PAYMENTS UNDER PARTS A AND B OF THIS SUBCHAPTER; ISSUANCE OF

REGULATIONS

Section 2308(a) of Pub. L. 98-369 provided that: "The Secretary

of Health and Human Services shall issue regulations which require,

for purposes of title XVIII of the Social Security Act [this

subchapter], that providers of services calculate and report the

lesser-of-cost-or-charges determinations separately with respect to

payments for services under part A and services under part B of

such title (other than clinical diagnostic laboratory tests paid

under section 1833(h) [section 1395l(h) of this title]), and that

payment under such title be based upon such separate

determinations. Such regulations shall apply to cost reporting

periods beginning on or after October 1, 1984."

DETERMINATION OF NOMINAL CHARGES FOR APPLYING NOMINALITY TEST

Section 2308(b)(1) of Pub. L. 98-369 provided that: "For purposes

of applying the nominality test under sections 1814(b)(2) [subsec.

(b)(2) of this section] and 1833(a)(2)(B)(ii) [section

1395l(a)(2)(B)(ii) of this title] of the Social Security Act, the

Secretary shall, in addition to those rules for establishing

nominality which the Secretary determines to be appropriate,

provide that charges representing 60 percent or less of costs shall

be considered nominal. The charges used in making such

determinations shall be the charges actually billed to

charge-paying patients who are not entitled to benefits under

either part of such title [sections 1395c et seq., 1395j et seq. of

this title]. Such determination shall be made separately with

respect to payments for services under part A and services under

part B of such title (other than clinical diagnostic laboratory

tests paid under section 1833(h)), or on the basis of inpatient and

outpatient services, except that the determination need not be made

separately for home health services if the Secretary finds that

such separation is not appropriate."

REVISION OF REGULATIONS REGARDING ACCESS TO HOME HEALTH SERVICES

Section 2336(c)(2) of Pub. L. 98-369 provided that: "The

Secretary shall provide, not later than 90 days after the date of

the enactment of this Act [July 18, 1984], for such revision of

regulations as may be required to reflect the amendments made by

subsection (b) [amending this section and section 1395n of this

title]."

PROMULGATION OF REGULATIONS

Section 122(h)(2) of Pub. L. 97-248 provided that: "In order to

provide for the timely implementation of the amendments made by

this Act [probably means section 122 of Pub. L. 97-248, which

amended this section and sections 1395c to 1395e, 1395h, and 1395x

to 1395cc of this title and section 231f of Title 45, Railroads,

and enacted provisions set out as notes under this section and

sections 1395b-1 and 1395c of this title], the Secretary of Health

and Human Services shall, not later than September 1, 1983,

promulgate such final regulations as may be necessary to set forth

-

"(A) a description of the care included in 'hospice care' and

the standards for qualification of a 'hospice program', under

section 1861(dd) of the Social Security Act [section 1395x(dd) of

this title], and

"(B) the standards for payment for hospice care under part A of

title XVIII of such Act [this part], pursuant to section 1814(i)

of such Act [subsec. (i) of this section]."

STUDY AND REPORT RELATING TO THE REIMBURSEMENT METHOD AND BENEFIT

STRUCTURE FOR HOSPICE CARE; SUPERVISION OF REPORT BY COMPTROLLER

GENERAL

Section 122(j), formerly Sec. 122(i), of Pub. L. 97-248,

redesignated Sec. 122(i), by Pub. L. 97-448, title III, Sec.

309(a)(6), Jan. 12, 1983, 96 Stat. 2408, provided that:

"(1) The Secretary of Health and Human Services shall conduct a

study and, prior to January 1, 1986, report to the Congress on

whether or not the reimbursement method and benefit structure

(including copayments) for hospice care under title XVIII of the

Social Security Act [this subchapter] are fair and equitable and

promote the most efficient provision of hospice care. Such report

shall include the feasibility and advisability of providing for

prospective reimbursement for hospice care, an evaluation of the

inclusion of payment for outpatient drugs, an evaluation of the

need to alter the method of reimbursement for nutritional, dietary,

and bereavement counseling as hospice care, and any recommendations

for legislative changes in the hospice care reimbursement or

benefit structure.

"(2) The Comptroller General shall monitor and evaluate the study

and the preparation of the report under paragraph (1)."

WAIVER OF LIMITATIONS TO ALLOW PRE-EXISTING HOSPICES TO PARTICIPATE

AS A HOSPICE PROGRAM

Section 122(k), formerly Sec. 122(j), of Pub. L. 97-248, as

redesignated and amended by Pub. L. 97-448, title III, Sec.

309(a)(6), (7), Jan. 12, 1983, 96 Stat. 2408, provided that: "The

Secretary of Health and Human Services shall grant waivers of the

limitations imposed by section 1814(i)(2) of the Social Security

Act [subsec. (i)(2) of this section] (relating to the cap amount),

section 1861(dd)(1)(G) of such Act [section 1395x(dd)(1)(G) of this

title] (relating to the limitations on the frequency and number of

respite care days), and section 1861(dd)(2)(A)(iii) of such Act

[section 1395x(dd)(2)(A)(iii) of this title] (relating to the

aggregate limit on the number of days of inpatient care), as may be

necessary to allow any institution which commenced operations as a

hospice prior to January 1, 1975, to participate until October 1,

1986, in a viable manner as a hospice program under title XVIII of

the Social Security Act [this subchapter]."

MEDICARE PAYMENT BASIS FOR SERVICES PROVIDED BY AGENCIES AND

PROVIDERS; EFFECTIVE DATE

Section 16 of Pub. L. 93-233 provided that: "In the

administration of titles V, XVIII, and XIX of the Social Security

Act [subchapters V, XVIII, and XIX of this chapter], the amount

payable under such title to any provider of services on account of

services provided by such hospital, skilled nursing facility, or

home health agency shall be determined (for any period with respect

to which the amendments made by section 233 of Public Law 92-603

[this section and sections 706, 709, 1395l, and 1396b of this

title] would, except for the provisions of this section, be

applicable) in like manner as if the date contained in the first

and second sentences of subsection (f) of such section 233 [set out

as an Effective Date of 1972 Amendment note above] were December

31, 1973, rather than December 31, 1972."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 426, 1320a-7a, 1395d,

1395e, 1395g, 1395l, 1395n, 1395w-23, 1395x, 1395y, 1395cc, 1395gg,

1395mm, 1395pp, 1395qq, 1395uu, 1395ww, 1395eee, 1395fff, 1395ggg

of this title; title 5 section 8904.

-FOOTNOTE-

(!1) So in original. Probably should be followed by a comma.

-End-

-CITE-

42 USC Sec. 1395g 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395g. Payments to providers of services

-STATUTE-

(a) Determination of amount

The Secretary shall periodically determine the amount which

should be paid under this part to each provider of services with

respect to the services furnished by it, and the provider of

services shall be paid, at such time or times as the Secretary

believes appropriate (but not less often than monthly) and prior to

audit or settlement by the General Accounting Office, from the

Federal Hospital Insurance Trust Fund, the amounts so determined,

with necessary adjustments on account of previously made

overpayments or underpayments; except that no such payments shall

be made to any provider unless it has furnished such information as

the Secretary may request in order to determine the amounts due

such provider under this part for the period with respect to which

the amounts are being paid or any prior period.

(b) Conditions

No payment shall be made to a provider of services which is a

hospital for or with respect to services furnished by it for any

period with respect to which it is deemed, under section

1395x(w)(2) of this title, to have in effect an arrangement with a

quality control and peer review organization for the conduct of

utilization review activities by such organization unless such

hospital has paid to such organization the amount due (as

determined pursuant to such section) to such organization for the

review activities conducted by it pursuant to such arrangements or

such hospital has provided assurances satisfactory to the Secretary

that such organization will promptly be paid the amount so due to

it from the proceeds of the payment claimed by the hospital.

Payment under this subchapter for utilization review activities

provided by a quality control and peer review organization pursuant

to an arrangement or deemed arrangement with a hospital under

section 1395x(w)(2) of this title shall be calculated without any

requirement that the reasonable cost of such activities be

apportioned among the patients of such hospital, if any, to whom

such activities were not applicable.

(c) Payments under assignment or power of attorney

No payment which may be made to a provider of services under this

subchapter for any service furnished to an individual shall be made

to any other person under an assignment or power of attorney; but

nothing in this subsection shall be construed (1) to prevent the

making of such a payment in accordance with an assignment from the

provider if such assignment is made to a governmental agency or

entity or is established by or pursuant to the order of a court of

competent jurisdiction, or (2) to preclude an agent of the provider

of services from receiving any such payment if (but only if) such

agent does so pursuant to an agency agreement under which the

compensation to be paid to the agent for his services for or in

connection with the billing or collection of payments due such

provider under this subchapter is unrelated (directly or

indirectly) to the amount of such payments or the billings

therefor, and is not dependent upon the actual collection of any

such payment.

(d) Accrual of interest on balance of excess or deficit not paid

Whenever a final determination is made that the amount of payment

made under this part to a provider of services was in excess of or

less than the amount of payment that is due, and payment of such

excess or deficit is not made (or effected by offset) within 30

days of the date of the determination, interest shall accrue on the

balance of such excess or deficit not paid or offset (to the extent

that the balance is owed by or owing to the provider) at a rate

determined in accordance with the regulations of the Secretary of

the Treasury applicable to charges for late payments.

(e) Periodic interim payments

(1) The Secretary shall provide payment under this part for

inpatient hospital services furnished by a subsection (d) hospital

(as defined in section 1395ww(d)(1)(B) of this title, and including

a distinct psychiatric or rehabilitation unit of such a hospital)

and a subsection (d) Puerto Rico hospital (as defined in section

1395ww(d)(9)(A) of this title) on a periodic interim payment basis

(rather than on the basis of bills actually submitted) in the

following cases:

(A) Upon the request of a hospital which is paid through an

agency or organization with an agreement with the Secretary under

section 1395h of this title, if the agency or organization, for

three consecutive calendar months, fails to meet the requirements

of subsection (c)(2) of such section and if the hospital meets

the requirements (in effect as of October 1, 1986) applicable to

payment on such a basis, until such time as the agency or

organization meets such requirements for three consecutive

calendar months.

(B) In the case of (!1) hospital that -

(i) has a disproportionate share adjustment percentage (as

established in clause (iv) of such section) of at least 5.1

percent (as computed for purposes of establishing the average

standardized amounts for discharges occurring during fiscal

year 1987), and

(ii) requests payment on such basis,

but only if the hospital was being paid for inpatient hospital

services on such a periodic interim payment basis as of June 30,

1987, and continues to meet the requirements (in effect as of

October 1, 1986) applicable to payment on such a basis.

(C) In the case of a hospital that -

(i) is located in a rural area,

(ii) has 100 or fewer beds, and

(iii) requests payment on such basis,

but only if the hospital was being paid for inpatient hospital

services on such a periodic interim payment basis as of June 30,

1987, and continues to meet the requirements (in effect as of

October 1, 1986) applicable to payment on such a basis.

(2) The Secretary shall provide (or continue to provide) for

payment on a periodic interim payment basis (under the standards

established under section 405.454(j) of title 42, Code of Federal

Regulations, as in effect on October 1, 1986) with respect to -

(A) inpatient hospital services of a hospital that is not a

subsection (d) hospital (as defined in section 1395ww(d)(1)(B) of

this title);

(B) a hospital which is receiving payment under a State

hospital reimbursement system under section 1395f(b)(3) or

1395ww(c) of this title, if payment on a periodic interim payment

basis is an integral part of such reimbursement system;

(C) extended care services; and

(D) hospice care;

if the provider of such services elects to receive, and qualifies

for, such payments.

(3) In the case of a subsection (d) hospital or a subsection (d)

Puerto Rico hospital (as defined for purposes of section 1395ww of

this title) which has significant cash flow problems resulting from

operations of its intermediary or from unusual circumstances of the

hospital's operation, the Secretary may make available appropriate

accelerated payments.

(4) A hospital created by the merger or consolidation of 2 or

more hospitals or hospital campuses shall be eligible to receive

periodic interim payment on the basis described in paragraph (1)(B)

if -

(A) at least one of the hospitals or campuses received periodic

interim payment on such basis prior to the merger or

consolidation; and

(B) the merging or consolidating hospitals or campuses would

each meet the requirement of paragraph (1)(B)(i) if such

hospitals or campuses were treated as independent hospitals for

purposes of this subchapter.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1815, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 297; amended

Pub. L. 94-182, title I, Sec. 112(a)(2), Dec. 31, 1975, 89 Stat.

1055; Pub. L. 95-142, Sec. 2(a)(2), Oct. 25, 1977, 91 Stat. 1175;

Pub. L. 96-473, Sec. 6(i), Oct. 19, 1980, 94 Stat. 2266; Pub. L.

97-248, title I, Secs. 117(a)(1), 148(b), Sept. 3, 1982, 96 Stat.

354, 394; Pub. L. 99-509, title IX, Sec. 9311(a)(1), Oct. 21, 1986,

100 Stat. 1996; Pub. L. 101-239, title VI, Sec. 6021(a), Dec. 19,

1989, 103 Stat. 2166; Pub. L. 105-33, title IV, Sec. 4603(b), Aug.

5, 1997, 111 Stat. 470.)

-MISC1-

AMENDMENTS

1997 - Subsec. (e)(2)(C) to (E). Pub. L. 105-33 inserted "and" at

end of subpar. (C), redesignated subpar. (E) as (D), and struck out

former subpar. (D) which read as follows: "home health services;

and".

1989 - Subsec. (e)(4). Pub. L. 101-239 added par. (4).

1986 - Subsec. (e). Pub. L. 99-509 added subsec. (e).

1982 - Subsec. (b). Pub. L. 97-248, Sec. 148(b), substituted

"quality control and peer review organization" for "Professional

Standards Review Organization" wherever appearing.

Subsec. (d). Pub. L. 97-248, Sec. 117(a)(1), added subsec. (d).

1980 - Subsec. (c). Pub. L. 96-473 substituted "for or in

connection with" for "for on in connection with".

1977 - Subsec. (c). Pub. L. 95-142 added subsec. (c).

1975 - Pub. L. 94-182 designated existing provisions as subsec.

(a) and added subsec. (b).

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by Pub. L. 105-33 applicable to cost reporting periods

beginning on or after Oct. 1, 1999, except as otherwise provided,

see section 4603(d) of Pub. L. 105-33, set out as an Effective Date

note under section 1395fff of this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Section 6021(b) of Pub. L. 101-239 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

payments made for discharges occurring on or after the expiration

of the 30-day period that begins on the date of the enactment of

this Act [Dec. 19, 1989], regardless of the date of the merger or

consolidation involved."

EFFECTIVE DATE OF 1986 AMENDMENT

Section 9311(a)(2) of Pub. L. 99-509 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to claims received on or after July 1, 1987."

EFFECTIVE DATE OF 1982 AMENDMENT

Section 117(b) of Pub. L. 97-248 provided that: "The amendments

made by subsection (a) [amending this section and section 1395l of

this title] apply to final determinations made on or after the date

of the enactment of this Act [Sept. 3, 1982]."

Amendment by section 148(b) of Pub. L. 97-248 effective with

respect to contracts entered into or renewed on or after Sept. 3,

1982, see section 149 of Pub. L. 97-248, set out as an Effective

Date note under section 1320c of this title.

EFFECTIVE DATE OF 1977 AMENDMENT

Section 2(a)(4) of Pub. L. 95-142 provided that: "The amendments

made by this subsection [amending this section and sections 1395u

and 1396a of this title] shall apply with respect to care and

services furnished on or after the date of the enactment of this

Act [Oct. 25, 1977]."

EFFECTIVE DATE OF 1975 AMENDMENT

Amendment by Pub. L. 94-182 effective with respect to utilization

review activities conducted on and after the first day of the first

month which begins more than 30 days after Dec. 31, 1975, see

section 112(d) of Pub. L. 94-182, set out as a note under section

1395x of this title.

TRANSITION

Section 9311(a)(3) of Pub. L. 99-509 provided that: "Upon the

request of a hospital which -

"(A) as of June 30, 1987, is receiving payments under part A of

title XVIII of such Act [this part] for inpatient hospital

services on a periodic interim payment basis,

"(B) requests continuation of payment on such basis, and

"(C) is paid through an agency or organization with an

agreement under section 1816 of such Act [section 1395h of this

title],

the Secretary of Health and Human Services shall continue payment

on such a basis until not earlier than the end of the first period

of three consecutive calendar months (beginning no earlier than

April 1987) during all of which the agency or organization has met

the requirements of section 1816(c)(2) of such Act (relating to

prompt payment of claims)."

DELAY IN PERIODIC INTERIM PAYMENTS

Section 120 of Pub. L. 97-248 provided that: "Notwithstanding

section 1815(a) of the Social Security Act [subsec. (a) of this

section], in the case of a hospital which is paid periodic interim

payments under such section, the Secretary of Health and Human

Services shall provide that -

"(1) with respect to the last 21 days for which such payments

would otherwise be made during fiscal year 1983, such payments

shall be deferred until fiscal year 1984; and

"(2) with respect to the last 21 days for which such payments

would otherwise be made during fiscal year 1984, such payments

shall be deferred until fiscal year 1985."

Pub. L. 96-499, title IX, Sec. 959, Dec. 5, 1980, 94 Stat. 2650,

provided for deferral of interim payments to be made during last

twenty-one days of fiscal year 1981 until fiscal year 1982, prior

to repeal by Pub. L. 97-35, title XXI, Sec. 2155, Aug. 13, 1981, 95

Stat. 802.

-FOOTNOTE-

(!1) So in original. Probably should be followed by "a".

-End-

-CITE-

42 USC Sec. 1395h 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395h. Use of public or private agencies or organizations to

facilitate payment to providers of services

-STATUTE-

(a) Authorization for agreement by Secretary for implementation;

scope of agreement

If any group or association of providers of services wishes to

have payments under this part to such providers made through a

national, State, or other public or private agency or organization

and nominates such agency or organization for this purpose, the

Secretary is authorized to enter into an agreement with such agency

or organization providing for the determination by such agency or

organization (subject to the provisions of section 1395oo of this

title and to such review by the Secretary as may be provided for by

the agreement) of the amount of the payments required pursuant to

this part to be made to such providers (and to providers assigned

to such agency or organization under subsection (e) of this

section), and for the making of such payments by such agency or

organization to such providers (and to providers assigned to such

agency or organization under subsection (e) of this section). Such

agreement may also include provision for the agency or organization

to do all or any part of the following: (1) to provide consultative

services to institutions or agencies to enable them to establish

and maintain fiscal records necessary for purposes of this part and

otherwise to qualify as hospitals, extended care facilities, or

home health agencies, and (2) with respect to the providers of

services which are to receive payments through it (A) to serve as a

center for, and communicate to providers, any information or

instructions furnished to it by the Secretary, and serve as a

channel of communication from providers to the Secretary; (B) to

make such audits of the records of providers as may be necessary to

insure that proper payments are made under this part; and (C) to

perform such other functions as are necessary to carry out this

subsection. As used in this subchapter and part B of subchapter XI

of this chapter, the term "fiscal intermediary" means an agency or

organization with a contract under this section.

(b) Prerequisites for agreement or renewal of agreement by

Secretary

The Secretary shall not enter into or renew an agreement with any

agency or organization under this section unless -

(1) he finds -

(A) after applying the standards, criteria, and procedures

developed under subsection (f) of this section, that to do so

is consistent with the effective and efficient administration

of this part, and

(B) that such agency or organization is willing and able to

assist the providers to which payments are made through it

under this part in the application of safeguards against

unnecessary utilization of services furnished by them to

individuals entitled to hospital insurance benefits under

section 426 of this title, and the agreement provides for such

assistance; and

(2) such agency or organization agrees -

(A) to furnish to the Secretary such of the information

acquired by it in carrying out its agreement under this

section, and

(B) to provide the Secretary with access to all such data,

information, and claims processing operations,

as the Secretary may find necessary in performing his functions

under this part.

(c) Terms and conditions of agreements; prompt payment of claims

(1) An agreement with any agency or organization under this

section may contain such terms and conditions as the Secretary

finds necessary or appropriate, may provide for advances of funds

to the agency or organization for the making of payments by it

under subsection (a) of this section, and shall provide for payment

of so much of the cost of administration of the agency or

organization as is determined by the Secretary to be necessary and

proper for carrying out the functions covered by the agreement. The

Secretary shall provide that in determining the necessary and

proper cost of administration, the Secretary shall, with respect to

each agreement, take into account the amount that is reasonable and

adequate to meet the costs which must be incurred by an efficiently

and economically operated agency or organization in carrying out

the terms of its agreement. The Secretary shall cause to have

published in the Federal Register, by not later than September 1

before each fiscal year, data, standards, and methodology to be

used to establish budgets for fiscal intermediaries under this

section for that fiscal year, and shall cause to be published in

the Federal Register for public comment, at least 90 days before

such data, standards, and methodology are published, the data,

standards, and methodology proposed to be used. The Secretary may

not require, as a condition of entering into or renewing an

agreement under this section or under section 1395hh of this title,

that a fiscal intermediary match data obtained other than in its

activities under this part with data used in the administration of

this part for purposes of identifying situations in which the

provisions of section 1395y(b) of this title may apply.

(2)(A) Each agreement under this section shall provide that

payment shall be issued, mailed, or otherwise transmitted with

respect to not less than 95 percent of all claims submitted under

this subchapter -

(i) which are clean claims, and

(ii) for which payment is not made on a periodic interim

payment basis,

within the applicable number of calendar days after the date on

which the claim is received.

(B) In this paragraph:

(i) The term "clean claim" means a claim that has no defect or

impropriety (including any lack of any required substantiating

documentation) or particular circumstance requiring special

treatment that prevents timely payment from being made on the

claim under this subchapter.

(ii) The term "applicable number of calendar days" means -

(I) with respect to claims received in the 12-month period

beginning October 1, 1986, 30 calendar days,

(II) with respect to claims received in the 12-month period

beginning October 1, 1987, 26 calendar days,

(III) with respect to claims received in the 12-month period

beginning October 1, 1988, 25 calendar days, and (!1)

(IV) with respect to claims received in the 12-month period

beginning October 1, 1989, and claims received in any

succeeding 12-month period ending on or before September 30,

1993, 24 calendar days.(!2)

(V) with respect to claims received in the 12-month period

beginning October 1, 1993, and claims received in any

succeeding 12-month period, 30 calendar days.

(C) If payment is not issued, mailed, or otherwise transmitted

within the applicable number of calendar days (as defined in clause

(ii) of subparagraph (B)) after a clean claim (as defined in clause

(i) of such subparagraph) is received from a hospital, critical

access hospital, skilled nursing facility, home health agency,

hospice program, comprehensive outpatient rehabilitation facility,

or rehabilitation agency that is not receiving payments on a

periodic interim payment basis with respect to such services,

interest shall be paid at the rate used for purposes of section

3902(a) of title 31 (relating to interest penalties for failure to

make prompt payments) for the period beginning on the day after the

required payment date and ending on the date on which payment is

made.

(3)(A) Each agreement under this section shall provide that no

payment shall be issued, mailed, or otherwise transmitted with

respect to any claim submitted under this subchapter within the

applicable number of calendar days after the date on which the

claim is received.

(B) In this paragraph, the term "applicable number of calendar

days" means -

(i) with respect to claims submitted electronically as

prescribed by the Secretary, 13 days, and

(ii) with respect to claims submitted otherwise, 26 days.

(d) Nomination of agency or organization; withdrawal

If the nomination of an agency or organization as provided in

this section is made by a group or association of providers of

services, it shall not be binding on members of the group or

association which notify the Secretary of their election to that

effect. Any provider may, upon such notice as may be specified in

the agreement under this section with an agency or organization,

withdraw its nomination to receive payments through such agency or

organization. Any provider which has withdrawn its nomination, and

any provider which has not made a nomination, may elect to receive

payments from any agency or organization which has entered into an

agreement with the Secretary under this section if the Secretary

and such agency or organization agree to it.

(e) Assignment or reassignment of provider of services; designation

of agency or organization to perform provider services and home

health agency functions

(1) Notwithstanding subsections (a) and (d) of this section, the

Secretary, after taking into consideration any preferences of

providers of services, may assign or reassign any provider of

services to any agency or organization which has entered into an

agreement with him under this section, if he determines, after

applying the standards, criteria, and procedures developed under

subsection (f) of this section, that such assignment or

reassignment would result in the more effective and efficient

administration of this part.

(2) Notwithstanding subsections (a) and (d) of this section, the

Secretary may (subject to the provisions of paragraph (4))

designate a national or regional agency or organization which has

entered into an agreement with him under this section to perform

functions under the agreement with respect to a class of providers

of services in the Nation or region (as the case may be), if he

determines, after applying the standards, criteria, and procedures

developed under subsection (f) of this section, that such

designation would result in more effective and efficient

administration of this part.

(3)(A) Before the Secretary makes an assignment or reassignment

under paragraph (1) of a provider of services to other than the

agency or organization nominated by the provider, he shall furnish

(i) the provider and such agency or organization with a full

explanation of the reasons for his determination as to the

efficiency and effectiveness of the agency or organization to

perform the functions required under this part with respect to the

provider, and (ii) such agency or organization with opportunity for

a hearing, and such determination shall be subject to judicial

review in accordance with chapter 7 of title 5.

(B) Before the Secretary makes a designation under paragraph (2)

with respect to a class of providers of services, he shall furnish

(i) such providers and the agencies and organizations adversely

affected by such designation with a full explanation of the reasons

for his determination as to the efficiency and effectiveness of

such agencies and organizations to perform the functions required

under this part with respect to such providers, and (ii) the

agencies and organizations adversely affected by such designation

with opportunity for a hearing, and such determination shall be

subject to judicial review in accordance with chapter 7 of title 5.

(4) Notwithstanding subsections (a) and (d) of this section and

paragraphs (1), (2), and (3) of this subsection, the Secretary

shall designate regional agencies or organizations which have

entered into an agreement with him under this section to perform

functions under such agreement with respect to home health agencies

(as defined in section 1395x(o) of this title) in the region,

except that in assigning such agencies to such designated regional

agencies or organizations the Secretary shall assign a home health

agency which is a subdivision of a hospital (and such agency and

hospital are affiliated or under common control) only if, after

applying such criteria relating to administrative efficiency and

effectiveness as he shall promulgate, he determines that such

assignment would result in the more effective and efficient

administration of this subchapter. By not later than July 1, 1987,

the Secretary shall limit the number of such regional agencies or

organizations to not more than ten.

(5) Notwithstanding any other provision of this subchapter, the

Secretary shall designate the agency or organization which has

entered into an agreement under this section to perform functions

under such an agreement with respect to each hospice program,

except that with respect to a hospice program which is a

subdivision of a provider of services (and such hospice program and

provider of services are under common control) due regard shall be

given to the agency or organization which performs the functions

under this section for the provider of services.

(f) Development of standards, criteria, and procedures by Secretary

for evaluation of agency or organization performance

(1) In order to determine whether the Secretary should enter

into, renew, or terminate an agreement under this section with an

agency or organization, whether the Secretary should assign or

reassign a provider of services to an agency or organization, and

whether the Secretary should designate an agency or organization to

perform services with respect to a class of providers of services,

the Secretary shall develop standards, criteria, and procedures to

evaluate such agency's or organization's (A) overall performance of

claims processing (including the agency's or organization's success

in recovering payments made under this subchapter for services for

which payment has been or could be made under a primary plan (as

defined in section 1395y(b)(2)(A) of this title)) and other related

functions required to be performed by such an agency or

organization under an agreement entered into under this section,

and (B) performance of such functions with respect to specific

providers of services, and the Secretary shall establish standards

and criteria with respect to the efficient and effective

administration of this part. No agency or organization shall be

found under such standards and criteria not to be efficient or

effective or to be less efficient or effective solely on the ground

that the agency or organization serves only providers located in a

single State.

(2) The standards and criteria established under paragraph (1)

shall include -

(A) with respect to claims for services furnished under this

part by any provider of services other than a hospital -

(i) whether such agency or organization is able to process 75

percent of reconsiderations within 60 days (except in the case

of fiscal year 1989, 66 percent of reconsiderations) and 90

percent of reconsiderations within 90 days, and

(ii) the extent to which such agency's or organization's

determinations are reversed on appeal; and

(B) with respect to applications for an exemption from or

exception or adjustment to the target amount applicable under

section 1395ww(b) of this title to a hospital that is not a

subsection (d) hospital (as defined in section 1395ww(d)(1)(B) of

this title) -

(i) if such agency or organization receives a completed

application, whether such agency or organization is able to

process such application not later than 75 days after the

application is filed, and

(ii) if such agency or organization receives an incomplete

application, whether such agency or organization is able to

return the application with instructions on how to complete the

application not later than 60 days after the application is

filed.

(g) Termination of agreement; procedures applicable

An agreement with the Secretary under this section may be

terminated -

(1) by the agency or organization which entered into such

agreement at such time and upon such notice to the Secretary, to

the public, and to the providers as may be provided in

regulations, or

(2) by the Secretary at such time and upon such notice to the

agency or organization, to the providers which have nominated it

for purposes of this section, and to the public, as may be

provided in regulations, but only if he finds, after applying the

standards, criteria, and procedures developed under subsection

(f) of this section and after reasonable notice and opportunity

for hearing to the agency or organization, that (A) the agency or

organization has failed substantially to carry out the agreement,

or (B) the continuation of some or all of the functions provided

for in the agreement with the agency or organization is

disadvantageous or is inconsistent with the efficient

administration of this part.

(h) Bonding requirement under agreement for officers and employees

of agency or organization

An agreement with an agency or organization under this section

may require any of its officers or employees certifying payments or

disbursing funds pursuant to the agreement, or otherwise

participating in carrying out the agreement, to give surety bond to

the United States in such amount as the Secretary may deem

appropriate.

(i) Liability of certifying and disbursing officers designated

under agreement for negligent, etc., payments

(1) No individual designated pursuant to an agreement under this

section as a certifying officer shall, in the absence of gross

negligence or intent to defraud the United States, be liable with

respect to any payments certified by him under this section.

(2) No disbursing officer shall, in the absence of gross

negligence or intent to defraud the United States, be liable with

respect to any payment by him under this section if it was based

upon a voucher signed by a certifying officer designated as

provided in paragraph (1) of this subsection.

(3) No such agency or organization shall be liable to the United

States for any payments referred to in paragraph (1) or (2).

(j) Denial of claim; notification and reconsideration

An agreement with an agency or organization under this section

shall require that, with respect to a claim for home health

services, extended care services, or post-hospital extended care

services submitted by a provider to such agency or organization

that is denied, such agency or organization -

(1) furnish the provider and the individual with respect to

whom the claim is made with a written explanation of the denial

and of the statutory or regulatory basis for the denial; and

(2) in the case of a request for reconsideration of a denial,

promptly notify such individual and the provider of the

disposition of such reconsideration.

(k) Annual reporting requirement on erroneous payment recovery

An agreement with an agency or organization under this section

shall require that such agency or organization submit an annual

report to the Secretary describing the steps taken to recover

payments made for items or services for which payment has been or

could be made under a primary plan (as defined in section

1395y(b)(2)(A) of this title).

(l) No authority for activities carried out under Medicare

Integrity Program

No agency or organization may carry out (or receive payment for

carrying out) any activity pursuant to an agreement under this

section to the extent that the activity is carried out pursuant to

a contract under the Medicare Integrity Program under section

1395ddd of this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1816, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 297; amended

Pub. L. 92-603, title II, Sec. 243(b), Oct. 30, 1972, 86 Stat.

1422; Pub. L. 95-142, Sec. 14(a), Oct. 25, 1977, 91 Stat. 1198;

Pub. L. 96-499, title IX, Sec. 930(o), Dec. 5, 1980, 94 Stat. 2632;

Pub. L. 97-248, title I, Sec. 122(c)(3), Sept. 3, 1982, 96 Stat.

359; Pub. L. 98-369, div. B, title III, Sec. 2326(b), (c)(1),

(d)(1), July 18, 1984, 98 Stat. 1087; Pub. L. 99-509, title IX,

Secs. 9311(b), 9352(a)(2), Oct. 21, 1986, 100 Stat. 1997, 2044;

Pub. L. 100-203, title IV, Secs. 4031(a)(1), 4032(a), (b),

4035(a)(1), 4085(d)(1), Dec. 22, 1987, 101 Stat. 1330-75 to

1330-78, 1330-130; Pub. L. 100-360, title II, Sec. 203(f), title

IV, Sec. 411(e)(1)(B), July 1, 1988, 102 Stat. 725, 775; Pub. L.

101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981; Pub.

L. 101-239, title VI, Secs. 6003(g)(3)(D)(vi), 6202(d)(1), Dec. 19,

1989, 103 Stat. 2153, 2234; Pub. L. 101-508, title IV, Sec.

4005(c)(1)(A), Nov. 5, 1990, 104 Stat. 1388-41; Pub. L. 103-66,

title XIII, Sec. 13568(a), (b), Aug. 10, 1993, 107 Stat. 608; Pub.

L. 103-432, title I, Secs. 110(d)(2), 151(b)(1)(A), (2)(A), Oct.

31, 1994, 108 Stat. 4408, 4433, 4434; Pub. L. 104-191, title II,

Sec. 202(b)(1), Aug. 21, 1996, 110 Stat. 1998; Pub. L. 105-33,

title IV, Sec. 4201(c)(1), Aug. 5, 1997, 111 Stat. 373.)

-REFTEXT-

REFERENCES IN TEXT

Part B of subchapter XI of this chapter, referred to in subsec.

(a), is classified to section 1320c et seq. of this title.

-MISC1-

AMENDMENTS

1997 - Subsec. (c)(2)(C). Pub. L. 105-33 substituted "critical

access" for "rural primary care".

1996 - Subsec. (l). Pub. L. 104-191 added subsec. (l).

1994 - Subsec. (f)(1)(A). Pub. L. 103-432, Sec. 151(b)(2)(A),

inserted "(including the agency's or organization's success in

recovering payments made under this subchapter for services for

which payment has been or could be made under a primary plan (as

defined in section 1395y(b)(2)(A) of this title))" after

"processing".

Subsec. (f)(2)(A)(ii). Pub. L. 103-432, Sec. 110(d)(2),

substituted "such agency's" for "such agency".

Subsec. (k). Pub. L. 103-432, Sec. 151(b)(1)(A), added subsec.

(k).

1993 - Subsec. (c)(2)(B)(ii)(IV), (V). Pub. L. 103-66, Sec.

13568(b), substituted "period ending on or before September 30,

1993" for "period" in subcl. (IV) and added subcl. (V).

Subsec. (c)(3)(B). Pub. L. 103-66, Sec. 13568(a), added cls. (i)

and (ii) and struck out former cls. (i) and (ii) which read as

follows:

"(i) with respect to claims received in the 3-month period

beginning July 1, 1988, 10 days, and

"(ii) with respect to claims received in the 12-month period

beginning October 1, 1988, 14 days."

1990 - Subsec. (f). Pub. L. 101-508 designated existing

provisions as par. (1), redesignated former pars. (1) and (2) as

subpars. (A) and (B), respectively, struck out "Such standards and

criteria" and all that follows, which was executed by striking out

"Such standards and criteria shall be published in the Federal

Register, and opportunity shall be provided for public comment

prior to implementation. Such standards and criteria shall include

with respect to claims for services furnished under this part by

any provider of services other than a hospital whether such agency

or organization is able to process 75 percent of reconsiderations

within 60 days (except in the case of the fiscal year 1989, 66

percent of reconsiderations) and 90 percent of reconsiderations

within 90 days and the extent to which its determinations are

reversed on appeal.", and added par. (2).

1989 - Subsec. (c)(1). Pub. L. 101-239, Sec. 6202(d)(1), inserted

at end "The Secretary may not require, as a condition of entering

into or renewing an agreement under this section or under section

1395hh of this title, that a fiscal intermediary match data

obtained other than in its activities under this part with data

used in the administration of this part for purposes of identifying

situations in which the provisions of section 1395y(b) of this

title may apply."

Subsec. (c)(2)(C). Pub. L. 101-239, Sec. 6003(g)(3)(D)(vi),

inserted "rural primary care hospital," after "hospital,".

Subsec. (k). Pub. L. 101-234 repealed Pub. L. 100-360, Sec.

203(f), and provided that the provisions of law amended or repealed

by such section are restored or revived as if such section had not

been enacted, see 1988 Amendment note below.

1988 - Subsec. (j)(2). Pub. L. 100-360, Sec. 411(e)(1)(B),

inserted "in the case of a request for reconsideration of a

denial," and substituted "the disposition" for "disposition".

Subsec. (k). Pub. L. 100-360, Sec. 203(f), added subsec. (k)

relating to use of regional intermediaries in administration of

benefits.

1987 - Subsec. (c)(1). Pub. L. 100-203, Sec. 4035(a)(1), inserted

at end "The Secretary shall cause to have published in the Federal

Register, by not later than September 1 before each fiscal year,

data, standards, and methodology to be used to establish budgets

for fiscal intermediaries under this section for that fiscal year,

and shall cause to be published in the Federal Register for public

comment, at least 90 days before such data, standards, and

methodology are published, the data, standards, and methodology

proposed to be used."

Subsec. (c)(2)(C). Pub. L. 100-203, Sec. 4085(d)(1), substituted

"hospice program, comprehensive outpatient rehabilitation facility,

or rehabilitation agency" for "or hospice program".

Subsec. (c)(3). Pub. L. 100-203, Sec. 4031(a)(1), added par. (3).

Subsec. (f). Pub. L. 100-203, Sec. 4023(b), inserted at end "Such

standards and criteria shall include with respect to claims for

services furnished under this part by any provider of services

other than a hospital whether such agency or organization is able

to process 75 percent of reconsiderations within 60 days (except in

the case of the fiscal year 1989, 66 percent of reconsiderations)

and 90 percent of reconsiderations within 90 days and the extent to

which its determinations are reversed on appeal."

Subsec. (j). Pub. L. 100-203, Sec. 4032(a), added subsec. (j).

1986 - Subsec. (a). Pub. L. 99-509, Sec. 9352(a)(2), inserted at

end "As used in this subchapter and part B of subchapter XI of this

chapter, the term 'fiscal intermediary' means an agency or

organization with a contract under this section."

Subsec. (c). Pub. L. 99-509, Sec. 9311(b), designated existing

provisions as par. (1) and added par. (2).

1984 - Subsec. (c). Pub. L. 98-369, Sec. 2326(d)(1), inserted

provision that the Secretary, in determining the necessary and

proper cost of administration with respect to each agreement, take

into account the amount that is reasonable and adequate to meet the

costs which must be incurred by an efficiently and economically

operated agency or organization in carrying out the terms of its

agreement.

Subsec. (e)(4). Pub. L. 98-369, Sec. 2326(b), inserted provision

that not later than July 1, 1987, the Secretary limit the number of

regional agencies or organizations to not more than ten.

Subsec. (f). Pub. L. 98-369, Sec. 2326(c)(1), struck out in cl.

(2) ", by regulation," after "Secretary shall establish" and

inserted provision that the standards and criteria be published in

the Federal Register and an opportunity be provided for public

comment prior to implementation.

1982 - Subsec. (e)(5). Pub. L. 97-248 added par. (5).

1980 - Subsec. (e)(2). Pub. L. 96-499, Sec. 930(o)(1), inserted

"(subject to the provisions of paragraph (4))".

Subsec. (e)(4). Pub. L. 96-499, Sec. 930(o)(2), added par. (4).

1977 - Subsec. (a). Pub. L. 95-142, Sec. 14(a)(1), inserted

provisions relating to applicability to providers assigned to the

agency or organization under subsec. (e) of this section.

Subsec. (b). Pub. L. 95-142, Sec. 14(a)(2), substituted

provisions setting forth criteria for agreements by the Secretary

or renewal of such agreements with agencies or organizations, for

provisions setting forth criteria for agreements by the Secretary

with agencies or organizations.

Subsecs. (e), (f). Pub. L. 95-142, Sec. 14(a)(4), (5), added

subsecs. (e) and (f). Former subsecs. (e) and (f) redesignated (g)

and (h), respectively.

Subsec. (g). Pub. L. 95-142, Sec. 14(a)(3), (4), redesignated

former subsec. (e) as (g) and inserted provisions relating to

applicability of standards, etc., developed under subsec. (f) of

this section. Former subsec. (g) redesignated (i).

Subsecs. (h), (i). Pub. L. 95-142, Sec. 14(a)(4), redesignated

former subsecs. (f) and (g) as (h) and (i), respectively.

1972 - Subsec. (a). Pub. L. 92-603 inserted reference to

provisions of section 1395oo of this title.

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by Pub. L. 105-33 applicable to services furnished on

or after Oct. 1, 1997, see section 4201(d) of Pub. L. 105-33, set

out as a note under section 1395f of this title.

EFFECTIVE DATE OF 1994 AMENDMENT

Section 151(b)(4) of Pub. L. 103-432 provided that: "The

amendments made by paragraphs (1) and (2) [amending this section

and section 1395u of this title] shall apply to contracts with

fiscal intermediaries and carriers under title XVIII of the Social

Security Act [this subchapter] for contract years beginning with

1995."

EFFECTIVE DATE OF 1993 AMENDMENT

Section 13568(c) of Pub. L. 103-66 provided that: "The amendments

made by this section [amending this section and section 1395u of

this title] shall apply to claims received on or after October 1,

1993."

EFFECTIVE DATE OF 1989 AMENDMENTS

Section 6202(d)(3) of Pub. L. 101-239 provided that: "The

amendments made by this subsection [amending this section and

section 1395u of this title] shall apply to agreements and

contracts entered into or renewed on or after the date of the

enactment of this Act [Dec. 19, 1989]."

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section

201(c) of Pub. L. 101-234, set out as a note under section 1320a-7a

of this title.

EFFECTIVE DATE OF 1988 AMENDMENT

Amendment by section 203(f) of Pub. L. 100-360 applicable to

items and services furnished on or after Jan. 1, 1990, see section

203(g) of Pub. L. 100-360, set out as a note under section 1320c-3

of this title.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by section 411(e)(1)(B) of Pub. L. 100-360, as

it relates to a provision in the Omnibus Budget Reconciliation Act

of 1987, Pub. L. 100-203, effective as if included in the enactment

of that provision in Pub. L. 100-203, see section 411(a) of Pub. L.

100-360, set out as a Reference to OBRA; Effective Date note under

section 106 of Title 1, General Provisions.

EFFECTIVE DATE OF 1987 AMENDMENT

Section 4031(a)(3)(A) of Pub. L. 100-203 provided that: "The

amendments made by paragraphs (1) and (2) [amending this section

and section 1395u of this title] shall apply to claims received on

or after July 1, 1988."

Section 4032(c)(1) of Pub. L. 100-203, as amended by Pub. L.

100-360, title IV, Sec. 411(e)(1)(C), July 1, 1988, 102 Stat. 775,

provided that:

"(A) The amendment made by subsection (a) [amending this section]

shall apply with respect to claims received on or after January 1,

1988.

"(B) The amendment made by subsection (b) [amending this section]

shall apply with respect to reconsiderations requested on or after

October 1, 1988."

Section 4035(a)(3) of Pub. L. 100-203 provided that: "The

amendments made by this section [amending this section and sections

1395u and 1395hh of this title] shall take effect on the date of

the enactment of this Act [Dec. 22, 1987] and shall apply to

budgets for fiscal years beginning with fiscal year 1989."

Section 4085(d)(2) of Pub. L. 100-203 provided that:

"(A) The amendment made by paragraph (1) [amending this section]

shall apply to claims received on or after the date of enactment of

this Act [Dec. 22, 1987].

"(B) The Secretary of Health and Human Services shall provide for

such timely amendments to agreements under section 1816 [this

section], and regulations, to such extent as may be necessary to

implement the amendment made by paragraph (1)."

EFFECTIVE DATE OF 1986 AMENDMENT

Section 9311(d) of Pub. L. 99-509 provided that:

"(1) Except as provided in paragraph (2), the amendments made by

subsections (b) and (c) [amending this section and section 1395u of

this title] shall apply to claims received on or after November 1,

1986.

"(2) Sections 1816(c)(2)(C)) [sic] and 1842(c)(2)(C) of the

Social Security Act [subsec. (c)(2)(C) of this section and section

1395u(c)(2)(C) of this title], as added by such amendments, shall

apply to claims received on or after April 1, 1987.

"(3) The Secretary of Health and Human Services shall provide for

such timely amendments to agreements under section 1816 of the

Social Security Act [this section] and contracts under section 1842

of such Act [section 1395u of this title], and regulations, to such

extent as may be necessary to implement the provisions of this Act

on a timely basis."

Amendment by section 9352(a)(2) of Pub. L. 99-509 to be

implemented by Secretary of Health and Human Services not later

than 6 months after Oct. 21, 1986, see section 9352(c)(1) of Pub.

L. 99-509, set out as a note under section 1320c-2 of this title.

EFFECTIVE DATE OF 1984 AMENDMENT

Section 2326(d)(3) of Pub. L. 98-369 provided that: "The

amendments made by this subsection [amending this section and

section 1395u of this title] shall apply to agreements and

contracts entered into or renewed after September 30, 1984."

EFFECTIVE DATE OF 1982 AMENDMENT

Amendment by Pub. L. 97-248 applicable to hospice care provided

on or after Nov. 1, 1983, see section 122(h)(1) of Pub. L. 97-248,

as amended, set out as a note under section 1395c of this title.

EFFECTIVE DATE OF 1980 AMENDMENT

Amendment by Pub. L. 96-499 effective Dec. 5, 1980, see section

930(s)(1) of Pub. L. 96-499, set out as a note under section 1395x

of this title.

EFFECTIVE DATE OF 1977 AMENDMENT

Section 14(c), (d) of Pub. L. 95-142 provided that:

"(c) The amendment made by paragraphs (2) and (3) of subsection

(a) [amending this section] to the extent that they require

application of standards, criteria, and procedures developed under

section 1816(f) of the Social Security Act [subsec. (f) of this

section] shall apply to the entering into, renewal, or termination

of agreements on and after October 1, 1978.

"(d) Except as provided in subsection (c), the amendment made by

subsection (a)(2) [amending this section] shall apply to agreements

entered into or renewed on or after the date of enactment of this

Act [Oct. 25, 1977]."

EFFECTIVE DATE OF 1972 AMENDMENT

Amendment by Pub. L. 92-603 applicable with respect to cost

reports of providers of services for accounting periods ending on

or after June 30, 1973, see section 243(c) of Pub. L. 92-603, set

out as an Effective Date note under section 1395oo of this title.

ADVISORY COMMITTEE ON MEDICARE HOME HEALTH CLAIMS

Section 427 of Pub. L. 100-360, which provided that the

Administrator of the Health Care Financing Administration was to

establish an advisory committee to be known as the Advisory

Committee on Medicare Home Health Claims to study the reasons for

the increase in the denial of claims for home health services

during 1986 and 1987, the ramifications of such increase, and the

need to reform the process involved in such denials, was repealed

by Pub. L. 101-234, title III, Sec. 301(a), Dec. 13, 1989, 103

Stat. 1985.

AMENDMENTS TO AGREEMENTS AND CONTRACTS NECESSARY TO IMPLEMENT

SECTION 4031(A) OF PUB. L. 100-203

Section 4031(a)(3)(B) of Pub. L. 100-203 provided that: "The

Secretary of Health and Human Services shall provide for such

timely amendments to agreements under section 1816 of the Social

Security Act [this section] and contracts under section 1842 of

such Act [section 1395u of this title], and regulations, to such

extent as may be necessary to implement the provisions of this

subsection [amending this section and section 1395u of this title]

on a timely basis."

PROHIBITION OF POLICIES OTHER THAN AS PROVIDED BY SECTION 4031 OF

PUB. L. 100-203 INTENDED TO SLOW DOWN MEDICARE PAYMENTS; BUDGET

CONSIDERATIONS

Section 4031(b), (c) of Pub. L. 100-203 provided that:

"(b) Prohibition of Other Policies Intended to Slow Down Medicare

Payments. - Notwithstanding any other provision of law, except as

specifically provided in this section [amending this section and

section 1395u of this title and enacting provisions set out as

notes under this section], the Secretary of Health and Human

Services is not authorized to issue, after the date of the

enactment of this Act [Dec. 22, 1987], and before October 1, 1990,

any final regulation, instruction, or other policy change which is

primarily intended to have the effect of slowing down claims

processing, or delaying payment of claims, under title XVIII of the

Social Security Act [this subchapter].

"(c) Budget Considerations. - For purposes of section 202 of the

Balanced Budget and Emergency Deficit Control Reaffirmation Act of

1987 [2 U.S.C. 909], this section is a necessary (but secondary)

result of a significant policy change."

AMENDMENTS TO AGREEMENTS AND CONTRACTS NECESSARY TO IMPLEMENT

SECTION 4032(A), (B) OF PUB. L. 100-203

Section 4032(c)(2) provided that: "The Secretary of Health and

Human Services shall provide for such timely amendments to

agreements under section 1816 [this section] and contracts under

section 1842 of the Social Security Act [section 1395u of this

title], and regulations, to such extent as may be necessary to

implement the amendments made by subsections (a) and (b) [amending

this section] on a timely basis."

REPLACEMENT OF AGENCY, ORGANIZATION, OR CARRIER PROCESSING MEDICARE

CLAIMS; NUMBER OF AGREEMENTS AND CONTRACTS AUTHORIZED FOR FISCAL

YEARS 1985 THROUGH 1993

Section 2326(a) of Pub. L. 98-369, as amended by Pub. L. 98-617,

Sec. 3(a)(2), Nov. 8, 1984, 98 Stat. 3295; Pub. L. 99-509, title

IX, Sec. 9321(b), Oct. 21, 1986, 100 Stat. 2016; Pub. L. 101-239,

title VI, Sec. 6215(a), Dec. 19, 1989, 103 Stat. 2252; Pub. L.

103-432, title I, Sec. 159(a), Oct. 31, 1994, 108 Stat. 4443,

provided that: "During each fiscal year (beginning with fiscal year

1985 and ending with fiscal year 1993), the Secretary of Health and

Human Services may enter into not more than two agreements under

section 1816 of the Social Security Act [this section], and not

more than two contracts under section 1842 of such Act [section

1395u of this title], on the basis of competitive bidding, without

regard to the nominating process under section 1816(a) of such Act

or cost reimbursement provisions under sections 1816(c) or 1842(c)

of such Act during the term of the agreement. Such procedure may be

used only for the purpose of replacing an agency or organization or

carrier which over a 2-year period of time has been in the lowest

20th percentile of agencies and organizations or carriers having

agreements or contracts under the respective section, as measured

by the Secretary's cost and performance criteria. In addition,

beginning with fiscal year 1990 and any subsequent fiscal year the

Secretary may enter into such additional agreements and contracts

without regard to such cost reimbursement provisions if the fiscal

intermediary or carrier involved and the Secretary agree to waive

such provisions, but the Secretary may not take any action that has

the effect of requiring that the intermediary or carrier agree to

waive such provisions, including requiring such a waiver as a

condition for entering into or renewing such an agreement or

contract. Any agency or organization or carrier selected on the

basis of competitive bidding must perform all of the duties listed

in section 1816(a) of such Act, or the duties listed in paragraphs

(1) through (4) of section 1842(a) of such Act, as the case may be,

and must be a health insuring organization (as determined by the

Secretary)."

[Section 159(b) of Pub. L. 103-432 provided that: "The amendment

made by subsection (a) [amending section 2326(a) of Pub. L. 98-369,

set out above] shall apply beginning with fiscal year 1994."]

[Section 6215(b) of Pub. L. 101-239 provided that: "The

amendments made by subsection (a) [amending section 2326(a) of Pub.

L. 98-369, set out above] shall apply beginning with fiscal year

1990."]

AUDIT AND MEDICAL CLAIMS REVIEW

Section 118 of Pub. L. 97-248, as amended by Pub. L. 99-272,

title IX, Sec. 9216(a), Apr. 7, 1986, 100 Stat. 180, provided that:

"In addition to any funds otherwise provided for payments to

intermediaries and carriers under agreements entered into under

sections 1816 and 1842 of the Social Security Act [this section and

section 1395u of this title], there are transferred from the

Federal Hospital Insurance Trust Fund and the Federal Supplementary

Medical Insurance Fund in such proportions as the Secretary of

Health and Human Services determines to be appropriate, an

additional $45,000,000 for each of fiscal years 1983, 1984, and

1985, and $105,000,000 for each of fiscal years 1986, 1987, and

1988 for payments to such intermediaries and carriers under such

agreements to be used exclusively for purposes of carrying out

provider cost audits, of reviewing medical necessity, and of

recovering third-party liability payments, consistent with the

provisions of sections 1816 and 1842 of the Social Security Act."

[Section 9216(b) of Pub. L. 99-272 provided that: "The amendments

made by subsection (a) [amending section 118 of Pub. L. 97-248, set

out above] shall apply to fiscal years beginning with fiscal year

1986."]

DEVELOPMENTAL DATE FOR STANDARDS, CRITERIA, AND PROCEDURES PURSUANT

TO SUBSEC. (F) OF THIS SECTION

Section 14(b) of Pub. L. 95-142 directed the Secretary of Health,

Education, and Welfare to develop the standards, criteria, and

procedures described in subsection (f) of section 1816 of the

Social Security Act [subsec. (f) of this section] (as added by

subsection (a)(5)) not later than Oct. 1, 1978.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1320a-3, 1320c-2,

1320c-3, 1395g, 1395u, 1395w-27, 1395cc-2, 1395ff, 1395hh, 1395mm,

1395oo, 1395pp, 1395ddd of this title.

-FOOTNOTE-

(!1) So in original. The word "and" probably should not appear.

(!2) So in original. The period probably should be ", and".

-End-

-CITE-

42 USC Sec. 1395i 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395i. Federal Hospital Insurance Trust Fund

-STATUTE-

(a) Creation; deposits; transfers from Treasury

There is hereby created on the books of the Treasury of the

United States a trust fund to be known as the "Federal Hospital

Insurance Trust Fund" (hereinafter in this section referred to as

the "Trust Fund"). The Trust Fund shall consist of such gifts and

bequests as may be made as provided in section 401(i)(1) of this

title, and such amounts as may be deposited in, or appropriated to,

such fund as provided in this part. There are hereby appropriated

to the Trust Fund for the fiscal year ending June 30, 1966, and for

each fiscal year thereafter, out of any moneys in the Treasury not

otherwise appropriated, amounts equivalent to 100 per centum of -

(1) the taxes imposed by sections 3101(b) and 3111(b) of the

Internal Revenue Code of 1986 with respect to wages reported to

the Secretary of the Treasury or his delegate pursuant to

subtitle F of such Code after December 31, 1965, as determined by

the Secretary of the Treasury by applying the applicable rates of

tax under such sections to such wages, which wages shall be

certified by the Commissioner of Social Security on the basis of

records of wages established and maintained by the Commissioner

of Social Security in accordance with such reports; and

(2) the taxes imposed by section 1401(b) of the Internal

Revenue Code of 1986 with respect to self-employment income

reported to the Secretary of the Treasury or his delegate on tax

returns under subtitle F of such Code, as determined by the

Secretary of the Treasury by applying the applicable rate of tax

under such section to such self-employment income, which

self-employment income shall be certified by the Commissioner of

Social Security on the basis of records of self-employment

established and maintained by the Commissioner of Social Security

in accordance with such returns.

The amounts appropriated by the preceding sentence shall be

transferred from time to time from the general fund in the Treasury

to the Trust Fund, such amounts to be determined on the basis of

estimates by the Secretary of the Treasury of the taxes, specified

in the preceding sentence, paid to or deposited into the Treasury;

and proper adjustments shall be made in amounts subsequently

transferred to the extent prior estimates were in excess of or were

less than the taxes specified in such sentence.

(b) Board of Trustees; composition; meetings; duties

With respect to the Trust Fund, there is hereby created a body to

be known as the Board of Trustees of the Trust Fund (hereinafter in

this section referred to as the "Board of Trustees") composed of

the Commissioner of Social Security, the Secretary of the Treasury,

the Secretary of Labor, and the Secretary of Health and Human

Services, all ex officio, and of two members of the public (both of

whom may not be from the same political party), who shall be

nominated by the President for a term of four years and subject to

confirmation by the Senate. A member of the Board of Trustees

serving as a member of the public and nominated and confirmed to

fill a vacancy occurring during a term shall be nominated and

confirmed only for the remainder of such term. An individual

nominated and confirmed as a member of the public may serve in such

position after the expiration of such member's term until the

earlier of the time at which the member's successor takes office or

the time at which a report of the Board is first issued under

paragraph (2) after the expiration of the member's term. The

Secretary of the Treasury shall be the Managing Trustee of the

Board of Trustees (hereinafter in this section referred to as the

"Managing Trustee"). The Administrator of the Health Care Financing

Administration shall serve as the Secretary of the Board of

Trustees. The Board of Trustees shall meet not less frequently than

once each calendar year. It shall be the duty of the Board of

Trustees to -

(1) Hold the Trust Fund;

(2) Report to the Congress not later than the first day of

April of each year on the operation and status of the Trust Fund

during the preceding fiscal year and on its expected operation

and status during the current fiscal year and the next 2 fiscal

years;

(3) Report immediately to the Congress whenever the Board is of

the opinion that the amount of the Trust Fund is unduly small;

and

(4) Review the general policies followed in managing the Trust

Fund, and recommend changes in such policies, including necessary

changes in the provisions of law which govern the way in which

the Trust Fund is to be managed.

The report provided for in paragraph (2) shall include a statement

of the assets of, and the disbursements made from, the Trust Fund

during the preceding fiscal year, an estimate of the expected

income to, and disbursements to be made from, the Trust Fund during

the current fiscal year and each of the next 2 fiscal years, and a

statement of the actuarial status of the Trust Fund. Such report

shall also include an actuarial opinion by the Chief Actuarial

Officer of the Health Care Financing Administration certifying that

the techniques and methodologies used are generally accepted within

the actuarial profession and that the assumptions and cost

estimates used are reasonable. Such report shall be printed as a

House document of the session of the Congress to which the report

is made. A person serving on the Board of Trustees shall not be

considered to be a fiduciary and shall not be personally liable for

actions taken in such capacity with respect to the Trust Fund.

(c) Investment of Trust Fund by Managing Trustee

It shall be the duty of the Managing Trustee to invest such

portion of the Trust Fund as is not, in his judgment, required to

meet current withdrawals. Such investments may be made only in

interest-bearing obligations of the United States or in obligations

guaranteed as to both principal and interest by the United States.

For such purpose such obligations may be acquired (1) on original

issue at the issue price, or (2) by purchase of outstanding

obligations at the market price. The purposes for which obligations

of the United States may be issued under chapter 31 of title 31 are

hereby extended to authorize the issuance at par of public-debt

obligations for purchase by the Trust Fund. Such obligations issued

for purchase by the Trust Fund shall have maturities fixed with due

regard for the needs of the Trust Fund and shall bear interest at a

rate equal to the average market yield (computed by the Managing

Trustee on the basis of market quotations as of the end of the

calendar month next preceding the date of such issue) on all

marketable interest-bearing obligations of the United States then

forming a part of the public debt which are not due or callable

until after the expiration of 4 years from the end of such calendar

month; except that where such average market yield is not a

multiple of one-eighth of 1 per centum, the rate of interest on

such obligations shall be the multiple of one-eighth of 1 per

centum nearest such market yield. The Managing Trustee may purchase

other interest-bearing obligations of the United States or

obligations guaranteed as to both principal and interest by the

United States, on original issue or at the market price, only where

he determines that the purchase of such other obligations is in the

public interest.

(d) Authority of Managing Trustee to sell obligations

Any obligations acquired by the Trust Fund (except public-debt

obligations issued exclusively to the Trust Fund) may be sold by

the Managing Trustee at the market price, and such public-debt

obligations may be redeemed at par plus accrued interest.

(e) Interest on and proceeds from sale or redemption of obligations

The interest on, and the proceeds from the sale or redemption of,

any obligations held in the Trust Fund shall be credited to and

form a part of the Trust Fund.

(f) Payment of estimated taxes

(1) The Managing Trustee is directed to pay from time to time

from the Trust Fund into the Treasury the amount estimated by him

as taxes imposed under section 3101(b) which are subject to refund

under section 6413(c) of the Internal Revenue Code of 1986 with

respect to wages paid after December 31, 1965. Such taxes shall be

determined on the basis of the records of wages established and

maintained by the Commissioner of Social Security in accordance

with the wages reported to the Secretary of the Treasury or his

delegate pursuant to subtitle F of the Internal Revenue Code of

1986, and the Commissioner of Social Security shall furnish the

Managing Trustee such information as may be required by the

Managing Trustee for such purpose. The payments by the Managing

Trustee shall be covered into the Treasury as repayments to the

account for refunding internal revenue collections.

(2) Repayments made under paragraph (1) shall not be available

for expenditures but shall be carried to the surplus fund of the

Treasury. If it subsequently appears that the estimates under such

paragraph in any particular period were too high or too low,

appropriate adjustments shall be made by the Managing Trustee in

future payments.

(g) Transfers from other Funds

There shall be transferred periodically (but not less often than

once each fiscal year) to the Trust Fund from the Federal Old-Age

and Survivors Insurance Trust Fund and from the Federal Disability

Insurance Trust Fund amounts equivalent to the amounts not

previously so transferred which the Secretary of Health and Human

Services shall have certified as overpayments (other than amounts

so certified to the Railroad Retirement Board) pursuant to section

1395gg(b) of this title. There shall be transferred periodically

(but not less often than once each fiscal year) to the Trust Fund

from the Railroad Retirement Account amounts equivalent to the

amounts not previously so transferred which the Secretary of Health

and Human Services shall have certified as overpayments to the

Railroad Retirement Board pursuant to section 1395gg(b) of this

title.

(h) Payments from Trust Fund amounts certified by Secretary

The Managing Trustee shall also pay from time to time from the

Trust Fund such amounts as the Secretary of Health and Human

Services certifies are necessary to make the payments provided for

by this part, and the payments with respect to administrative

expenses in accordance with section 401(g)(1) of this title.

(i) Payment of travel expenses for travel within United States;

reconsideration interviews and proceedings before administrative

law judges

There are authorized to be made available for expenditure out of

the Trust Fund such amounts as are required to pay travel expenses,

either on an actual cost or commuted basis, to parties, their

representatives, and all reasonably necessary witnesses for travel

within the United States (as defined in section 410(i) of this

title) to attend reconsideration interviews and proceedings before

administrative law judges with respect to any determination under

this subchapter. The amount available under the preceding sentence

for payment for air travel by any person shall not exceed the coach

fare for air travel between the points involved unless the use of

first-class accommodations is required (as determined under

regulations of the Secretary) because of such person's health

condition or the unavailability of alternative accommodations; and

the amount available for payment for other travel by any person

shall not exceed the cost of travel (between the points involved)

by the most economical and expeditious means of transportation

appropriate to such person's health condition, as specified in such

regulations. The amount available for payment under this subsection

for travel by a representative to attend an administrative

proceeding before an administrative law judge or other adjudicator

shall not exceed the maximum amount allowable under this subsection

for such travel originating within the geographic area of the

office having jurisdiction over such proceeding.

(j) Loans from other Funds; interest; repayment; report to Congress

(1) If at any time prior to January 1988 the Managing Trustee

determines that borrowing authorized under this subsection is

appropriate in order to best meet the need for financing the

benefit payments from the Federal Hospital Insurance Trust Fund,

the Managing Trustee may, subject to paragraph (5), borrow such

amounts as he determines to be appropriate from either the Federal

Old-Age and Survivors Insurance Trust Fund or the Federal

Disability Insurance Trust Fund for transfer to and deposit in the

Federal Hospital Insurance Trust Fund.

(2) In any case where a loan has been made to the Federal

Hospital Insurance Trust Fund under paragraph (1), there shall be

transferred on the last day of each month after such loan is made,

from such Trust Fund to the lending Trust Fund, the total interest

accrued to such day with respect to the unrepaid balance of such

loan at a rate equal to the rate which the lending Trust Fund would

earn on the amount involved if the loan were an investment under

subsection (c) of this section (even if such an investment would

earn interest at a rate different than the rate earned by

investments redeemed by the lending fund in order to make the

loan).

(3)(A) If in any month after a loan has been made to the Federal

Hospital Insurance Trust Fund under paragraph (1), the Managing

Trustee determines that the assets of such Trust Fund are

sufficient to permit repayment of all or part of any loans made to

such Fund under paragraph (1), he shall make such repayments as he

determines to be appropriate.

(B)(i) If on the last day of any year after a loan has been made

under paragraph (1) by the Federal Old-Age and Survivors Insurance

Trust Fund or the Federal Disability Insurance Trust Fund to the

Federal Hospital Insurance Trust Fund, the Managing Trustee

determines that the Hospital Insurance Trust Fund ratio exceeds 15

percent, he shall transfer from such Trust Fund to the lending

trust fund an amount that -

(I) together with any amounts transferred to another lending

trust fund under this paragraph for such year, will reduce the

Hospital Insurance Trust Fund ratio to 15 percent; and

(II) does not exceed the outstanding balance of such loan.

(ii) Amounts required to be transferred under clause (i) shall be

transferred on the last day of the first month of the year

succeeding the year in which the determination described in clause

(i) is made.

(iii) For purposes of this subparagraph, the term "Hospital

Insurance Trust Fund ratio" means, with respect to any calendar

year, the ratio of -

(I) the balance in the Federal Hospital Insurance Trust Fund,

as of the last day of such calendar year; to

(II) the amount estimated by the Secretary to be the total

amount to be paid from the Federal Hospital Insurance Trust Fund

during the calendar year following such calendar year (other than

payments of interest on, and repayments of, loans from the

Federal Old-Age and Survivors Insurance Trust Fund and the

Federal Disability Insurance Trust Fund under paragraph (1)), and

reducing the amount of any transfer to the Railroad Retirement

Account by the amount of any transfers into such Trust Fund from

the Railroad Retirement Account.

(C)(i) The full amount of all loans made under paragraph (1)

(whether made before or after January 1, 1983) shall be repaid at

the earliest feasible date and in any event no later than December

31, 1989.

(ii) For the period after December 31, 1987 and before January 1,

1990, the Managing Trustee shall transfer each month from the

Federal Hospital Insurance Trust Fund to any Trust Fund that is

owed any amount by the Federal Hospital Insurance Trust Fund on a

loan made under paragraph (1), an amount not less than an amount

equal to (I) the amount owed to such Trust Fund by the Federal

Hospital Insurance Trust Fund at the beginning of such month (plus

the interest accrued on the outstanding balance of such loan during

such month), divided by (II) the number of months elapsing after

the preceding month and before January 1990. The Managing Trustee

may, during this period, transfer larger amounts than prescribed by

the preceding sentence.

(4) The Board of Trustees shall make a timely report to the

Congress of any amounts transferred (including interest payments)

under this subsection.

(5)(A) No amounts may be loaned by the Federal Old-Age and

Survivors Insurance Trust Fund or the Federal Disability Insurance

Trust Fund under paragraph (1) during any month if the OASDI trust

fund ratio for such month is less than 10 percent.

(B) For purposes of this paragraph, the term "OASDI trust fund

ratio" means, with respect to any month, the ratio of -

(i) the combined balance in the Federal Old-Age and Survivors

Insurance Trust Fund and the Federal Disability Insurance Trust

Fund, reduced by the outstanding amount of any loan (including

interest thereon) theretofore made to either such Trust Fund from

the Federal Hospital Insurance Trust Fund under section 401(l) of

this title, as of the last day of the second month preceding such

month, to

(ii) the amount obtained by multiplying by twelve the total

amount which (as estimated by the Secretary) will be paid from

the Federal Old-Age and Survivors Insurance Trust Fund and the

Federal Disability Insurance Trust Fund during the month for

which such ratio is to be determined for all purposes authorized

by section 401 of this title (other than payments of interest on,

or repayments of, loans from the Federal Hospital Insurance Trust

Fund under section 401(l) of this title), but excluding any

transfer payments between such trust funds and reducing the

amount of any transfers to the Railroad Retirement Account by the

amount of any transfers into either such trust fund from that

Account.

(k) Health Care Fraud and Abuse Control Account

(1) Establishment

There is hereby established in the Trust Fund an expenditure

account to be known as the "Health Care Fraud and Abuse Control

Account" (in this subsection referred to as the "Account").

(2) Appropriated amounts to Trust Fund

(A) In general

There are hereby appropriated to the Trust Fund -

(i) such gifts and bequests as may be made as provided in

subparagraph (B);

(ii) such amounts as may be deposited in the Trust Fund as

provided in sections 242(b) and 249(c) of the Health

Insurance Portability and Accountability Act of 1996, and

subchapter XI of this chapter; and

(iii) such amounts as are transferred to the Trust Fund

under subparagraph (C).

(B) Authorization to accept gifts

The Trust Fund is authorized to accept on behalf of the

United States money gifts and bequests made unconditionally to

the Trust Fund, for the benefit of the Account or any activity

financed through the Account.

(C) Transfer of amounts

The Managing Trustee shall transfer to the Trust Fund, under

rules similar to the rules in section 9601 of the Internal

Revenue Code of 1986, an amount equal to the sum of the

following:

(i) Criminal fines recovered in cases involving a Federal

health care offense (as defined in section 24(a) of title

18).

(ii) Civil monetary penalties and assessments imposed in

health care cases, including amounts recovered under this

subchapter and subchapters XI and XIX of this chapter, and

chapter 38 of title 31 (except as otherwise provided by law).

(iii) Amounts resulting from the forfeiture of property by

reason of a Federal health care offense.

(iv) Penalties and damages obtained and otherwise

creditable to miscellaneous receipts of the general fund of

the Treasury obtained under sections 3729 through 3733 of

title 31 (known as the False Claims Act), in cases involving

claims related to the provision of health care items and

services (other than funds awarded to a relator, for

restitution or otherwise authorized by law).

(D) Application

Nothing in subparagraph (C)(iii) shall be construed to limit

the availability of recoveries and forfeitures obtained under

title I of the Employee Retirement Income Security Act of 1974

[29 U.S.C. 1001 et seq.] for the purpose of providing equitable

or remedial relief for employee welfare benefit plans, and for

participants and beneficiaries under such plans, as authorized

under such title.

(3) Appropriated amounts to Account for fraud and abuse control

program, etc.

(A) Departments of Health and Human Services and Justice

(i) In general

There are hereby appropriated to the Account from the Trust

Fund such sums as the Secretary and the Attorney General

certify are necessary to carry out the purposes described in

subparagraph (C), to be available without further

appropriation, in an amount not to exceed -

(I) for fiscal year 1997, $104,000,000,(!1)

(II) for each of the fiscal years 1998 through 2003, the

limit for the preceding fiscal year, increased by 15

percent; and

(III) for each fiscal year after fiscal year 2003, the

limit for fiscal year 2003.

(ii) Medicare and medicaid activities

For each fiscal year, of the amount appropriated in clause

(i), the following amounts shall be available only for the

purposes of the activities of the Office of the Inspector

General of the Department of Health and Human Services with

respect to the Medicare and medicaid programs -

(I) for fiscal year 1997, not less than $60,000,000 and

not more than $70,000,000;

(II) for fiscal year 1998, not less than $80,000,000 and

not more than $90,000,000;

(III) for fiscal year 1999, not less than $90,000,000 and

not more than $100,000,000;

(IV) for fiscal year 2000, not less than $110,000,000 and

not more than $120,000,000;

(V) for fiscal year 2001, not less than $120,000,000 and

not more than $130,000,000;

(VI) for fiscal year 2002, not less than $140,000,000 and

not more than $150,000,000; and

(VII) for each fiscal year after fiscal year 2002, not

less than $150,000,000 and not more than $160,000,000.

(B) Federal Bureau of Investigation

There are hereby appropriated from the general fund of the

United States Treasury and hereby appropriated to the Account

for transfer to the Federal Bureau of Investigation to carry

out the purposes described in subparagraph (C), to be available

without further appropriation -

(i) for fiscal year 1997, $47,000,000;

(ii) for fiscal year 1998, $56,000,000;

(iii) for fiscal year 1999, $66,000,000;

(iv) for fiscal year 2000, $76,000,000;

(v) for fiscal year 2001, $88,000,000;

(vi) for fiscal year 2002, $101,000,000; and

(vii) for each fiscal year after fiscal year 2002,

$114,000,000.

(C) Use of funds

The purposes described in this subparagraph are to cover the

costs (including equipment, salaries and benefits, and travel

and training) of the administration and operation of the health

care fraud and abuse control program established under section

1320a-7c(a) of this title, including the costs of -

(i) prosecuting health care matters (through criminal,

civil, and administrative proceedings);

(ii) investigations;

(iii) financial and performance audits of health care

programs and operations;

(iv) inspections and other evaluations; and

(v) provider and consumer education regarding compliance

with the provisions of subchapter XI of this chapter.

(4) Appropriated amounts to Account for Medicare Integrity

Program

(A) In general

There are hereby appropriated to the Account from the Trust

Fund for each fiscal year such amounts as are necessary to

carry out the Medicare Integrity Program under section 1395ddd

of this title, subject to subparagraph (B) and to be available

without further appropriation.

(B) Amounts specified

The amount appropriated under subparagraph (A) for a fiscal

year is as follows:

(i) For fiscal year 1997, such amount shall be not less

than $430,000,000 and not more than $440,000,000.

(ii) For fiscal year 1998, such amount shall be not less

than $490,000,000 and not more than $500,000,000.

(iii) For fiscal year 1999, such amount shall be not less

than $550,000,000 and not more than $560,000,000.

(iv) For fiscal year 2000, such amount shall be not less

than $620,000,000 and not more than $630,000,000.

(v) For fiscal year 2001, such amount shall be not less

than $670,000,000 and not more than $680,000,000.

(vi) For fiscal year 2002, such amount shall be not less

than $690,000,000 and not more than $700,000,000.

(vii) For each fiscal year after fiscal year 2002, such

amount shall be not less than $710,000,000 and not more than

$720,000,000.

(5) Annual report

Not later than January 1, the Secretary and the Attorney

General shall submit jointly a report to Congress which

identifies -

(A) the amounts appropriated to the Trust Fund for the

previous fiscal year under paragraph (2)(A) and the source of

such amounts; and

(B) the amounts appropriated from the Trust Fund for such

year under paragraph (3) and the justification for the

expenditure of such amounts.

(6) GAO report

Not later than June 1, 1998, and January 1 of 2000, 2002, and

2004, the Comptroller General of the United States shall submit a

report to Congress which -

(A) identifies -

(i) the amounts appropriated to the Trust Fund for the

previous two fiscal years under paragraph (2)(A) and the

source of such amounts; and

(ii) the amounts appropriated from the Trust Fund for such

fiscal years under paragraph (3) and the justification for

the expenditure of such amounts;

(B) identifies any expenditures from the Trust Fund with

respect to activities not involving the Medicare program under

this subchapter;

(C) identifies any savings to the Trust Fund, and any other

savings, resulting from expenditures from the Trust Fund; and

(D) analyzes such other aspects of the operation of the Trust

Fund as the Comptroller General of the United States considers

appropriate.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1817, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 299; amended

Pub. L. 90-248, title I, Sec. 169(a), Jan. 2, 1968, 81 Stat. 875;

Pub. L. 92-603, title I, Sec. 132(d), Oct. 30, 1972, 86 Stat. 1361;

Pub. L. 95-292, Sec. 5, June 13, 1978, 92 Stat. 315; Pub. L.

96-265, title III, Sec. 310(c), June 9, 1980, 94 Stat. 460; Pub. L.

97-123, Sec. 1(b), Dec. 29, 1981, 95 Stat. 1659; Pub. L. 98-21,

title I, Secs. 141(b), 142(b)(1), (2)(A), (3), (4), 154(b), title

III, Sec. 341(b), Apr. 20, 1983, 97 Stat. 98, 100, 101, 107, 135;

Pub. L. 98-369, div. B, title III, Secs. 2337(a), 2354(b)(2), title

VI, Sec. 2663(j)(2)(F)(i), July 18, 1984, 98 Stat. 1091, 1100,

1170; Pub. L. 99-272, title IX, Sec. 9213(b), Apr. 7, 1986, 100

Stat. 180; Pub. L. 99-514, Sec. 2, Oct. 22, 1986, 100 Stat. 2095;

Pub. L. 100-360, title II, Sec. 212(c)(3), July 1, 1988, 102 Stat.

741; Pub. L. 100-647, title VIII, Sec. 8005(a), Nov. 10, 1988, 102

Stat. 3781; Pub. L. 101-234, title II, Sec. 202(a), Dec. 13, 1989,

103 Stat. 1981; Pub. L. 101-508, title V, Sec. 5106(c), Nov. 5,

1990, 104 Stat. 1388-268; Pub. L. 103-296, title I, Sec. 108(c)(1),

Aug. 15, 1994, 108 Stat. 1485; Pub. L. 104-191, title II, Sec.

201(b), Aug. 21, 1996, 110 Stat. 1993; Pub. L. 105-33, title IV,

Sec. 4318, Aug. 5, 1997, 111 Stat. 392; Pub. L. 106-113, div. B,

Sec. 1000(a)(6) [title III, Sec. 321(j)(1)], Nov. 29, 1999, 113

Stat. 1536, 1501A-366.)

-REFTEXT-

REFERENCES IN TEXT

The Internal Revenue Code of 1986, referred to in subsecs.

(a)(1), (2), (f)(1), and (k)(2)(C), is classified generally to

Title 26, Internal Revenue Code. Subtitle F of such Code appears at

section 6001 et seq. of Title 26.

Sections 242(b) and 249(b) of the Health Insurance Portability

and Accountability Act of 1996, referred to in subsec.

(k)(2)(A)(ii), are sections 242(b) and 249(b) of Pub. L. 104-191,

which are set out as notes under this section.

The Employee Retirement Income Security Act of 1974, referred to

in subsec. (k)(2)(D), is Pub. L. 93-406, Sept. 2, 1974, 88 Stat.

832, as amended. Title I of the Act is classified generally to

subchapter I (Sec. 1001 et seq.) of chapter 18 of Title 29, Labor.

For complete classification of this Act to the Code, see Short

Title note set out under section 1001 of Title 29 and Tables.

-MISC1-

AMENDMENTS

1999 - Subsec. (k)(2)(C)(i). Pub. L. 106-113 substituted "section

24(a)" for "section 982(a)(6)(B)".

1997 - Subsec. (k)(6). Pub. L. 105-33 inserted "June 1, 1998,

and" after "Not later than" in introductory provisions.

1996 - Subsec. (k). Pub. L. 104-191 added subsec. (k).

1994 - Subsec. (a). Pub. L. 103-296, Sec. 108(c)(1)(A),

substituted "Commissioner of Social Security" for "Secretary of

Health and Human Services" wherever appearing.

Subsec. (b). Pub. L. 103-296, Sec. 108(c)(1)(B), inserted "the

Commissioner of Social Security," after "composed of" in

introductory provisions.

Subsec. (f)(1). Pub. L. 103-296, Sec. 108(c)(1)(C), substituted

"Commissioner of Social Security" for "Secretary of Health and

Human Services" in two places.

1990 - Subsec. (i). Pub. L. 101-508 inserted at end "The amount

available for payment under this subsection for travel by a

representative to attend an administrative proceeding before an

administrative law judge or other adjudicator shall not exceed the

maximum amount allowable under this subsection for such travel

originating within the geographic area of the office having

jurisdiction over such proceeding."

1989 - Subsec. (b). Pub. L. 101-234 repealed Pub. L. 100-360,

Sec. 212(c)(3), and provided that the provisions of law amended or

repealed by such section are restored or revised as if such section

had not been enacted, see 1988 Amendment note below.

1988 - Subsec. (b). Pub. L. 100-647 inserted after first sentence

"A member of the Board of Trustees serving as a member of the

public and nominated and confirmed to fill a vacancy occurring

during a term shall be nominated and confirmed only for the

remainder of such term. An individual nominated and confirmed as a

member of the public may serve in such position after the

expiration of such member's term until the earlier of the time at

which the member's successor takes office or the time at which a

report of the Board is first issued under paragraph (2) after the

expiration of the member's term."

Pub. L. 100-360 inserted after sixth sentence "Such report shall

also identify (and treat separately) those outlays from the Trust

Fund which are also outlays from the Medicare Catastrophic Coverage

Account created under section 1395t-2 of this title and those

outlays for which there are amounts transferred into the Federal

Hospital Insurance Catastrophic Coverage Reserve Fund."

1986 - Subsec. (a)(1), (2). Pub. L. 99-514 substituted "Internal

Revenue Code of 1986" for "Internal Revenue Code of 1954".

Subsec. (b). Pub. L. 99-272 struck out provision at end of

penultimate sentence that certification shall not refer to economic

assumptions underlying Trustee's report.

Subsec. (f)(1). Pub. L. 99-514 substituted "Internal Revenue Code

of 1986" for "Internal Revenue Code of 1954" wherever appearing.

1984 - Subsec. (a). Pub. L. 98-369, Sec. 2337(a), in provisions

following par. (2) substituted "from time to time" for "monthly on

the first day of each calendar month", "paid to or deposited into

the Treasury" for "to be paid to or deposited into the Treasury

during such month", and struck out provision that all amounts

transferred to the Trust Fund under the preceding sentence had to

be invested by the Managing Trustee in the same manner and to the

same extent as the other assets of the Trust Fund, and the Trust

Fund had to pay interest to the general fund on the amount so

transferred on the first day of any month at a rate (calculated on

a daily basis, and applied against the difference between the

amount so transferred on such first day and the amount which would

have been transferred to the Trust Fund up to that day under the

procedures in effect on January 1, 1983) equal to the rate earned

by the investments of the Trust Fund in the same month under

subsec. (c).

Subsec. (a)(1), (2). Pub. L. 98-369, Sec. 2663(j)(2)(F)(i),

substituted "Health and Human Services" for "Health, Education, and

Welfare" wherever appearing.

Subsec. (c). Pub. L. 98-369, Sec. 2354(b)(2), substituted "under

chapter 31 of title 31" for "under the Second Liberty Bond Act, as

amended".

Subsecs. (f)(1), (g), (h). Pub. L. 98-369, Sec. 2663(j)(2)(F)(i),

substituted "Health and Human Services" for "Health, Education, and

Welfare" wherever appearing.

1983 - Subsec. (a). Pub. L. 98-21, Sec. 141(b)(1)(A), in

provisions following par. (2) substituted "monthly on the first day

of each calendar month" for "from time to time", substituted "to be

paid to or deposited into the Treasury during such month" for "paid

to or deposited into the Treasury", and inserted provision that all

amounts transferred to the Trust Fund under existing provisions

shall be invested by the Managing Trustee in the same manner and to

the same extent as the other assets of the Trust Fund; and the

Trust Fund shall pay interest to the general fund on the amount so

transferred on the first day of any month at a rate (calculated on

a daily basis, and applied against the difference between the

amount so transferred on such first day and the amount which would

have been transferred to the Trust Fund up to that day under the

procedures in effect on Jan. 1, 1983) equal to the rate earned by

the investments of the Trust Fund in the same month under

subsection (c).

Subsec. (b). Pub. L. 98-21, Sec. 341(b)(1), substituted in

provisions preceding par. (1) "Secretary of Health and Human

Services, all ex officio, and of two members of the public (both of

whom may not be from the same political party), who shall be

nominated by the President for a term of four years and subject to

confirmation by the Senate" for "Secretary of Health, Education,

and Welfare, all ex officio".

Pub. L. 98-21, Sec. 154(b), inserted at end provision that the

report referred to in par. (2) shall also include an actuarial

opinion by the Chief Actuarial Officer of the Health Care Financing

Administration certifying that the techniques and methodologies

used are generally accepted within the actuarial profession and

that the assumptions and cost estimates used are reasonable and

provided further that the certification shall not refer to economic

assumptions underlying the Trustee's report.

Pub. L. 98-21, Sec. 341(b)(2), inserted at end provision that a

person serving on the Board of Trustees shall not be considered to

be a fiduciary and shall not be personally liable for actions taken

in such capacity with respect to the Trust Fund.

Subsec. (j)(1). Pub. L. 98-21, Sec. 142(b)(1), substituted

reference to January 1988 for reference to January 1983 and

inserted ", subject to paragraph (5)," after "may".

Subsec. (j)(2). Pub. L. 98-21, Sec. 142(b)(2)(A), substituted "on

the last day of each month after such loan is made" for "from time

to time", substituted "the total interest accrued to such day" for

"interest", and inserted "(even if such an investment would earn

interest at a rate different than the rate earned by investments

redeemed by the lending fund in order to make the loan)".

Subsec. (j)(3)(A). Pub. L. 98-21, Sec. 142(b)(3), designated

existing provisions as subpar. (A) and added subpars. (B) and (C).

Subsec. (j)(5). Pub. L. 98-21, Sec. 142(b)(4), added par. (5).

1981 - Subsec. (j). Pub. L. 97-123 added subsec. (j).

1980 - Subsec. (i). Pub. L. 96-265 added subsec. (i).

1978 - Subsec. (b). Pub. L. 95-292 substituted "Administrator of

the Health Care Financing Administration" for "Commissioner of

Social Security" in provisions preceding par. (1).

1972 - Subsec. (a). Pub. L. 92-603 inserted "such gifts and

bequests as may be made as provided in section 401(i)(1) of this

title, and" after "consist of" and before "such amounts" in

provisions preceding par. (1).

1968 - Subsec. (b)(2). Pub. L. 90-248 substituted "April" for

"March".

EFFECTIVE DATE OF 1999 AMENDMENT

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec.

321(j)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-366, provided

that: "The amendment made by this subsection [amending this

section] shall take effect as if included in the amendment made by

section 201 of the Health Insurance Portability and Accountability

Act of 1996 (Public Law 104-191; 110 Stat. 1992)."

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by Pub. L. 103-296 effective Mar. 31, 1995, see section

110(a) of Pub. L. 103-296, set out as a note under section 401 of

this title.

EFFECTIVE DATE OF 1990 AMENDMENT

Amendment by Pub. L. 101-508 applicable with respect to

determinations made on or after July 1, 1991, and to reimbursement

for travel expenses incurred on or after Apr. 1, 1991, see section

5106(d) of Pub. L. 101-508, set out as a note under section 401 of

this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section

202(b) of Pub. L. 100-234, set out as a note under section 401 of

this title.

EFFECTIVE DATE OF 1988 AMENDMENT

Amendment by Pub. L. 100-647 applicable to members of Board of

Trustees of Federal Hospital Insurance Trust Fund serving on such

Board as members of the public on or after Nov. 10, 1988, see

section 8005(b) of Pub. L. 100-647, set out as a note under section

401 of this title.

EFFECTIVE DATE OF 1984 AMENDMENT

Section 2337(b) of Pub. L. 98-369 provided that: "The amendments

made by subsection (a) [amending this section] shall become

effective on the first day of the month following the month in

which this Act is enacted [July 1984]."

Amendment by section 2354(b)(2) of Pub. L. 98-369 effective July

18, 1984, but not to be construed as changing or affecting any

right, liability, status, or interpretation which existed (under

the provisions of law involved) before that date, see section

2354(e)(1) of Pub. L. 98-369, set out as a note under section

1320a-1 of this title.

Amendment by section 2663(j)(2)(F)(i) of Pub. L. 98-369 effective

July 18, 1984, but not to be construed as changing or affecting any

right, liability, status, or interpretation which existed (under

the provisions of law involved) before that date, see section

2664(b) of Pub. L. 98-369, set out as a note under section 401 of

this title.

EFFECTIVE DATE OF 1983 AMENDMENT

Amendment by section 141(b) of Pub. L. 98-21 effective on first

day of month following April 1983, see section 141(c) of Pub. L.

98-21, set out as a note under section 401 of this title.

Section 142(b)(2)(B) of Pub. L. 98-21 provided that: "The

amendment made by this paragraph [amending this section] shall

apply with respect to months beginning more than 30 days after the

date of enactment of this Act [Apr. 20, 1983]."

Amendment by sections 154(b) and 341(b) of Pub. L. 98-21

effective Apr. 20, 1983, see sections 154(e) and 341(d) of Pub. L.

98-21, set out as notes under section 401 of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Amendment by Pub. L. 97-123 effective Dec. 29, 1981, see section

1(c) of Pub. L. 97-123, set out as a note under section 401 of this

title.

EFFECTIVE DATE OF 1978 AMENDMENT

Amendment by Pub. L. 95-292 effective with respect to services,

supplies, and equipment furnished after the third calendar month

beginning after June 13, 1978, except that provisions for the

implementation of an incentive reimbursement system for dialysis

services furnished in facilities and providers to become effective

with respect to a facility's or provider's first accounting period

beginning after the last day of the twelfth month following the

month of June 1978, and except that provisions for reimbursement

rates for home dialysis to become effective on Apr. 1, 1979, see

section 6 of Pub. L. 95-292, set out as a note under section 426 of

this title.

EFFECTIVE DATE OF 1972 AMENDMENT

Amendment by Pub. L. 92-603 applicable with respect to gifts and

bequests received after Oct. 30, 1972, see section 132(f) of Pub.

L. 92-603, set out as a note under section 401 of this title.

TERMINATION OF REPORTING REQUIREMENTS

For termination, effective May 15, 2000, of provisions of law

requiring submittal to Congress of any annual, semiannual, or other

regular periodic report listed in House Document No. 103-7 (in

which certain reporting requirements under subsec. (b)(2) of this

section are listed in item 7 on page 143), see section 3003 of Pub.

L. 104-66, as amended, and section 1(a)(4) [div. A, Sec. 1402(1)]

of Pub. L. 106-554, set out as notes under section 1113 of Title

31, Money and Finance.

CRIMINAL FINES DEPOSITED IN FEDERAL HOSPITAL INSURANCE TRUST FUND

Section 242(b) of Pub. L. 104-191 provided that: "The Secretary

of the Treasury shall deposit into the Federal Hospital Insurance

Trust Fund pursuant to section 1817(k)(2)(C) of the Social Security

Act (42 U.S.C. 1395i) an amount equal to the criminal fines imposed

under section 1347 of title 18, United States Code (relating to

health care fraud)."

PROPERTY FORFEITED DEPOSITED IN FEDERAL HOSPITAL INSURANCE TRUST

FUND

Section 249(c) of Pub. L. 104-191 provided that:

"(1) In general. - After the payment of the costs of asset

forfeiture has been made and after all restoration payments (if

any) have been made, and notwithstanding any other provision of

law, the Secretary of the Treasury shall deposit into the Federal

Hospital Insurance Trust Fund pursuant to section 1817(k)(2)(C) of

the Social Security Act [subsec. (k)(2)(C) of this section], as

added by section 301(b), an amount equal to the net amount realized

from the forfeiture of property by reason of a Federal health care

offense pursuant to section 982(a)(6) of title 18, United States

Code.

"(2) Costs of asset forfeiture. - For purposes of paragraph (1),

the term 'payment of the costs of asset forfeiture' means -

"(A) the payment, at the discretion of the Attorney General, of

any expenses necessary to seize, detain, inventory, safeguard,

maintain, advertise, sell, or dispose of property under seizure,

detention, or forfeited, or of any other necessary expenses

incident to the seizure, detention, forfeiture, or disposal of

such property, including payment for -

"(i) contract services;

"(ii) the employment of outside contractors to operate and

manage properties or provide other specialized services

necessary to dispose of such properties in an effort to

maximize the return from such properties; and

"(iii) reimbursement of any Federal, State, or local agency

for any expenditures made to perform the functions described in

this subparagraph;

"(B) at the discretion of the Attorney General, the payment of

awards for information or assistance leading to a civil or

criminal forfeiture involving any Federal agency participating in

the Health Care Fraud and Abuse Control Account;

"(C) the compromise and payment of valid liens and mortgages

against property that has been forfeited, subject to the

discretion of the Attorney General to determine the validity of

any such lien or mortgage and the amount of payment to be made,

and the employment of attorneys and other personnel skilled in

State real estate law as necessary;

"(D) payment authorized in connection with remission or

mitigation procedures relating to property forfeited; and

"(E) the payment of State and local property taxes on forfeited

real property that accrued between the date of the violation

giving rise to the forfeiture and the date of the forfeiture

order.

"(3) Restoration payment. - Notwithstanding any other provision

of law, if the Federal health care offense referred to in paragraph

(1) resulted in a loss to an employee welfare benefit plan within

the meaning of section 3(1) of the Employee Retirement Income

Security Act of 1974 [29 U.S.C. 1002(1)], the Secretary of the

Treasury shall transfer to such employee welfare benefit plan, from

the amount realized from the forfeiture of property referred to in

paragraph (1), an amount equal to such loss. For purposes of

paragraph (1), the term 'restoration payment' means the amount

transferred to an employee welfare benefit plan pursuant to this

paragraph."

DUE DATE FOR 1983 REPORT ON OPERATION AND STATUS OF TRUST FUND

Notwithstanding subsec. (b)(2) of this section, the annual report

of the Board of Trustees of the Trust Fund required for calendar

year 1983 under this section may be filed at any time not later

than forty-five days after Apr. 20, 1983, see section 154(d) of

Pub. L. 98-21, set out as a note under section 401 of this title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 401, 417, 426a, 429, 910,

1320a-7a, 1320b-12, 1395b-1, 1395i-1, 1395gg, 1395vv, 1395yy,

1395ggg, 1396m of this title.

-FOOTNOTE-

(!1) So in original. The comma probably should be a semicolon.

-End-

-CITE-

42 USC Sec. 1395i-1 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395i-1. Authorization of appropriations

-STATUTE-

There are authorized to be appropriated to the Federal Hospital

Insurance Trust Fund (established by section 1395i of this title)

from time to time such sums as the Secretary deems necessary for

any fiscal year, on account of -

(1) payments made or to be made during such fiscal year from

such Trust Fund under this part with respect to individuals who

are qualified railroad retirement beneficiaries (as defined in

section 426(c) of this title) and who are not, and upon filing

application for monthly insurance benefits under section 402 of

this title would not be, entitled to such benefits if service as

an employee (as defined in the Railroad Retirement Act of 1937

[45 U.S.C. 228a et seq.]) after December 31, 1936, had been

included in the term "employment" as defined in this chapter,

(2) the additional administrative expenses resulting or

expected to result therefrom, and

(3) any loss of interest to such Trust Fund resulting from the

payment of such amounts,

in order to place such Trust Fund in the same position at the end

of such fiscal year in which it would have been if the individuals

described in paragraph (1) had not been entitled to benefits under

this part.

-SOURCE-

(Pub. L. 89-97, title I, Sec. 111(d), July 30, 1965, 79 Stat. 343.)

-REFTEXT-

REFERENCES IN TEXT

The Railroad Retirement Act of 1937, referred to in text, is act

Aug. 29, 1935, ch. 812, 49 Stat. 867, as amended generally by act

June 24, 1937, ch. 382, part I, 50 Stat. 307, and which was

classified principally to subchapter III (Sec. 228a et seq.) of

chapter 9 of Title 45, Railroads. The Railroad Retirement Act of

1937 was amended generally and redesignated the Railroad Retirement

Act of 1974 by Pub. L. 93-445, title I, Oct. 16, 1974, 88 Stat.

1305. The Railroad Retirement Act of 1974 is classified generally

to subchapter IV (Sec. 231 et seq.) of chapter 9 of title 45. For

complete classification of these Acts to the Code, see Tables.

-COD-

CODIFICATION

Section was enacted as part of the Social Security Amendments of

1965 and also as part of the Health Insurance for the Aged Act, and

not as part of the Social Security Act which comprises this

chapter.

-MISC1-

EFFECTIVE DATE

Section 111(e) of Pub. L. 89-97 provided that:

"(1) The amendments made by the preceding provisions of this

section [enacting this section and section 228s-2 of Title 45,

Railroads, and amending section 1395kk of this title and sections

1401, 3101, 3111, 3201, 3211, and 3221 of Title 26, Internal

Revenue Code, and section 228e of Title 45] shall apply to the

calendar year 1966 or to any subsequent calendar year, but only if

the requirement in paragraph (2) has been met with respect to such

calendar year.

"(2) The requirement referred to in paragraph (1) shall be deemed

to have been met with respect to any calendar year if, as of the

October 1 immediately preceding such calendar year, the Railroad

Retirement Tax Act [section 3101 et seq. of Title 26] provides that

the maximum amount of monthly compensation taxable under such Act

during all months of such calendar year will be an amount equal to

one-twelfth of the maximum wages which the Federal Insurance

Contributions Act [section 3201 et seq. of Title 26] provides may

be counted for such calendar year."

-End-

-CITE-

42 USC Sec. 1395i-1a 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395i-1a. Repealed. Pub. L. 101-234, title I, Sec. 102(a),

Dec. 13, 1989, 103 Stat. 1980

-MISC1-

Section, act Aug. 14, 1935, ch. 531, title XVIII, Sec. 1817A, as

added July 1, 1988, Pub. L. 100-360, title I, Sec. 112(a), 102

Stat. 698, provided for establishment and operation of Federal

Hospital Insurance Catastrophic Coverage Reserve Fund.

EFFECTIVE DATE OF REPEAL

Repeal effective Jan. 1, 1990, see section 102(d)(1) of Pub. L.

101-234, set out as a note under section 59B of Title 26, Internal

Revenue Code.

ADJUSTMENTS FOR INTEREST LOST DUE TO DELAY OF TRANSFERS TO RESERVE

FUND DURING 1989

Section 112(b) of Pub. L. 100-360, which directed Secretary of

the Treasury, in July of 1990, to calculate interest lost to

Federal Hospital Insurance Catastrophic Coverage Reserve Fund due

to lag between outlays (attributable to amendments made by Pub. L.

100-360) from Federal Hospital Insurance Trust Fund during 1989 and

transfers made to such Reserve Fund to cover such outlays, and

provided that appropriations under subsection (a)(2) of this

section include amount so calculated, was repealed by Pub. L.

101-234, title I, Sec. 102(a), Dec. 13, 1989, 103 Stat. 1980.

-End-

-CITE-

42 USC Sec. 1395i-2 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395i-2. Hospital insurance benefits for uninsured elderly

individuals not otherwise eligible

-STATUTE-

(a) Individuals eligible to enroll

Every individual who -

(1) has attained the age of 65,

(2) is enrolled under part B of this subchapter,

(3) is a resident of the United States, and is either (A) a

citizen or (B) an alien lawfully admitted for permanent residence

who has resided in the United States continuously during the 5

years immediately preceding the month in which he applies for

enrollment under this section, and

(4) is not otherwise entitled to benefits under this part,

shall be eligible to enroll in the insurance program established by

this part.

(b) Time, manner, and form of enrollment

An individual may enroll under this section only in such manner

and form as may be prescribed in regulations, and only during an

enrollment period prescribed in or under this section.

(c) Period of enrollment; scope of coverage

The provisions of section 1395p of this title (except subsection

(f) thereof), section 1395q of this title, subsection (b) of

section 1395r of this title, and subsections (f) and (h) of section

1395s of this title shall apply to persons authorized to enroll

under this section except that -

(1) individuals who meet the conditions of subsection (a)(1),

(3), and (4) of this section on or before the last day of the

seventh month after October 1972 may enroll under this part and

(if not already so enrolled) may also enroll under part B of this

subchapter during an initial general enrollment period which

shall begin on the first day of the second month which begins

after October 30, 1972, and shall end on the last day of the

tenth month after October 1972;

(2) in the case of an individual who first meets the conditions

of eligibility under this section on or after the first day of

the eighth month after October 1972, the initial enrollment

period shall begin on the first day of the third month before the

month in which he first becomes eligible and shall end 7 months

later;

(3) in the case of an individual who enrolls pursuant to

paragraph (1) of this subsection, entitlement to benefits shall

begin on -

(A) the first day of the second month after the month in

which he enrolls,

(B) July 1, 1973, or

(C) the first day of the first month in which he meets the

requirements of subsection (a) of this section,

whichever is the latest;

(4) an individual's entitlement under this section shall

terminate with the month before the first month in which he

becomes eligible for hospital insurance benefits under section

426 of this title or section 426a of this title; and upon such

termination, such individual shall be deemed, solely for purposes

of hospital insurance entitlement, to have filed in such first

month the application required to establish such entitlement;

(5) termination of coverage for supplementary medical insurance

shall result in simultaneous termination of hospital insurance

benefits for uninsured individuals who are not otherwise entitled

to benefits under this chapter;

(6) any percent increase effected under section 1395r(b) of

this title in an individual's monthly premium may not exceed 10

percent and shall only apply to premiums paid during a period

equal to twice the number of months in the full 12-month periods

described in that section and shall be subject to reduction in

accordance with subsection (d)(6) of this section;

(7) an individual who meets the conditions of subsection (a) of

this section may enroll under this part during a special

enrollment period that includes any month during any part of

which the individual is enrolled under section 1395mm of this

title with an eligible organization and ending with the last day

of the 8th consecutive month in which the individual is at no

time so enrolled;

(8) in the case of an individual who enrolls during a special

enrollment period under paragraph (7) -

(A) in any month of the special enrollment period in which

the individual is at any time enrolled under section 1395mm of

this title with an eligible organization or in the first month

following such a month, the coverage period shall begin on the

first day of the month in which the individual so enrolls (or,

at the option of the individual, on the first day of any of the

following three months), or

(B) in any other month of the special enrollment period, the

coverage period shall begin on the first day of the month

following the month in which the individual so enrolls; and

(9) in applying the provisions of section 1395r(b) of this

title, there shall not be taken into account months for which the

individual can demonstrate that the individual was enrolled under

section 1395mm of this title with an eligible organization.

(d) Monthly premiums

(1) The Secretary shall, during September of each year (beginning

with 1988), estimate the monthly actuarial rate for months in the

succeeding year. Such actuarial rate shall be one-twelfth of the

amount which the Secretary estimates (on an average, per capita

basis) is equal to 100 percent of the benefits and administrative

costs which will be payable from the Federal Hospital Insurance

Trust Fund for services performed and related administrative costs

incurred in the succeeding year with respect to individuals age 65

and over who will be entitled to benefits under this part during

that year.

(2) The Secretary shall, during September of each year (!1)

determine and promulgate the dollar amount which shall be

applicable for premiums for months occurring in the following year.

Subject to paragraphs (4) and (5), the amount of an individual's

monthly premium under this section shall be equal to the monthly

actuarial rate determined under paragraph (1) for that following

year. Any amount determined under the preceding sentence which is

not a multiple of $1 shall be rounded to the nearest multiple of $1

(or, if it is a multiple of 50 cents but not a multiple of $1, to

the next higher multiple of $1).

(3) Whenever the Secretary promulgates the dollar amount which

shall be applicable as the monthly premium under this section, he

shall, at the time such promulgation is announced, issue a public

statement setting forth the actuarial assumptions and bases

employed by him in arriving at the amount of an adequate actuarial

rate for individuals 65 and older as provided in paragraph (1).

(4)(A) In the case of an individual described in subparagraph

(B), the monthly premium for a month shall be reduced by the

applicable reduction percent specified in the following table:

The applicable

reduction

For a month in: percent is:

1994 25 percent

1995 30 percent

1996 35 percent

1997 40 percent

1998 or subsequent year 45 percent.

(B) An individual described in this subparagraph with respect to

a month is an individual who establishes to the satisfaction of the

Secretary that, as of the last day of the previous month, the

individual -

(i) had at least 30 quarters of coverage under subchapter II of

this chapter;

(ii) was married (and had been married for the previous 1-year

period) to an individual who had at least 30 quarters of coverage

under such subchapter;

(iii) had been married to an individual for a period of at

least 1 year (at the time of such individual's death) if at such

time the individual had at least 30 quarters of coverage under

such subchapter; or

(iv) is divorced from an individual and had been married to the

individual for a period of at least 10 years (at the time of the

divorce) if at such time the individual had at least 30 quarters

of coverage under such subchapter.

(5)(A) The amount of the monthly premium shall be zero in the

case of an individual who is a person described in subparagraph (B)

for a month, if -

(i) the individual's premium under this section for the month

is not (and will not be) paid for, in whole or in part, by a

State (under subchapter XIX of this chapter or otherwise), a

political subdivision of a State, or an agency or instrumentality

of one or more States or political subdivisions thereof; and

(ii) in each of 84 months before such month, the individual was

enrolled in this part under this section and the payment of the

individual's premium under this section for the month was not

paid for, in whole or in part, by a State (under subchapter XIX

of this chapter or otherwise), a political subdivision of a

State, or an agency or instrumentality of one or more States or

political subdivisions thereof.

(B) A person described in this subparagraph for a month is a

person who establishes to the satisfaction of the Secretary that,

as of the last day of the previous month -

(i)(I) the person was receiving cash benefits under a qualified

State or local government retirement system (as defined in

subparagraph (C)) on the basis of the person's employment in one

or more positions covered under any such system, and (II) the

person would have at least 40 quarters of coverage under

subchapter II of this chapter if remuneration for medicare

qualified government employment (as defined in paragraph (1) of

section 410(p) of this title, but determined without regard to

paragraph (3) of such section) paid to such person were treated

as wages paid to such person and credited for purposes of

determining quarters of coverage under section 413 of this title;

(ii)(I) the person was married (and had been married for the

previous 1-year period) to an individual who is described in

clause (i), or (II) the person met the requirement of clause

(i)(II) and was married (and had been married for the previous

1-year period) to an individual described in clause (i)(I);

(iii) the person had been married to an individual for a period

of at least 1 year (at the time of such individual's death) if

(I) the individual was described in clause (i) at the time of the

individual's death, or (II) the person met the requirement of

clause (i)(II) and the individual was described in clause (i)(I)

at the time of the individual's death; or

(iv) the person is divorced from an individual and had been

married to the individual for a period of at least 10 years (at

the time of the divorce) if (I) the individual was described in

clause (i) at the time of the divorce, or (II) the person met the

requirement of clause (i)(II) and the individual was described in

clause (i)(I) at the time of the divorce.

(C) For purposes of subparagraph (B)(i)(I), the term "qualified

State or local government retirement system" means a retirement

system that -

(i) is established or maintained by a State or political

subdivision thereof, or an agency or instrumentality of one or

more States or political subdivisions thereof;

(ii) covers positions of some or all employees of such a State,

subdivision, agency, or instrumentality; and

(iii) does not adjust cash retirement benefits based on

eligibility for a reduction in premium under this paragraph.

(6)(A) In the case where a State, a political subdivision of a

State, or an agency or instrumentality of a State or political

subdivision thereof determines to pay, for the life of each

individual, the monthly premiums due under paragraph (1) on behalf

of each of the individuals in a qualified State or local government

retiree group who meets the conditions of subsection (a) of this

section, the amount of any increase otherwise applicable under

section 1395r(b) of this title (as applied and modified by

subsection (c)(6) of this section) with respect to the monthly

premium for benefits under this part for an individual who is a

member of such group shall be reduced by the total amount of taxes

paid under section 3101(b) of the Internal Revenue Code of 1986 by

such individual and under section 3111(b) by the employers of such

individual on behalf of such individual with respect to employment

(as defined in section 3121(b) of such Code).

(B) For purposes of this paragraph, the term "qualified State or

local government retiree group" means all of the individuals who

retire prior to a specified date that is before January 1, 2002,

from employment in one or more occupations or other broad classes

of employees of -

(i) the State;

(ii) a political subdivision of the State; or

(iii) an agency or instrumentality of the State or political

subdivision of the State.

(e) Contract or other arrangement for payment of monthly premiums

Payment of the monthly premiums on behalf of any individual who

meets the conditions of subsection (a) of this section may be made

by any public or private agency or organization under a contract or

other arrangement entered into between it and the Secretary if the

Secretary determines that payment of such premiums under such

contract or arrangement is administratively feasible.

(f) Deposit of amounts into Treasury

Amounts paid to the Secretary for coverage under this section

shall be deposited in the Treasury to the credit of the Federal

Hospital Insurance Trust Fund.

(g) Buy-in under this part for qualified medicare beneficiaries

(1) The Secretary shall, at the request of a State made after

1989, enter into a modification of an agreement entered into with

the State pursuant to section 1395v(a) of this title under which

the agreement provides for enrollment in the program established by

this part of qualified medicare beneficiaries (as defined in

section 1396d(p)(1) of this title).

(2)(A) Except as provided in subparagraph (B), the provisions of

subsections (c), (d), (e), and (f) of section 1395v of this title

shall apply to qualified medicare beneficiaries enrolled, pursuant

to such agreement, in the program established by this part in the

same manner and to the same extent as they apply to qualified

medicare beneficiaries enrolled, pursuant to such agreement, in

part B of this subchapter.

(B) For purposes of this subsection, section 1395v(d)(1) of this

title shall be applied by substituting "section 1395i-2 of this

title" for "section 1395r of this title" and "subsection (c)(6)

(with reference to subsection (b) of section 1395r of this title)"

for "subsection (b).".(!2)

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1818, as added Pub. L.

92-603, title II, Sec. 202, Oct. 30, 1972, 86 Stat. 1374; amended

Pub. L. 98-21, title VI, Sec. 606(a)(3)(D), (b), Apr. 20, 1983, 97

Stat. 170, 171; Pub. L. 98-369, div. B, title III, Secs. 2315(e),

2354(b)(3), (4), July 18, 1984, 98 Stat. 1080, 1100; Pub. L.

99-272, title IX, Sec. 9124(a), Apr. 7, 1986, 100 Stat. 168; Pub.

L. 100-203, title IV, Sec. 4009(j)(9), Dec. 22, 1987, as added Pub.

L. 100-360, title IV, Sec. 411(b)(8)(D), July 1, 1988, 102 Stat.

772; Pub. L. 100-360, title I, Sec. 103, July 1, 1988, 102 Stat.

687; Pub. L. 100-485, title VI, Sec. 608(d)(2), Oct. 13, 1988, 102

Stat. 2413; Pub. L. 101-239, title VI, Secs. 6012(a)(1), 6013(a),

Dec. 19, 1989, 103 Stat. 2161, 2163; Pub. L. 101-508, title IV,

Sec. 4008(g)(1), (m)(3)(D), Nov. 5, 1990, 104 Stat. 1388-45,

1388-54; Pub. L. 103-66, title XIII, Sec. 13508(a), Aug. 10, 1993,

107 Stat. 579; Pub. L. 105-33, title IV, Sec. 4453(a), Aug. 5,

1997, 111 Stat. 425; Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec.

331(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A-502.)

-REFTEXT-

REFERENCES IN TEXT

Part B of this subchapter, referred to in subsecs. (a)(2),

(c)(1), and (g)(2)(A), is classified to section 1395j et seq. of

this title.

The Internal Revenue Code of 1986, referred to in subsec.

(d)(6)(A), is classified generally to Title 26, Internal Revenue

Code.

-MISC1-

AMENDMENTS

2000 - Subsec. (c)(6). Pub. L. 106-554, Sec. 1(a)(6) [title III,

Sec. 331(a)(1)], inserted "and shall be subject to reduction in

accordance with subsection (d)(6) of this section" before

semicolon.

Subsec. (d)(6). Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec.

331(a)(2)], added par. (6).

1997 - Subsec. (d)(2). Pub. L. 105-33, Sec. 4453(a)(1),

substituted "paragraphs (4) and (5)" for "paragraph (4)".

Subsec. (d)(5). Pub. L. 105-33, Sec. 4453(a)(2), added par. (5).

1993 - Subsec. (d)(2). Pub. L. 103-66, Sec. 13508(a)(1),

substituted "Subject to paragraph (4), the amount of an

individual's monthly premium under this section" for "Such amount".

Subsec. (d)(4). Pub. L. 103-66, Sec. 13508(a)(2), added par. (4).

1990 - Subsec. (c)(7) to (9). Pub. L. 101-508, Sec. 4008(g)(1),

added pars. (7) to (9).

Subsec. (g)(2)(B). Pub. L. 101-508, Sec. 4008(m)(3)(D),

substituted " 'subsection (c)(6)" for " 'subsection (c)".

1989 - Pub. L. 101-239, Sec. 6012(a)(1), inserted "elderly" after

"uninsured" in section catchline.

Subsec. (g). Pub. L. 101-239, Sec. 6013(a), added subsec. (g).

1988 - Subsec. (c)(4) to (7). Pub. L. 100-360, Sec. 411(b)(8)(D),

added Pub. L. 100-203, Sec. 4009(j)(9), see 1987 Amendment note

below.

Subsec. (d). Pub. L. 100-360, Sec. 103, amended subsec. (d)

generally. Prior to amendment, subsec. (d) read as follows:

"(1) The monthly premium of each individual for each month in his

coverage period before July 1974 shall be $33.

"(2) The Secretary shall, during the next to last calendar

quarter of each year determine and promulgate the dollar amount

(whether or not such dollar amount was applicable for premiums for

any prior month) which shall be applicable for premiums for months

occurring in the following calendar year. Such amount shall be

equal to $33, multiplied by the ratio of (A) the inpatient hospital

deductible for that following calendar year, as promulgated under

section 1395e(b)(2) of this title, to (B) such deductible

promulgated for 1973. Any amount determined under the preceding

sentence which is not a multiple of $1 shall be rounded to the

nearest multiple of $1, or, if a multiple of 50 cents but not a

multiple of $1, to the next higher multiple of $1."

Subsec. (d)(1). Pub. L. 100-485 substituted "during that year"

for "during that entire year".

1987 - Subsec. (c)(4) to (7). Pub. L. 100-203, Sec. 4009(j)(9),

as added by Pub. L. 100-360, Sec. 411(b)(8)(D), redesignated pars.

(5) to (7) as (4) to (6), respectively, and struck out former par.

(4) which read as follows: "termination of coverage under this

section by the filing of notice that the individual no longer

wishes to participate in the hospital insurance program shall take

effect at the close of the month following the month in which such

notice is filed;".

1986 - Subsec. (c)(7). Pub. L. 99-272 added par. (7).

1984 - Subsec. (c). Pub. L. 98-369, Sec. 2315(e), substituted

"subsection (b) of section 1395r of this title" for "subsection (a)

of section 1395r of this title".

Subsec. (c)(1). Pub. L. 98-369, Sec. 2354(b)(3), substituted

"October 1972" for "the month in which this Act is enacted".

Subsec. (d)(2). Pub. L. 98-369, Sec. 2354(b)(4), substituted ",

if a multiple of 50 cents but not a multiple of $1," for "if midway

between multiples of $1".

1983 - Subsec. (c). Pub. L. 98-21, Sec. 606(a)(3)(D), substituted

"subsection (a) of section 1395r" for "subsection (c) of section

1395r".

Subsec. (d)(2). Pub. L. 98-21, Sec. 606(b), substituted "during

the next to last calendar quarter of each year" for "during the

last calendar quarter of each year, beginning in 1973,", "the

following calendar year" for "the 12-month period commencing July 1

of the next year", and "for that following calendar year" for "for

such next year".

EFFECTIVE DATE OF 2000 AMENDMENT

Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 331(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-502, provided that: "The amendments

made by subsection (a) [amending this section] shall apply to

premiums for months beginning with January 1, 2002."

EFFECTIVE DATE OF 1997 AMENDMENT

Section 4453(b) of Pub. L. 105-33 provided that: "The amendments

made by subsection (a) [amending this section] shall apply to

premiums for months beginning with January 1998, and months before

such month may be taken into account for purposes of meeting the

requirement of section 1818(d)(5)(B)(iii) of the Social Security

Act [subsec. (d)(5)(B)(iii) of this section], as added by

subsection (a)."

EFFECTIVE DATE OF 1993 AMENDMENT

Section 13508(b) of Pub. L. 103-66 provided that: "The amendments

made by this section [amending this section] shall apply to monthly

premiums under section 1818 of the Social Security Act [this

section] for months beginning with January 1, 1994."

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4008(g)(2) of Pub. L. 101-508 provided that: "The

amendment made by paragraph (1) [amending this section] shall take

effect on February 1, 1991."

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by section 6012(a)(1) of Pub. L. 101-239 effective Dec.

19, 1989, but not applicable so as to provide coverage under this

part for any month before July 1990, see section 6012(b) of Pub. L.

101-239, set out as an Effective Date note under section 1395i-2a

of this title.

Section 6013(c) of Pub. L. 101-239 provided that: "The amendments

made by this section [amending this section and section 1395v of

this title] shall become effective January 1, 1990."

EFFECTIVE DATE OF 1988 AMENDMENTS

Amendment by Pub. L. 100-485 effective as if originally included

in the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100-360,

see section 608(g)(1) of Pub. L. 100-485, set out as a note under

section 704 of this title.

Amendment by section 103 of Pub. L. 100-360 effective Jan. 1,

1989, except as otherwise provided, and applicable to inpatient

hospital deductible for 1989 and succeeding years, to care and

services furnished on or after Jan. 1, 1989, to premiums for

January 1989 and succeeding months, and to blood or blood cells

furnished on or after Jan. 1, 1989, see section 104(a) of Pub. L.

100-360, set out as a note under section 1395d of this title.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by section 411(b)(8)(D) of Pub. L. 100-360, as

it relates to a provision in the Omnibus Budget Reconciliation Act

of 1987, Pub. L. 100-203, effective as if included in the enactment

of that provision in Pub. L. 100-203, see section 411(a) of Pub. L.

100-360, set out as a Reference to OBRA; Effective Date note under

section 106 of Title 1, General Provisions.

EFFECTIVE DATE OF 1986 AMENDMENT

Section 9124(b) of Pub. L. 99-272 provided that:

"(1) The amendment made by subsection (a)(3) [amending this

section] shall apply to premiums paid for months beginning with

July 1986.

"(2) In applying that amendment, months (before, during, or after

April 1986) in which an individual was required to pay a premium

increased under the section that was so amended shall be taken into

account in determining the month in which the premium will no

longer be subject to an increase under that section as so amended."

EFFECTIVE DATE OF 1984 AMENDMENT

Amendment by section 2315(e) of Pub. L. 98-369 effective as

though included in the enactment of the Social Security Amendments

of 1983, Pub. L. 98-21, see section 2315(g) of Pub. L. 98-369, set

out as an Effective and Termination Dates of 1984 Amendments note

under section 1395ww of this title.

Amendment by section 2354(b)(3), (4) of Pub. L. 98-369 effective

July 18, 1984, but not to be construed as changing or affecting any

right, liability, status, or interpretation which existed (under

the provisions of law involved) before that date, see section

2354(e)(1) of Pub. L. 98-369, set out as a note under section

1320a-1 of this title.

EFFECTIVE DATE OF 1983 AMENDMENT; TRANSITIONAL RULE

Amendment by Pub. L. 98-21 applicable to premiums for months

beginning with January 1984, but for months after June 1983 and

before January 1984, the monthly premium for June 1983 shall apply

to individuals enrolled under parts A and B of this subchapter, see

section 606(c) of Pub. L. 98-21, set out as a note under section

1395r of this title.

SPECIAL ENROLLMENT PROVISIONS FOR MERCHANT SEAMEN

Pub. L. 97-248, title I, Sec. 125, Sept. 3, 1982, 96 Stat. 365,

provided that:

"(a) Any individual who -

"(1) was entitled to medical, surgical, and dental treatment

and hospitalization under section 322(a) of the Public Health

Service Act [section 249(a) of this title] (as in effect on

September 30, 1981), including such entitlement on the basis of

continuing medical care under 42 C.F.R. Sec. 32.17, at any time

during the period beginning on March 10, 1981, and ending on

October 1, 1981, and

"(2) as of September 30, 1981, was eligible under section

1818(a) or section 1836 of the Social Security Act [this section

or section 1395o of this title] to enroll in the insurance

program established by part A or part B, respectively, of title

XVIII of that Act [this subchapter] (hereinafter in this section

referred to as the 'respective program'),

may enroll (if not otherwise enrolled) in the respective program

during the period beginning on the first day of the first month

beginning at least 20 days after the date of the enactment of this

Act [Sept. 3, 1982] and ending on December 31, 1982.

"(b)(1) The coverage period under the respective program of an

individual who enrolls under subsection (a) shall begin -

"(A) on the first day of the month following the month in which

the individual enrolls, or

"(B) on October 1, 1981, if the individual files a request for

this subparagraph to apply and pays the monthly premiums for the

months so covered.

"(2) The coverage period under the respective program of an

individual described in subsection (a) who enrolled in the

respective program before the enrollment period described in that

subsection shall be retroactively extended to October 1, 1981, if

the individual files a request before January 1, 1983, for such

retroactive extension and pays the monthly premiums for the months

so covered.

"(c)(1) For purposes of section 1839(d) of the Social Security

Act [section 1395r(d) of this title] with respect to the monthly

premium for months after September 1981, if an individual described

in subsection (a) has enrolled in the insurance program under part

B of title XVIII of the Social Security Act [part B of this

subchapter] at any time before the end of the enrollment period

described in subsection (a), any month (before the end of that

enrollment period) in which he was not enrolled in that program

shall not be treated as a month in which he could have been

enrolled in the program.

"(2) Paragraph (1) shall not apply to an individual -

"(A) if the individual has enrolled in the insurance program

before March 10, 1981, unless the enrollment was terminated

solely because the individual lost eligibility to be so enrolled,

or

"(B) unless the individual applies for the benefit of such

paragraph before January 1, 1983.

"(d)(1) The Secretary of Health and Human Services, beginning as

soon as possible but not later than 30 days after the date of the

enactment of this Act [Sept. 3, 1982], shall provide for the

dissemination of information -

"(A) to unions and other associations representing or assisting

seamen,

"(B) to offices enrolling individuals under the respective

programs, and

"(C) to such other entities and in such a manner as will

effectively inform individuals eligible for benefits under this

section,

concerning the special benefits provided under this section.

"(2) An individual may establish that the individual was entitled

at a date to medical, surgical, and dental treatment and

hospitalization under section 322(a) of the Public Health Service

Act [section 249(a) of this title] (as in effect before October 1,

1981) by providing -

"(A) documentation relating to the status under which the

individual was provided care in (or under arrangements with) a

Public Health Service facility on that date,

"(B) the individual's seamen's papers covering that date, or

"(C) such other reasonable documentation as the Secretary may

require."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395i-2a, 1395p, 1395v,

1395ff, 1395gg, 1396d of this title; title 25 section 1644; title

26 section 6103.

-FOOTNOTE-

(!1) So in original. Probably should be followed by a comma.

(!2) So in original.

-End-

-CITE-

42 USC Sec. 1395i-2a 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395i-2a. Hospital insurance benefits for disabled individuals

who have exhausted other entitlement

-STATUTE-

(a) Eligibility

Every individual who -

(1) has not attained the age of 65;

(2)(A) has been entitled to benefits under this part under

section 426(b) of this title, and

(B)(i) continues to have the disabling physical or mental

impairment on the basis of which the individual was found to be

under a disability or to be a disabled qualified railroad

retirement beneficiary, or (ii) is blind (within the meaning of

section 416(i)(1) of this title), but

(C) whose entitlement under section 426(b) of this title ends

due solely to the individual having earnings that exceed the

substantial gainful activity amount (as defined in section

423(d)(4) of this title); and

(3) is not otherwise entitled to benefits under this part,

shall be eligible to enroll in the insurance program established by

this part.

(b) Enrollment

(1) An individual may enroll under this section only in such

manner and form as may be prescribed in regulations, and only

during an enrollment period prescribed in or under this section.

(2) The individual's initial enrollment period shall begin with

the month in which the individual receives notice that the

individual's entitlement to benefits under section 426(b) of this

title will end due solely to the individual having earnings that

exceed the substantial gainful activity amount (as defined in

section 423(d)(4) of this title and shall end 7 months later.

(3) There shall be a general enrollment period during the period

beginning on January 1 and ending on March 31 of each year

(beginning with 1990).

(c) Coverage period

(1) The period (in this subsection referred to as a "coverage

period") during which an individual is entitled to benefits under

the insurance program under this part shall begin on whichever of

the following is the latest:

(A) In the case of an individual who enrolls under subsection

(b)(2) of this section before the month in which the individual

first satisfies subsection (a) of this section, the first day of

such month.

(B) In the case of an individual who enrolls under subsection

(b)(2) of this section in the month in which the individual first

satisfies subsection (a) of this section, the first day of the

month following the month in which the individual so enrolls.

(C) In the case of an individual who enrolls under subsection

(b)(2) of this section in the month following the month in which

the individual first satisfies subsection (a) of this section,

the first day of the second month following the month in which

the individual so enrolls.

(D) In the case of an individual who enrolls under subsection

(b)(2) of this section more than one month following the month in

which the individual first satisfies subsection (a) of this

section, the first day of the third month following the month in

which the individual so enrolls.

(E) In the case of an individual who enrolls under subsection

(b)(3) of this section, the July 1 following the month in which

the individual so enrolls.

(2) An individual's coverage period under this section shall

continue until the individual's enrollment is terminated as

follows:

(A) As of the month following the month in which the Secretary

provides notice to the individual that the individual no longer

meets the condition described in subsection (a)(2)(B) of this

section.

(B) As of the month following the month in which the individual

files notice that the individual no longer wishes to participate

in the insurance program established by this part.

(C) As of the month before the first month in which the

individual becomes eligible for hospital insurance benefits under

section 426(a) or 426-1 of this title.

(D) As of a date, determined under regulations of the

Secretary, for nonpayment of premiums.

The regulations under subparagraph (D) may provide a grace period

of not longer than 90 days, which may be extended to not to exceed

180 days in any case where the Secretary determines that there was

good cause for failure to pay the overdue premiums within such

90-day period. Termination of coverage under this section shall

result in simultaneous termination of any coverage affected under

any other part of this subchapter.

(3) The provisions of subsections (h) and (i) of section 1395p of

this title apply to enrollment and nonenrollment under this section

in the same manner as they apply to enrollment and nonenrollment

and special enrollment periods under section 1395i-2 of this title.

(d) Payment of premiums

(1)(A) Premiums for enrollment under this section shall be paid

to the Secretary at such times, and in such manner, as the

Secretary shall by regulations prescribe, and shall be deposited in

the Treasury to the credit of the Federal Hospital Insurance Trust

Fund.

(B)(i) Subject to clause (ii), such premiums shall be payable for

the period commencing with the first month of an individual's

coverage period and ending with the month in which the individual

dies or, if earlier, in which the individual's coverage period

terminates.

(ii) Such premiums shall not be payable for any month in which

the individual is eligible for benefits under this part pursuant to

section 426(b) of this title.

(2) The provisions of subsections (d) through (f) of section

1395i-2 of this title (relating to premiums) shall apply to

individuals enrolled under this section in the same manner as they

apply to individuals enrolled under that section.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1818A, as added Pub. L.

101-239, title VI, Sec. 6012(a)(2), Dec. 19, 1989, 103 Stat. 2161;

amended Pub. L. 101-508, title IV, Sec. 4008(m)(3)(C), Nov. 5,

1990, 104 Stat. 1388-54.)

-MISC1-

AMENDMENTS

1990 - Subsec. (d)(1)(A). Pub. L. 101-508, Sec. 4008(m)(3)(C)(i),

inserted "for enrollment under this section" after "Premiums".

Subsec. (d)(1)(C). Pub. L. 101-508, Sec. 4008(m)(3)(C)(ii),

struck out subpar. (C) which read as follows: "For purposes of

applying section 1395r(g) of this title and section 59B(f)(1)(B)(i)

of the Internal Revenue Code of 1986, any reference to section

1395i-2 of this title shall be deemed to include a reference to

this section."

EFFECTIVE DATE

Section 6012(b) of Pub. L. 101-239 provided that: "The amendments

made by this section [enacting this section and amending section

1395i-2 of this title] shall take effect on the date of the

enactment of this Act [Dec. 19, 1989], but shall not apply so as to

provide for coverage under part A of title XVIII of the Social

Security Act [this part] for any month before July 1990."

-End-

-CITE-

42 USC Sec. 1395i-3 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part A - Hospital Insurance Benefits for Aged and Disabled

-HEAD-

Sec. 1395i-3. Requirements for, and assuring quality of care in,

skilled nursing facilities

-STATUTE-

(a) "Skilled nursing facility" defined

In this subchapter, the term "skilled nursing facility" means an

institution (or a distinct part of an institution) which -

(1) is primarily engaged in providing to residents -

(A) skilled nursing care and related services for residents

who require medical or nursing care, or

(B) rehabilitation services for the rehabilitation of

injured, disabled, or sick persons,

and is not primarily for the care and treatment of mental

diseases;

(2) has in effect a transfer agreement (meeting the

requirements of section 1395x(l) of this title) with one or more

hospitals having agreements in effect under section 1395cc of

this title; and

(3) meets the requirements for a skilled nursing facility

described in subsections (b), (c), and (d) of this section.

(b) Requirements relating to provision of services

(1) Quality of life

(A) In general

A skilled nursing facility must care for its residents in

such a manner and in such an environment as will promote

maintenance or enhancement of the quality of life of each

resident.

(B) Quality assessment and assurance

A skilled nursing facility must maintain a quality assessment

and assurance committee, consisting of the director of nursing

services, a physician designated by the facility, and at least

3 other members of the facility's staff, which (i) meets at

least quarterly to identify issues with respect to which

quality assessment and assurance activities are necessary and

(ii) develops and implements appropriate plans of action to

correct identified quality deficiencies. A State or the

Secretary may not require disclosure of the records of such

committee except insofar as such disclosure is related to the

compliance of such committee with the requirements of this

subparagraph.

(2) Scope of services and activities under plan of care

A skilled nursing facility must provide services to attain or

maintain the highest practicable physical, mental, and

psychosocial well-being of each resident, in accordance with a

written plan of care which -

(A) describes the medical, nursing, and psychosocial needs of

the resident and how such needs will be met;

(B) is initially prepared, with the participation to the

extent practicable of the resident or the resident's family or

legal representative, by a team which includes the resident's

attending physician and a registered professional nurse with

responsibility for the resident; and

(C) is periodically reviewed and revised by such team after

each assessment under paragraph (3).

(3) Residents' assessment

(A) Requirement

A skilled nursing facility must conduct a comprehensive,

accurate, standardized, reproducible assessment of each

resident's functional capacity, which assessment -

(i) describes the resident's capability to perform daily

life functions and significant impairments in functional

capacity;

(ii) is based on a uniform minimum data set specified by

the Secretary under subsection (f)(6)(A) of this section;

(iii) uses an instrument which is specified by the State

under subsection (e)(5) of this section; and

(iv) includes the identification of medical problems.

(B) Certification

(i) In general

Each such assessment must be conducted or coordinated (with

the appropriate participation of health professionals) by a

registered professional nurse who signs and certifies the

completion of the assessment. Each individual who completes a

portion of such an assessment shall sign and certify as to

the accuracy of that portion of the assessment.

(ii) Penalty for falsification

(I) An individual who willfully and knowingly certifies

under clause (i) a material and false statement in a resident

assessment is subject to a civil money penalty of not more

than $1,000 with respect to each assessment.

(II) An individual who willfully and knowingly causes

another individual to certify under clause (i) a material and

false statement in a resident assessment is subject to a

civil money penalty of not more than $5,000 with respect to

each assessment.

(III) The provisions of section 1320a-7a of this title

(other than subsections (a) and (b)) shall apply to a civil

money penalty under this clause in the same manner as such

provisions apply to a penalty or proceeding under section

1320a-7a(a) of this title.

(iii) Use of independent assessors

If a State determines, under a survey under subsection (g)

of this section or otherwise, that there has been a knowing

and willful certification of false assessments under this

paragraph, the State may require (for a period specified by

the State) that resident assessments under this paragraph be

conducted and certified by individuals who are independent of

the facility and who are approved by the State.

(C) Frequency

(i) In general

Subject to the timeframes prescribed by the Secretary under

section 1395yy(e)(6) of this title, such an assessment must

be conducted -

(I) promptly upon (but no later than 14 days after the

date of) admission for each individual admitted on or after

October 1, 1990, and by not later than January 1, 1991, for

each resident of the facility on that date;

(II) promptly after a significant change in the

resident's physical or mental condition; and

(III) in no case less often than once every 12 months.

(ii) Resident review

The skilled nursing facility must examine each resident no

less frequently than once every 3 months and, as appropriate,

revise the resident's assessment to assure the continuing

accuracy of the assessment.

(D) Use

The results of such an assessment shall be used in

developing, reviewing, and revising the resident's plan of care

under paragraph (2).

(E) Coordination

Such assessments shall be coordinated with any State-required

preadmission screening program to the maximum extent

practicable in order to avoid duplicative testing and effort.

(4) Provision of services and activities

(A) In general

To the extent needed to fulfill all plans of care described

in paragraph (2), a skilled nursing facility must provide,

directly or under arrangements (or, with respect to dental

services, under agreements) with others for the provision of -

(i) nursing services and specialized rehabilitative

services to attain or maintain the highest practicable

physical, mental, and psychosocial well-being of each

resident;

(ii) medically-related social services to attain or

maintain the highest practicable physical, mental, and

psychosocial well-being of each resident;

(iii) pharmaceutical services (including procedures that

assure the accurate acquiring, receiving, dispensing, and

administering of all drugs and biologicals) to meet the needs

of each resident;

(iv) dietary services that assure that the meals meet the

daily nutritional and special dietary needs of each resident;

(v) an on-going program, directed by a qualified

professional, of activities designed to meet the interests

and the physical, mental, and psychosocial well-being of each

resident;

(vi) routine and emergency dental services to meet the

needs of each resident; and

(vii) treatment and services required by mentally ill and

mentally retarded residents not otherwise provided or

arranged for (or required to be provided or arranged for) by

the State.

The services provided or arranged by the facility must meet

professional standards of quality. Nothing in clause (vi) shall

be construed as requiring a facility to provide or arrange for

dental services described in that clause without additional

charge.

(B) Qualified persons providing services

Services described in clauses (i), (ii), (iii), (iv), and

(vi) of subparagraph (A) must be provided by qualified persons

in accordance with each resident's written plan of care.

(C) Required nursing care

(i) In general

Except as provided in clause (ii), a skilled nursing

facility must provide 24-hour licensed nursing service which

is sufficient to meet nursing needs of its residents and must

use the services of a registered professional nurse at least

at least (!1) 8 consecutive hours a day, 7 days a week.

(ii) Exception

To the extent that clause (i) may be deemed to require that

a skilled nursing facility engage the services of a

registered professional nurse for more than 40 hours a week,

the Secretary is authorized to waive such requirement if the

Secretary finds that -

(I) the facility is located in a rural area and the

supply of skilled nursing facility services in such area is

not sufficient to meet the needs of individuals residing

therein,

(II) the facility has one full-time registered

professional nurse who is regularly on duty at such

facility 40 hours a week,

(III) the facility either has only patients whose

physicians have indicated (through physicians' orders or

admission notes) that each such patient does not require

the services of a registered nurse or a physician for a

48-hour period, or has made arrangements for a registered

professional nurse or a physician to spend such time at

such facility as may be indicated as necessary by the

physician to provide necessary skilled nursing services on

days when the regular full-time registered professional

nurse is not on duty,

(IV) the Secretary provides notice of the waiver to the

State long-term care ombudsman (established under section

307(a)(12) (!2) of the Older Americans Act of 1965) and the

protection and advocacy system in the State for the

mentally ill and the mentally retarded, and

(V) the facility that is granted such a waiver notifies

residents of the facility (or, where appropriate, the

guardians or legal representatives of such residents) and

members of their immediate families of the waiver.

A waiver under this subparagraph shall be subject to annual

renewal.

(5) Required training of nurse aides

(A) In general

(i) Except as provided in clause (ii), a skilled nursing

facility must not use on a full-time basis any individual as a

nurse aide in the facility on or after October 1, 1990 for more

than 4 months unless the individual -

(I) has completed a training and competency evaluation

program, or a competency evaluation program, approved by the

State under subsection (e)(1)(A) of this section, and

(II) is competent to provide nursing or nursing-related

services.

(ii) A skilled nursing facility must not use on a temporary,

per diem, leased, or on any basis other than as a permanent

employee any individual as a nurse aide in the facility on or

after January 1, 1991, unless the individual meets the

requirements described in clause (i).

(B) Offering competency evaluation programs for current

employees

A skilled nursing facility must provide, for individuals used

as a nurse aide (!3) by the facility as of January 1, 1990, for

a competency evaluation program approved by the State under

subsection (e)(1) of this section and such preparation as may

be necessary for the individual to complete such a program by

October 1, 1990.

(C) Competency

The skilled nursing facility must not permit an individual,

other than in a training and competency evaluation program

approved by the State, to serve as a nurse aide or provide

services of a type for which the individual has not

demonstrated competency and must not use such an individual as

a nurse aide unless the facility has inquired of any State

registry established under subsection (e)(2)(A) of this section

that the facility believes will include information concerning

the individual.

(D) Re-training required

For purposes of subparagraph (A), if, since an individual's

most recent completion of a training and competency evaluation

program, there has been a continuous period of 24 consecutive

months during none of which the individual performed nursing or

nursing-related services for monetary compensation, such

individual shall complete a new training and competency

evaluation program or a new competency evaluation program.

(E) Regular in-service education

The skilled nursing facility must provide such regular

performance review and regular in-service education as assures

that individuals used as nurse aides are competent to perform

services as nurse aides, including training for individuals

providing nursing and nursing-related services to residents

with cognitive impairments.

(F) "Nurse aide" defined

In this paragraph, the term "nurse aide" means any individual

providing nursing or nursing-related services to residents in a

skilled nursing facility, but does not include an individual -

(i) who is a licensed health professional (as defined in

subparagraph (G)) or a registered dietician, or

(ii) who volunteers to provide such services without

monetary compensation.

(G) "Licensed health professional" defined

In this paragraph, the term "licensed health professional"

means a physician, physician assistant, nurse practitioner,

physical, speech, or occupational therapist, physical or

occupational therapy assistant, registered professional nurse,

licensed practical nurse, licensed or certified social worker,

registered respiratory therapist, or certified respiratory

therapy technician.

(6) Physician supervision and clinical records

A skilled nursing facility must -

(A) require that the medical care of every resident be

provided under the supervision of a physician;

(B) provide for having a physician available to furnish

necessary medical care in case of emergency; and

(C) maintain clinical records on all residents, which records

include the plans of care (described in paragraph (2)) and the

residents' assessments (described in paragraph (3)).

(7) Required social services

In the case of a skilled nursing facility with more than 120

beds, the facility must have at least one social worker (with at

least a bachelor's degree in social work or similar professional

qualifications) employed full-time to provide or assure the

provision of social services.

(8) Information on nurse staffing

(A) In general

A skilled nursing facility shall post daily for each shift

the current number of licensed and unlicensed nursing staff

directly responsible for resident care in the facility. The

information shall be displayed in a uniform manner (as

specified by the Secretary) and in a clearly visible place.

(B) Publication of data

A skilled nursing facility shall, upon request, make

available to the public the nursing staff data described in

subparagraph (A).

(c) Requirements relating to residents' rights

(1) General rights

(A) Specified rights

A skilled nursing facility must protect and promote the

rights of each resident, including each of the following

rights:

(i) Free choice

The right to choose a personal attending physician, to be

fully informed in advance about care and treatment, to be

fully informed in advance of any changes in care or treatment

that may affect the resident's well-being, and (except with

respect to a resident adjudged incompetent) to participate in

planning care and treatment or changes in care and treatment.

(ii) Free from restraints

The right to be free from physical or mental abuse,

corporal punishment, involuntary seclusion, and any physical

or chemical restraints imposed for purposes of discipline or

convenience and not required to treat the resident's medical

symptoms. Restraints may only be imposed -

(I) to ensure the physical safety of the resident or

other residents, and

(II) only upon the written order of a physician that

specifies the duration and circumstances under which the

restraints are to be used (except in emergency

circumstances specified by the Secretary until such an

order could reasonably be obtained).

(iii) Privacy

The right to privacy with regard to accommodations, medical

treatment, written and telephonic communications, visits, and

meetings of family and of resident groups.

(iv) Confidentiality

The right to confidentiality of personal and clinical

records and to access to current clinical records of the

resident upon request by the resident or the resident's legal

representative, within 24 hours (excluding hours occurring

during a weekend or holiday) after making such a request.

(v) Accommodation of needs

The right -

(I) to reside and receive services with reasonable

accommodation of individual needs and preferences, except

where the health or safety of the individual or other

residents would be endangered, and

(II) to receive notice before the room or roommate of the

resident in the facility is changed.

(vi) Grievances

The right to voice grievances with respect to treatment or

care that is (or fails to be) furnished, without

discrimination or reprisal for voicing the grievances and the

right to prompt efforts by the facility to resolve grievances

the resident may have, including those with respect to the

behavior of other residents.

(vii) Participation in resident and family groups

The right of the resident to organize and participate in

resident groups in the facility and the right of the

resident's family to meet in the facility with the families

of other residents in the facility.

(viii) Participation in other activities

The right of the resident to participate in social,

religious, and community activities that do not interfere

with the rights of other residents in the facility.

(ix) Examination of survey results

The right to examine, upon reasonable request, the results

of the most recent survey of the facility conducted by the

Secretary or a State with respect to the facility and any

plan of correction in effect with respect to the facility.

(x) Refusal of certain transfers

The right to refuse a transfer to another room within the

facility, if a purpose of the transfer is to relocate the

resident from a portion of the facility that is a skilled

nursing facility (for purposes of this subchapter) to a

portion of the facility that is not such a skilled nursing

facility.

(xi) Other rights

Any other right established by the Secretary.

Clause (iii) shall not be construed as requiring the provision

of a private room. A resident's exercise of a right to refuse

transfer under clause (x) shall not affect the resident's

eligibility or entitlement to benefits under this subchapter or

to medical assistance under subchapter XIX of this chapter.

(B) Notice of rights and services

A skilled nursing facility must -

(i) inform each resident, orally and in writing at the time

of admission to the facility, of the resident's legal rights

during the stay at the facility;

(ii) make available to each resident, upon reasonable

request, a written statement of such rights (which statement

is updated upon changes in such rights) including the notice

(if any) of the State developed under section 1396r(e)(6) of

this title; and

(iii) inform each other resident, in writing before or at

the time of admission and periodically during the resident's

stay, of services available in the facility and of related

charges for such services, including any charges for services

not covered under this subchapter or by the facility's basic

per diem charge.

The written description of legal rights under this subparagraph

shall include a description of the protection of personal funds

under paragraph (6) and a statement that a resident may file a

complaint with a State survey and certification agency

respecting resident abuse and neglect and misappropriation of

resident property in the facility.

(C) Rights of incompetent residents

In the case of a resident adjudged incompetent under the laws

of a State, the rights of the resident under this subchapter

shall devolve upon, and, to the extent judged necessary by a

court of competent jurisdiction, be exercised by, the person

appointed under State law to act on the resident's behalf.

(D) Use of psychopharmacologic drugs

Psychopharmacologic drugs may be administered only on the

orders of a physician and only as part of a plan (included in

the written plan of care described in paragraph (2)) designed

to eliminate or modify the symptoms for which the drugs are

prescribed and only if, at least annually, an independent,

external consultant reviews the appropriateness of the drug

plan of each resident receiving such drugs. In determining

whether such a consultant is qualified to conduct reviews under

the preceding sentence, the Secretary shall take into account

the needs of nursing facilities under this subchapter to have

access to the services of such a consultant on a timely basis.

(E) Information respecting advance directives

A skilled nursing facility must comply with the requirement

of section 1395cc(f) of this title (relating to maintaining

written policies and procedures respecting advance directives).

(2) Transfer and discharge rights

(A) In general

A skilled nursing facility must permit each resident to

remain in the facility and must not transfer or discharge the

resident from the facility unless -

(i) the transfer or discharge is necessary to meet the

resident's welfare and the resident's welfare cannot be met

in the facility;

(ii) the transfer or discharge is appropriate because the

resident's health has improved sufficiently so the resident

no longer needs the services provided by the facility;

(iii) the safety of individuals in the facility is

endangered;

(iv) the health of individuals in the facility would

otherwise be endangered;

(v) the resident has failed, after reasonable and

appropriate notice, to pay (or to have paid under this

subchapter or subchapter XIX of this chapter on the

resident's behalf) for a stay at the facility; or

(vi) the facility ceases to operate.

In each of the cases described in clauses (i) through (v), the

basis for the transfer or discharge must be documented in the

resident's clinical record. In the cases described in clauses

(i) and (ii), the documentation must be made by the resident's

physician, and in the cases described in clauses (iii) and (iv)

the documentation must be made by a physician.

(B) Pre-transfer and pre-discharge notice

(i) In general

Before effecting a transfer or discharge of a resident, a

skilled nursing facility must -

(I) notify the resident (and, if known, a family member

of the resident or legal representative) of the transfer or

discharge and the reasons therefor,

(II) record the reasons in the resident's clinical record

(including any documentation required under subparagraph

(A)), and

(III) include in the notice the items described in clause

(iii).

(ii) Timing of notice

The notice under clause (i)(I) must be made at least 30

days in advance of the resident's transfer or discharge

except -

(I) in a case described in clause (iii) or (iv) of

subparagraph (A);

(II) in a case described in clause (ii) of subparagraph

(A), where the resident's health improves sufficiently to

allow a more immediate transfer or discharge;

(III) in a case described in clause (i) of subparagraph

(A), where a more immediate transfer or discharge is

necessitated by the resident's urgent medical needs; or

(IV) in a case where a resident has not resided in the

facility for 30 days.

In the case of such exceptions, notice must be given as many

days before the date of the transfer or discharge as is

practicable.

(iii) Items included in notice

Each notice under clause (i) must include -

(I) for transfers or discharges effected on or after

October 1, 1990, notice of the resident's right to appeal

the transfer or discharge under the State process

established under subsection (e)(3) of this section; and

(II) the name, mailing address, and telephone number of

the State long-term care ombudsman (established under title

III or VII of the Older Americans Act of 1965 [42 U.S.C.

3021 et seq., 3058 et seq.] in accordance with section 712

of the Act [42 U.S.C. 3058g]).

(C) Orientation

A skilled nursing facility must provide sufficient

preparation and orientation to residents to ensure safe and

orderly transfer or discharge from the facility.

(3) Access and visitation rights

A skilled nursing facility must -

(A) permit immediate access to any resident by any

representative of the Secretary, by any representative of the

State, by an ombudsman described in paragraph (2)(B)(iii)(II),

or by the resident's individual physician;

(B) permit immediate access to a resident, subject to the

resident's right to deny or withdraw consent at any time, by

immediate family or other relatives of the resident;

(C) permit immediate access to a resident, subject to

reasonable restrictions and the resident's right to deny or

withdraw consent at any time, by others who are visiting with

the consent of the resident;

(D) permit reasonable access to a resident by any entity or

individual that provides health, social, legal, or other

services to the resident, subject to the resident's right to

deny or withdraw consent at any time; and

(E) permit representatives of the State ombudsman (described

in paragraph (2)(B)(iii)(II)), with the permission of the

resident (or the resident's legal representative) and

consistent with State law, to examine a resident's clinical

records.

(4) Equal access to quality care

A skilled nursing facility must establish and maintain

identical policies and practices regarding transfer, discharge,

and covered services under this subchapter for all individuals

regardless of source of payment.

(5) Admissions policy

(A) Admissions

With respect to admissions practices, a skilled nursing

facility must -

(i)(I) not require individuals applying to reside or

residing in the facility to waive their rights to benefits

under this subchapter or under a State plan under subchapter

XIX of this chapter, (II) not require oral or written

assurance that such individuals are not eligible for, or will

not apply for, benefits under this subchapter or such a State

plan, and (III) prominently display in the facility and

provide to such individuals written information about how to

apply for and use such benefits and how to receive refunds

for previous payments covered by such benefits; and

(ii) not require a third party guarantee of payment to the

facility as a condition of admission (or expedited admission)

to, or continued stay in, the facility.

(B) Construction

(i) No preemption of stricter standards

Subparagraph (A) shall not be construed as preventing

States or political subdivisions therein from prohibiting,

under State or local law, the discrimination against

individuals who are entitled to medical assistance under this

subchapter with respect to admissions practices of skilled

nursing facilities.

(ii) Contracts with legal representatives

Subparagraph (A)(ii) shall not be construed as preventing a

facility from requiring an individual, who has legal access

to a resident's income or resources available to pay for care

in the facility, to sign a contract (without incurring

personal financial liability) to provide payment from the

resident's income or resources for such care.

(6) Protection of resident funds

(A) In general

The skilled nursing facility -

(i) may not require residents to deposit their personal

funds with the facility, and

(ii) upon the written authorization of the resident, must

hold, safeguard, and account for such personal funds under a

system established and maintained by the facility in

accordance with this paragraph.

(B) Management of personal funds

Upon written authorization of a resident under subparagraph

(A)(ii), the facility must manage and account for the personal

funds of the resident deposited with the facility as follows:

(i) Deposit

The facility must deposit any amount of personal funds in

excess of $100 with respect to a resident in an interest

bearing account (or accounts) that is separate from any of

the facility's operating accounts and credits (!4) all

interest earned on such separate account to such account.

With respect to any other personal funds, the facility must

maintain such funds in a non-interest bearing account or

petty cash fund.

(ii) Accounting and records

The facility must assure a full and complete separate

accounting of each such resident's personal funds, maintain a

written record of all financial transactions involving the

personal funds of a resident deposited with the facility, and

afford the resident (or a legal representative of the

resident) reasonable access to such record.

(iii) Conveyance upon death

Upon the death of a resident with such an account, the

facility must convey promptly the resident's personal funds

(and a final accounting of such funds) to the individual

administering the resident's estate.

(C) Assurance of financial security

The facility must purchase a surety bond, or otherwise

provide assurance satisfactory to the Secretary, to assure the

security of all personal funds of residents deposited with the

facility.

(D) Limitation on charges to personal funds

The facility may not impose a charge against the personal

funds of a resident for any item or service for which payment

is made under this subchapter or subchapter XIX of this

chapter.

(d) Requirements relating to administration and other matters

(1) Administration

(A) In general

A skilled nursing facility must be administered in a manner

that enables it to use its resources effectively and

efficiently to attain or maintain the highest practicable

physical (!5) mental, and psychosocial well-being of each

resident (consistent with requirements established under

subsection (f)(5) of this section).

(B) Required notices

If a change occurs in -

(i) the persons with an ownership or control interest (as

defined in section 1320a-3(a)(3) of this title) in the

facility,

(ii) the persons who are officers, directors, agents, or

managing employees (as defined in section 1320a-5(b) of this

title) of the facility,

(iii) the corporation, association, or other company

responsible for the management of the facility, or

(iv) the individual who is the administrator or director of

nursing of the facility,

the skilled nursing facility must provide notice to the State

agency responsible for the licensing of the facility, at the

time of the change, of the change and of the identity of each

new person, company, or individual described in the respective

clause.

(C) Skilled nursing facility administrator

The administrator of a skilled nursing facility must meet

standards established by the Secretary under subsection (f)(4)

of this section.

(2) Licensing and Life Safety Code

(A) Licensing

A skilled nursing facility must be licensed under applicable

State and local law.

(B) Life Safety Code

A skilled nursing facility must meet such provisions of such

edition (as specified by the Secretary in regulation) of the

Life Safety Code of the National Fire Protection Association as

are applicable to nursing homes; except that -

(i) the Secretary may waive, for such periods as he deems

appropriate, specific provisions of such Code which if

rigidly applied would result in unreasonable hardship upon a

facility, but only if such waiver would not adversely affect

the health and safety of residents or personnel, and

(ii) the provisions of such Code shall not apply in any

State if the Secretary finds that in such State there is in

effect a fire and safety code, imposed by State law, which

adequately protects residents of and personnel in skilled

nursing facilities.

(3) Sanitary and infection control and physical environment

A skilled nursing facility must -

(A) establish and maintain an infection control program

designed to provide a safe, sanitary, and comfortable

environment in which residents reside and to help prevent the

development and transmission of disease and infection, and

(B) be designed, constructed, equipped, and maintained in a

manner to protect the health and safety of residents,

personnel, and the general public.

(4) Miscellaneous

(A) Compliance with Federal, State, and local laws and

professional standards

A skilled nursing facility must operate and provide services

in compliance with all applicable Federal, State, and local

laws and regulations (including the requirements of section

1320a-3 of this title) and with accepted professional standards

and principles which apply to professionals providing services

in such a facility.

(B) Other

A skilled nursing facility must meet such other requirements

relating to the health, safety, and well-being of residents or

relating to the physical facilities thereof as the Secretary

may find necessary.

(e) State requirements relating to skilled nursing facility

requirements

The requirements, referred to in section 1395aa(d) of this title,

with respect to a State are as follows:

(1) Specification and review of nurse aide training and

competency evaluation programs and of nurse aide competency

evaluation programs

The State must -

(A) by not later than January 1, 1989, specify those training

and competency evaluation programs, and those competency

evaluation programs, that the State approves for purposes of

subsection (b)(5) of this section and that meet the

requirements established under subsection (f)(2) of this

section, and

(B) by not later than January 1, 1990, provide for the review

and reapproval of such programs, at a frequency and using a

methodology consistent with the requirements established under

subsection (f)(2)(A)(iii) of this section.

The failure of the Secretary to establish requirements under

subsection (f)(2) of this section shall not relieve any State of

its responsibility under this paragraph.

(2) Nurse aide registry

(A) In general

By not later than January 1, 1989, the State shall establish

and maintain a registry of all individuals who have

satisfactorily completed a nurse aide training and competency

evaluation program, or a nurse aide competency evaluation

program, approved under paragraph (1) in the State, or any

individual described in subsection (f)(2)(B)(ii) of this

section or in subparagraph (B), (C), or (D) of section

6901(b)(4) of the Omnibus Budget Reconciliation Act of 1989.

(B) Information in registry

The registry under subparagraph (A) shall provide (in

accordance with regulations of the Secretary) for the inclusion

of specific documented findings by a State under subsection

(g)(1)(C) of this section of resident neglect or abuse or

misappropriation of resident property involving an individual

listed in the registry, as well as any brief statement of the

individual disputing the findings, but shall not include any

allegations of resident abuse or neglect or misappropriation of

resident property that are not specifically documented by the

State under such subsection. The State shall make available to

the public information in the registry. In the case of

inquiries to the registry concerning an individual listed in

the registry, any information disclosed concerning such a

finding shall also include disclosure of any such statement in

the registry relating to the finding or a clear and accurate

summary of such a statement.

(C) Prohibition against charges

A State may not impose any charges on a nurse aide relating

to the registry established and maintained under subparagraph

(A).

(3) State appeals process for transfers and discharges

The State, for transfers and discharges from skilled nursing

facilities effected on or after October 1, 1989, must provide for

a fair mechanism for hearing appeals on transfers and discharges

of residents of such facilities. Such mechanism must meet the

guidelines established by the Secretary under subsection (f)(3)

of this section; but the failure of the Secretary to establish

such guidelines shall not relieve any State of its responsibility

to provide for such a fair mechanism.

(4) Skilled nursing facility administrator standards

By not later than January 1, 1990, the State must have

implemented and enforced the skilled nursing facility

administrator standards developed under subsection (f)(4) of this

section respecting the qualification of administrators of skilled

nursing facilities.

(5) Specification of resident assessment instrument

Effective July 1, 1990, the State shall specify the instrument

to be used by nursing facilities in the State in complying with

the requirement of subsection (b)(3)(A)(iii) of this section.

Such instrument shall be -

(A) one of the instruments designated under subsection

(f)(6)(B) of this section, or

(B) an instrument which the Secretary has approved as being

consistent with the minimum data set of core elements, common

definitions, and utilization guidelines specified by the

Secretary under subsection (f)(6)(A) of this section.

(f) Responsibilities of Secretary relating to skilled nursing

facility requirements

(1) General responsibility

It is the duty and responsibility of the Secretary to assure

that requirements which govern the provision of care in skilled

nursing facilities under this subchapter, and the enforcement of

such requirements, are adequate to protect the health, safety,

welfare, and rights of residents and to promote the effective and

efficient use of public moneys.

(2) Requirements for nurse aide training and competency

evaluation programs and for nurse aide competency evaluation

programs

(A) In general

For purposes of subsections (b)(5) and (e)(1)(A) of this

section, the Secretary shall establish, by not later than

September 1, 1988 -

(i) requirements for the approval of nurse aide training

and competency evaluation programs, including requirements

relating to (I) the areas to be covered in such a program

(including at least basic nursing skills, personal care

skills, recognition of mental health and social service

needs, care of cognitively impaired residents, basic

restorative services, and residents' rights) and content of

the curriculum, (II) minimum hours of initial and ongoing

training and retraining (including not less than 75 hours in

the case of initial training), (III) qualifications of

instructors, and (IV) procedures for determination of

competency;

(ii) requirements for the approval of nurse aide competency

evaluation programs, including requirement relating to the

areas to be covered in such a program, including at least

basic nursing skills, personal care skills, recognition of

mental health and social service needs, care of cognitively

impaired residents, basic restorative services, residents'

rights, and procedures for determination of competency;

(iii) requirements respecting the minimum frequency and

methodology to be used by a State in reviewing such programs'

compliance with the requirements for such programs; and

(iv) requirements, under both such programs, that -

(I) provide procedures for determining competency that

permit a nurse aide, at the nurse aide's option, to

establish competency through procedures or methods other

than the passing of a written examination and to have the

competency evaluation conducted at the nursing facility at

which the aide is (or will be) employed (unless the

facility is described in subparagraph (B)(iii)(I)),

(II) prohibit the imposition on a nurse aide who is

employed by (or who has received an offer of employment

from) a facility on the date on which the aide begins

either such program of any charges (including any charges

for textbooks and other required course materials and any

charges for the competency evaluation) for either such

program, and

(III) in the case of a nurse aide not described in

subclause (II) who is employed by (or who has received an

offer of employment from) a facility not later than 12

months after completing either such program, the State

shall provide for the reimbursement of costs incurred in

completing such program on a prorata (!6) basis during the

period in which the nurse aide is so employed.

(B) Approval of certain programs

Such requirements -

(i) may permit approval of programs offered by or in

facilities (subject to clause (iii)), as well as outside

facilities (including employee organizations), and of

programs in effect on December 22, 1987;

(ii) shall permit a State to find that an individual who

has completed (before July 1, 1989) a nurse aide training and

competency evaluation program shall be deemed to have

completed such a program approved under subsection (b)(5) of

this section if the State determines that, at the time the

program was offered, the program met the requirements for

approval under such paragraph; and

(iii) subject to subparagraph (C), shall prohibit approval

of such a program -

(I) offered by or in a skilled nursing facility which,

within the previous 2 years -

(a) has operated under a waiver under subsection

(b)(4)(C)(ii)(II) of this section;

(b) has been subject to an extended (or partial

extended) survey under subsection (g)(2)(B)(i) of this

section or section 1396r(g)(2)(B)(i) of this title,

unless the survey shows that the facility is in

compliance with the requirements of subsections (b), (c),

and (d) of this section; or

(c) has been assessed a civil money penalty described

in subsection (h)(2)(B)(ii) of this section or section

1396r(h)(2)(A)(ii) of this title of not less than $5,000,

or has been subject to a remedy described in clause (i)

or (iii) of subsection (h)(2)(B) of this section,

subsection (h)(4) of this section, section

1396r(h)(1)(B)(i) of this title, or in clause (i), (iii),

or (iv) of section 1396r(h)(2)(A) of this title, or

(II) offered by or in a skilled nursing facility unless

the State makes the determination, upon an individual's

completion of the program, that the individual is competent

to provide nursing and nursing-related services in skilled

nursing facilities.

A State may not delegate (through subcontract or otherwise)

its responsibility under clause (iii)(II) to the skilled

nursing facility.

(C) Waiver authorized

Clause (iii)(I) of subparagraph (B) shall not apply to a

program offered in (but not by) a nursing facility (or skilled

nursing facility for purposes of this subchapter) in a State if

the State -

(i) determines that there is no other such program offered

within a reasonable distance of the facility,

(ii) assures, through an oversight effort, that an adequate

environment exists for operating the program in the facility,

and

(iii) provides notice of such determination and assurances

to the State long-term care ombudsman.

(3) Federal guidelines for State appeals process for transfers

and discharges

For purposes of subsections (c)(2)(B)(iii)(I) and (e)(3) of

this section, by not later than October 1, 1988, the Secretary

shall establish guidelines for minimum standards which State

appeals processes under subsection (e)(3) of this section must

meet to provide a fair mechanism for hearing appeals on transfers

and discharges of residents from skilled nursing facilities.

(4) Secretarial standards for qualification of administrators

For purposes of subsections (d)(1)(C) and (e)(4) of this

section, the Secretary shall develop, by not later than March 1,

1989, standards to be applied in assuring the qualifications of

administrators of skilled nursing facilities.

(5) Criteria for administration

The Secretary shall establish criteria for assessing a skilled

nursing facility's compliance with the requirement of subsection

(d)(1) of this section with respect to -

(A) its governing body and management,

(B) agreements with hospitals regarding transfers of

residents to and from the hospitals and to and from other

skilled nursing facilities,

(C) disaster preparedness,

(D) direction of medical care by a physician,

(E) laboratory and radiological services,

(F) clinical records, and

(G) resident and advocate participation.

(6) Specification of resident assessment data set and instruments

The Secretary shall -

(A) not later than January 1, 1989, specify a minimum data

set of core elements and common definitions for use by nursing

facilities in conducting the assessments required under

subsection (b)(3) of this section, and establish guidelines for

utilization of the data set; and

(B) by not later than April 1, 1990, designate one or more

instruments which are consistent with the specification made

under subparagraph (A) and which a State may specify under

subsection (e)(5)(A) of this section for use by nursing

facilities in complying with the requirements of subsection

(b)(3)(A)(iii) of this section.

(7) List of items and services furnished in skilled nursing

facilities not chargeable to the personal funds of a resident

(A) Regulations required

Pursuant to the requirement of section 21(b) of the

Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, the

Secretary shall issue regulations, on or before the first day

of the seventh month to begin after December 22, 1987, that

define those costs which may be charged to the personal funds

of residents in skilled nursing facilities who are individuals

receiving benefits under this part and those costs which are to

be included in the reasonable cost (or other payment amount)

under this subchapter for extended care services.

(B) Rule if failure to publish regulations

If the Secretary does not issue the regulations under

subparagraph (A) on or before the date required in such

subparagraph, in the case of a resident of a skilled nursing

facility who is eligible to receive benefits under this part,

the costs which may not be charged to the personal funds of

such resident (and for which payment is considered to be made

under this subchapter) shall include, at a minimum, the costs

for routine personal hygiene items and services furnished by

the facility.

(g) Survey and certification process

(1) State and Federal responsibility

(A) In general

Pursuant to an agreement under section 1395aa of this title,

each State shall be responsible for certifying, in accordance

with surveys conducted under paragraph (2), the compliance of

skilled nursing facilities (other than facilities of the State)

with the requirements of subsections (b), (c), and (d) of this

section. The Secretary shall be responsible for certifying, in

accordance with surveys conducted under paragraph (2), the

compliance of State skilled nursing facilities with the

requirements of such subsections.

(B) Educational program

Each State shall conduct periodic educational programs for

the staff and residents (and their representatives) of skilled

nursing facilities in order to present current regulations,

procedures, and policies under this section.

(C) Investigation of allegations of resident neglect and abuse

and misappropriation of resident property

The State shall provide, through the agency responsible for

surveys and certification of nursing facilities under this

subsection, for a process for the receipt and timely review and

investigation of allegations of neglect and abuse and

misappropriation of resident property by a nurse aide of a

resident in a nursing facility or by another individual used by

the facility in providing services to such a resident. The

State shall, after providing the individual involved with a

written notice of the allegations (including a statement of the

availability of a hearing for the individual to rebut the

allegations) and the opportunity for a hearing on the record,

make a written finding as to the accuracy of the allegations.

If the State finds that a nurse aide has neglected or abused a

resident or misappropriated resident property in a facility,

the State shall notify the nurse aide and the registry of such

finding. If the State finds that any other individual used by

the facility has neglected or abused a resident or

misappropriated resident property in a facility, the State

shall notify the appropriate licensure authority. A State shall

not make a finding that an individual has neglected a resident

if the individual demonstrates that such neglect was caused by

factors beyond the control of the individual.

(D) Removal of name from nurse aide registry

(i) In general

In the case of a finding of neglect under subparagraph (C),

the State shall establish a procedure to permit a nurse aide

to petition the State to have his or her name removed from

the registry upon a determination by the State that -

(I) the employment and personal history of the nurse aide

does not reflect a pattern of abusive behavior or neglect;

and

(II) the neglect involved in the original finding was a

singular occurrence.

(ii) Timing of determination

In no case shall a determination on a petition submitted

under clause (i) be made prior to the expiration of the

1-year period beginning on the date on which the name of the

petitioner was added to the registry under subparagraph (C).

(E) Construction

The failure of the Secretary to issue regulations to carry

out this subsection shall not relieve a State of its

responsibility under this subsection.

(2) Surveys

(A) Standard survey

(i) In general

Each skilled nursing facility shall be subject to a

standard survey, to be conducted without any prior notice to

the facility. Any individual who notifies (or causes to be

notified) a skilled nursing facility of the time or date on

which such a survey is scheduled to be conducted is subject

to a civil money penalty of not to exceed $2,000. The

provisions of section 1320a-7a of this title (other than

subsections (a) and (b)) shall apply to a civil money penalty

under the previous sentence in the same manner as such

provisions apply to a penalty or proceeding under section

1320a-7a(a) of this title. The Secretary shall review each

State's procedures for the scheduling and conduct of standard

surveys to assure that the State has taken all reasonable

steps to avoid giving notice of such a survey through the

scheduling procedures and the conduct of the surveys

themselves.

(ii) Contents

Each standard survey shall include, for a case-mix

stratified sample of residents -

(I) a survey of the quality of care furnished, as

measured by indicators of medical, nursing, and

rehabilitative care, dietary and nutrition services,

activities and social participation, and sanitation,

infection control, and the physical environment,

(II) written plans of care provided under subsection

(b)(2) of this section and an audit of the residents'

assessments under subsection (b)(3) of this section to

determine the accuracy of such assessments and the adequacy

of such plans of care, and

(III) a review of compliance with residents' rights under

subsection (c) of this section.

(iii) Frequency

(I) In general

Each skilled nursing facility shall be subject to a

standard survey not later than 15 months after the date of

the previous standard survey conducted under this

subparagraph. The Statewide average interval between

standard surveys of skilled nursing facilities under this

subsection shall not exceed 12 months.

(II) Special surveys

If not otherwise conducted under subclause (I), a

standard survey (or an abbreviated standard survey) may be

conducted within 2 months of any change of ownership,

administration, management of a skilled nursing facility,

or the director of nursing in order to determine whether

the change has resulted in any decline in the quality of

care furnished in the facility.

(B) Extended surveys

(i) In general

Each skilled nursing facility which is found, under a

standard survey, to have provided substandard quality of care

shall be subject to an extended survey. Any other facility

may, at the Secretary's or State's discretion, be subject to

such an extended survey (or a partial extended survey).

(ii) Timing

The extended survey shall be conducted immediately after

the standard survey (or, if not practicable, not later than 2

weeks after the date of completion of the standard survey).

(iii) Contents

In such an extended survey, the survey team shall review

and identify the policies and procedures which produced such

substandard quality of care and shall determine whether the

facility has complied with all the requirements described in

subsections (b), (c), and (d) of this section. Such review

shall include an expansion of the size of the sample of

residents' assessments reviewed and a review of the staffing,

of in-service training, and, if appropriate, of contracts

with consultants.

(iv) Construction

Nothing in this paragraph shall be construed as requiring

an extended or partial extended survey as a prerequisite to

imposing a sanction against a facility under subsection (h)

of this section on the basis of findings in a standard

survey.

(C) Survey protocol

Standard and extended surveys shall be conducted -

(i) based upon a protocol which the Secretary has

developed, tested, and validated by not later than January 1,

1990, and

(ii) by individuals, of a survey team, who meet such

minimum qualifications as the Secretary establishes by not

later than such date.

The failure of the Secretary to develop, test, or validate such

protocols or to establish such minimum qualifications shall not

relieve any State of its responsibility (or the Secretary of

the Secretary's responsibility) to conduct surveys under this

subsection.

(D) Consistency of surveys

Each State and the Secretary shall implement programs to

measure and reduce inconsistency in the application of survey

results among surveyors.

(E) Survey teams

(i) In general

Surveys under this subsection shall be conducted by a

multidisciplinary team of professionals (including a

registered professional nurse).

(ii) Prohibition of conflicts of interest

A State may not use as a member of a survey team under this

subsection an individual who is serving (or has served within

the previous 2 years) as a member of the staff of, or as a

consultant to, the facility surveyed respecting compliance

with the requirements of subsections (b), (c), and (d) of

this section, or who has a personal or familial financial

interest in the facility being surveyed.

(iii) Training

The Secretary shall provide for the comprehensive training

of State and Federal surveyors in the conduct of standard and

extended surveys under this subsection, including the

auditing of resident assessments and plans of care. No

individual shall serve as a member of a survey team unless

the individual has successfully completed a training and

testing program in survey and certification techniques that

has been approved by the Secretary.

(3) Validation surveys

(A) In general

The Secretary shall conduct onsite surveys of a

representative sample of skilled nursing facilities in each

State, within 2 months of the date of surveys conducted under

paragraph (2) by the State, in a sufficient number to allow

inferences about the adequacies of each State's surveys

conducted under paragraph (2). In conducting such surveys, the

Secretary shall use the same survey protocols as the State is

required to use under paragraph (2). If the State has

determined that an individual skilled nursing facility meets

the requirements of subsections (b), (c), and (d) of this

section, but the Secretary determines that the facility does

not meet such requirements, the Secretary's determination as to

the facility's noncompliance with such requirements is binding

and supersedes that of the State survey.

(B) Scope

With respect to each State, the Secretary shall conduct

surveys under subparagraph (A) each year with respect to at

least 5 percent of the number of skilled nursing facilities

surveyed by the State in the year, but in no case less than 5

skilled nursing facilities in the State.

(C) Remedies for substandard performance

If the Secretary finds, on the basis of such surveys, that a

State has failed to perform surveys as required under paragraph

(2) or that a State's survey and certification performance

otherwise is not adequate, the Secretary shall provide for an

appropriate remedy, which may include the training of survey

teams in the State.

(D) Special surveys of compliance

Where the Secretary has reason to question the compliance of

a skilled nursing facility with any of the requirements of

subsections (b), (c), and (d) of this section, the Secretary

may conduct a survey of the facility and, on the basis of that

survey, make independent and binding determinations concerning

the extent to which the skilled nursing facility meets such

requirements.

(4) Investigation of complaints and monitoring compliance

Each State shall maintain procedures and adequate staff to -

(A) investigate complaints of violations of requirements by

skilled nursing facilities, and

(B) monitor, on-site, on a regular, as needed basis, a

skilled nursing facility's compliance with the requirements of

subsections (b), (c), and (d) of this section, if -

(i) the facility has been found not to be in compliance

with such requirements and is in the process of correcting

deficiencies to achieve such compliance;

(ii) the facility was previously found not to be in

compliance with such requirements, has corrected deficiencies

to achieve such compliance, and verification of continued

compliance is indicated; or

(iii) the State has reason to question the compliance of

the facility with such requirements.

A State may maintain and utilize a specialized team (including an

attorney, an auditor, and appropriate health care professionals)

for the purpose of identifying, surveying, gathering and

preserving evidence, and carrying out appropriate enforcement

actions against substandard skilled nursing facilities.

(5) Disclosure of results of inspections and activities

(A) Public information

Each State, and the Secretary, shall make available to the

public -

(i) information respecting all surveys and certifications

made respecting skilled nursing facilities, including

statements of deficiencies, within 14 calendar days after

such information is made available to those facilities, and

approved plans of correction,

(ii) copies of cost reports of such facilities filed under

this subchapter or subchapter XIX of this chapter,

(iii) copies of statements of ownership under section

1320a-3 of this title, and

(iv) information disclosed under section 1320a-5 of this

title.

(B) Notice to ombudsman

Each State shall notify the State long-term care ombudsman

(established under title III or VII of the Older Americans Act

of 1965 [42 U.S.C. 3021 et seq., 3058 et seq.] in accordance

with section 712 of the Act [42 U.S.C. 3058g]) of the State's

findings of noncompliance with any of the requirements of

subsections (b), (c), and (d) of this section, or of any

adverse action taken against a skilled nursing facility under

paragraph (1), (2), or (4) of subsection (h) of this section,

with respect to a skilled nursing facility in the State.

(C) Notice to physicians and skilled nursing facility

administrator licensing board

If a State finds that a skilled nursing facility has provided

substandard quality of care, the State shall notify -

(i) the attending physician of each resident with respect

to which such finding is made, and

(ii) the State board responsible for the licensing of the

skilled nursing facility administrator at the facility.

(D) Access to fraud control units

Each State shall provide its State medicaid fraud and abuse

control unit (established under section 1396b(q) of this title)

with access to all information of the State agency responsible

for surveys and certifications under this subsection.

(h) Enforcement process

(1) In general

If a State finds, on the basis of a standard, extended, or

partial extended survey under subsection (g)(2) of this section

or otherwise, that a skilled nursing facility no longer meets a

requirement of subsection (b), (c), or (d) of this section, and

further finds that the facility's deficiencies -

(A) immediately jeopardize the health or safety of its

residents, the State shall recommend to the Secretary that the

Secretary take such action as described in paragraph (2)(A)(i);

or

(B) do not immediately jeopardize the health or safety of its

residents, the State may recommend to the Secretary that the

Secretary take such action as described in paragraph

(2)(A)(ii).

If a State finds that a skilled nursing facility meets the

requirements of subsections (b), (c), and (d) of this section,

but, as of a previous period, did not meet such requirements, the

State may recommend a civil money penalty under paragraph

(2)(B)(ii) for the days in which it finds that the facility was

not in compliance with such requirements.

(2) Secretarial authority

(A) In general

With respect to any skilled nursing facility in a State, if

the Secretary finds, or pursuant to a recommendation of the

State under paragraph (1) finds, that a skilled nursing

facility no longer meets a requirement of subsection (b), (c),

(d), or (e) of this section, and further finds that the

facility's deficiencies -

(i) immediately jeopardize the health or safety of its

residents, the Secretary shall take immediate action to

remove the jeopardy and correct the deficiencies through the

remedy specified in subparagraph (B)(iii), or terminate the

facility's participation under this subchapter and may

provide, in addition, for one or more of the other remedies

described in subparagraph (B); or

(ii) do not immediately jeopardize the health or safety of

its residents, the Secretary may impose any of the remedies

described in subparagraph (B).

Nothing in this subparagraph shall be construed as restricting

the remedies available to the Secretary to remedy a skilled

nursing facility's deficiencies. If the Secretary finds, or

pursuant to the recommendation of the State under paragraph (1)

finds, that a skilled nursing facility meets such requirements

but, as of a previous period, did not meet such requirements,

the Secretary may provide for a civil money penalty under

subparagraph (B)(ii) for the days on which he finds that the

facility was not in compliance with such requirements.

(B) Specified remedies

The Secretary may take the following actions with respect to

a finding that a facility has not met an applicable

requirement:

(i) Denial of payment

The Secretary may deny any further payments under this

subchapter with respect to all individuals entitled to

benefits under this subchapter in the facility or with

respect to such individuals admitted to the facility after

the effective date of the finding.

(ii) Authority with respect to civil money penalties

The Secretary may impose a civil money penalty in an amount

not to exceed $10,000 for each day of noncompliance. The

provisions of section 1320a-7a of this title (other than

subsections (a) and (b)) shall apply to a civil money penalty

under the previous sentence in the same manner as such

provisions apply to a penalty or proceeding under section

1320a-7a(a) of this title.

(iii) Appointment of temporary management

In consultation with the State, the Secretary may appoint

temporary management to oversee the operation of the facility

and to assure the health and safety of the facility's

residents, where there is a need for temporary management

while -

(I) there is an orderly closure of the facility, or

(II) improvements are made in order to bring the facility

into compliance with all the requirements of subsections

(b), (c), and (d) of this section.

The temporary management under this clause shall not be

terminated under subclause (II) until the Secretary has

determined that the facility has the management capability to

ensure continued compliance with all the requirements of

subsections (b), (c), and (d) of this section.

The Secretary shall specify criteria, as to when and how each

of such remedies is to be applied, the amounts of any fines,

and the severity of each of these remedies, to be used in the

imposition of such remedies. Such criteria shall be designed so

as to minimize the time between the identification of

violations and final imposition of the remedies and shall

provide for the imposition of incrementally more severe fines

for repeated or uncorrected deficiencies. In addition, the

Secretary may provide for other specified remedies, such as

directed plans of correction.

(C) Continuation of payments pending remediation

The Secretary may continue payments, over a period of not

longer than 6 months after the effective date of the findings,

under this subchapter with respect to a skilled nursing

facility not in compliance with a requirement of subsection

(b), (c), or (d) of this section, if -

(i) the State survey agency finds that it is more

appropriate to take alternative action to assure compliance

of the facility with the requirements than to terminate the

certification of the facility,

(ii) the State has submitted a plan and timetable for

corrective action to the Secretary for approval and the

Secretary approves the plan of corrective action, and

(iii) the facility agrees to repay to the Federal

Government payments received under this subparagraph if the

corrective action is not taken in accordance with the

approved plan and timetable.

The Secretary shall establish guidelines for approval of

corrective actions requested by States under this subparagraph.

(D) Assuring prompt compliance

If a skilled nursing facility has not complied with any of

the requirements of subsections (b), (c), and (d) of this

section, within 3 months after the date the facility is found

to be out of compliance with such requirements, the Secretary

shall impose the remedy described in subparagraph (B)(i) for

all individuals who are admitted to the facility after such

date.

(E) Repeated noncompliance

In the case of a skilled nursing facility which, on 3

consecutive standard surveys conducted under subsection (g)(2)

of this section, has been found to have provided substandard

quality of care, the Secretary shall (regardless of what other

remedies are provided) -

(i) impose the remedy described in subparagraph (B)(i), and

(ii) monitor the facility under subsection (g)(4)(B) of

this section,

until the facility has demonstrated, to the satisfaction of the

Secretary, that it is in compliance with the requirements of

subsections (b), (c), and (d) of this section, and that it will

remain in compliance with such requirements.

(3) Effective period of denial of payment

A finding to deny payment under this subsection shall terminate

when the Secretary finds that the facility is in substantial

compliance with all the requirements of subsections (b), (c), and

(d) of this section.

(4) Immediate termination of participation for facility where

Secretary finds noncompliance and immediate jeopardy

If the Secretary finds that a skilled nursing facility has not

met a requirement of subsection (b), (c), or (d) of this section,

and finds that the failure immediately jeopardizes the health or

safety of its residents, the Secretary shall take immediate

action to remove the jeopardy and correct the deficiencies

through the remedy specified in paragraph (2)(B)(iii), or the

Secretary shall terminate the facility's participation under this

subchapter. If the facility's participation under this subchapter

is terminated, the State shall provide for the safe and orderly

transfer of the residents eligible under this subchapter

consistent with the requirements of subsection (c)(2) of this

section.

(5) Construction

The remedies provided under this subsection are in addition to

those otherwise available under State or Federal law and shall

not be construed as limiting such other remedies, including any

remedy available to an individual at common law. The remedies

described in clauses (i),(!7) and (iii) of paragraph (2)(B) may

be imposed during the pendency of any hearing.

(6) Sharing of information

Notwithstanding any other provision of law, all information

concerning skilled nursing facilities required by this section to

be filed with the Secretary or a State agency shall be made

available by such facilities to Federal or State employees for

purposes consistent with the effective administration of programs

established under this subchapter and subchapter XIX of this

chapter, including investigations by State medicaid fraud control

units.

(i) Construction

Where requirements or obligations under this section are

identical to those provided under section 1396r of this title, the

fulfillment of those requirements or obligations under section

1396r of this title shall be considered to be the fulfillment of

the corresponding requirements or obligations under this section.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1819, as added and

amended Pub. L. 100-203, title IV, Secs. 4201(a)(3), 4202(a)(2),

4203(a)(2), 4206, Dec. 22, 1987, 101 Stat. 1330-160, 1330-175,

1330-179, 1330-182; Pub. L. 100-360, title IV, Sec. 411(l)(1)(A),

(2)(A)-(D), (F)-(L)(i), (4), (5), (7), (11), July 1, 1988, 102

Stat. 800-805, as amended Pub. L. 100-485, title VI, Sec.

608(d)(27)(A), (C), (D), (I), (L), Oct. 13, 1988, 102 Stat. 2422,

2423; Pub. L. 101-239, title VI, Sec. 6901(b)(1), (3), (d)(4), Dec.

19, 1989, 103 Stat. 2298, 2301; Pub. L. 101-508, title IV, Secs.

4008(h)(1)(B)-(F)(i), (G), (2)(B)-(N), (m)(3)(F)[(E)], 4206(d)(1),

Nov. 5, 1990, 104 Stat. 1388-46 to 1388-50, 1388-54, 1388-116; Pub.

L. 102-375, title VII, Sec. 708(a)(1)(A), Sept. 30, 1992, 106 Stat.

1291; Pub. L. 103-432, title I, Secs. 106(c)(1)(A), (2)(A), (3)(A),

(4)(A), (B), (d)(1)-(5), 110(b), Oct. 31, 1994, 108 Stat.

4406-4408; Pub. L. 105-15, Sec. 1, May 15, 1997, 111 Stat. 34; Pub.

L. 105-33, title IV, Secs. 4432(b)(5)(A), 4755(a), Aug. 5, 1997,

111 Stat. 421, 526; Pub. L. 106-554, Sec. 1(a)(6) [title IX, Sec.

941(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A-585.)

-REFTEXT-

REFERENCES IN TEXT

The Older Americans Act of 1965, referred to in subsecs.

(b)(4)(C)(ii)(IV), (c)(2)(B)(iii)(II), and (g)(5)(B), is Pub. L.

89-73, July 14, 1965, 79 Stat. 218, as amended. Section 307(a)(12)

of the Act was repealed by Pub. L. 106-501, title III, Sec. 306(5),

Nov. 13, 2000, 114 Stat. 2244. Similar provisions are now contained

in section 307(a)(9) of the Act, which is classified to section

3027(a)(9) of this title. Titles III and VII of the Act are

classified generally to subchapters III (Sec. 3021 et seq.) and XI

(Sec. 3058 et seq.) of chapter 35 of this title. For complete

classification of this Act to the Code, see Short Title note set

out under section 3001 of this title and Tables.

Subparagraphs (B), (C), and (D) of section 6901(b)(4) of the

Omnibus Budget Reconciliation Act of 1989 [Pub. L. 101-239],

referred to in subsec. (e)(2)(A), are set out below.

Section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse

Amendments of 1977, referred to in subsec. (f)(7)(A), probably

means section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse

Amendments, Pub. L. 95-142, which is set out as a note under

section 1395x of this title.

-MISC1-

AMENDMENTS

2000-Subsec. (b)(8). Pub. L. 106-554 added par. (8).

1997 - Subsec. (b)(3)(C)(i). Pub. L. 105-33, Sec. 4432(b)(5)(A),

substituted "Subject to the timeframes prescribed by the Secretary

under section 1395yy(e)(6) of this title, such" for "Such" in

introductory provisions.

Subsec. (f)(2)(B)(iii). Pub. L. 105-15, Sec. 1(1), inserted

"subject to subparagraph (C)," after "(iii)".

Subsec. (f)(2)(C). Pub. L. 105-15, Sec. 1(2), added subpar. (C).

Subsec. (g)(1)(D), (E). Pub. L. 105-33, Sec. 4755(a), added

subpar. (D) and redesignated former subpar. (D) as (E).

1994 - Subsec. (b)(3)(C)(i)(I). Pub. L. 103-432, Sec. 110(b),

substituted "but no later than 14 days" for "but no later than not

later than 14 days".

Subsec. (b)(5)(D). Pub. L. 103-432, Sec. 106(d)(1), struck out

comma before "or a new competency evaluation program".

Subsec. (b)(5)(G). Pub. L. 103-432, Sec. 106(d)(2), substituted

"licensed or certified social worker, registered respiratory

therapist, or certified respiratory therapy technician" for "or

licensed or certified social worker".

Subsec. (c)(1)(D). Pub. L. 103-432, Sec. 106(c)(2)(A), inserted

at end "In determining whether such a consultant is qualified to

conduct reviews under the preceding sentence, the Secretary shall

take into account the needs of nursing facilities under this

subchapter to have access to the services of such a consultant on a

timely basis."

Subsec. (c)(6)(B)(i). Pub. L. 103-432, Sec. 106(c)(3)(A),

substituted "$100" for "$50".

Subsec. (e)(2)(B). Pub. L. 103-432, Sec. 106(c)(4)(A), inserted

", but shall not include any allegations of resident abuse or

neglect or misappropriation of resident property that are not

specifically documented by the State under such subsection" after

"individual disputing the findings" in first sentence.

Subsec. (f)(2)(B)(i). Pub. L. 103-432, Sec. 106(d)(3),

substituted "facilities (subject to clause (iii))," for

"facilities,".

Subsec. (f)(2)(B)(iii)(I)(b). Pub. L. 103-432, Sec. 106(c)(1)(A),

inserted before semicolon at end ", unless the survey shows that

the facility is in compliance with the requirements of subsections

(b), (c), and (d) of this section".

Subsec. (f)(2)(B)(iii)(I)(c). Pub. L. 103-432, Sec. 106(d)(4),

substituted "clause" for "clauses" in two places.

Subsec. (g)(1)(C). Pub. L. 103-432, Sec. 106(c)(4)(B),

substituted second sentence for former second sentence which read

as follows: "The State shall, after notice to the individual

involved and a reasonable opportunity for a hearing for the

individual to rebut allegations, make a finding as to the accuracy

of the allegations."

Subsec. (g)(5)(B). Pub. L. 103-432, Sec. 106(d)(5), substituted

"paragraph" for "paragraphs" before "(1), (2), or (4) of subsection

(h)".

1992 - Subsecs. (c)(2)(B)(iii)(II), (g)(5)(B). Pub. L. 102-375

substituted "title III or VII of the Older Americans Act of 1965 in

accordance with section 712 of the Act" for "section 307(a)(12) of

the Older Americans Act of 1965".

1990 - Subsec. (b)(1)(B). Pub. L. 101-508, Sec. 4008(h)(2)(B),

inserted at end "A State or the Secretary may not require

disclosure of the records of such committee except insofar as such

disclosure is related to the compliance of such committee with the

requirements of this subparagraph."

Subsec. (b)(3)(C)(i)(I). Pub. L. 101-508, Sec. 4008(h)(2)(C),

substituted "not later than 14 days" for "4 days".

Subsec. (b)(4)(A)(vii). Pub. L. 101-508, Sec. 4008(h)(2)(D),

added cl. (vii).

Subsec. (b)(4)(C)(ii)(IV), (V). Pub. L. 101-508, Sec.

4008(h)(2)(E), added subcls. (IV) and (V).

Subsec. (b)(5)(A). Pub. L. 101-508, Sec. 4008(h)(1)(B),

designated existing provisions as cl. (i), in introductory

provisions substituted "Except as provided in clause (ii), a

skilled nursing facility" for "A skilled nursing facility" and "on

a full-time basis" for "(on a full-time, temporary, per diem, or

other basis)", redesignated former cls. (i) and (ii) as subcls. (I)

and (II), respectively, and added cl. (ii).

Subsec. (b)(5)(C). Pub. L. 101-508, Sec. 4008(h)(1)(C),

substituted "any State registry established under subsection

(e)(2)(A) of this section that the facility believes will include

information" for "the State registry established under subsection

(e)(2)(A) of this section as to information in the registry".

Subsec. (b)(5)(D). Pub. L. 101-508, Sec. 4008(h)(1)(D), inserted

before period at end ", or a new competency evaluation program"

after "and competency evaluation program".

Subsec. (b)(5)(F)(i). Pub. L. 101-508, Sec. 4008(h)(2)(F),

substituted "(G)) or a registered dietician," for "(G)),".

Subsec. (c)(1)(A). Pub. L. 101-508, Sec. 4008(h)(2)(G)(B)[(ii)],

inserted at end "A resident's exercise of a right to refuse

transfer under clause (x) shall not affect the resident's

eligibility or entitlement to benefits under this subchapter or to

medical assistance under subchapter XIX of this chapter."

Subsec. (c)(1)(A)(iv). Pub. L. 101-508, Sec. 4008(h)(2)(H),

inserted before period at end "and to access to current clinical

records of the resident upon request by the resident or the

resident's legal representative, within 24 hours (excluding hours

occurring during a weekend or holiday) after making such a

request".

Subsec. (c)(1)(A)(x), (xi). Pub. L. 101-508, Sec.

4008(h)(2)(G)(i), added cl. (x) and redesignated former cl. (x) as

(xi).

Subsec. (c)(1)(B)(ii). Pub. L. 101-508, Sec. 4008(h)(2)(I),

inserted "including the notice (if any) of the State developed

under section 1396r(e)(6) of this title" after "in such rights)".

Subsec. (c)(1)(E). Pub. L. 101-508, Sec. 4206(d)(1), added

subpar. (E).

Subsec. (e)(1)(A). Pub. L. 101-508, Sec. 4008(h)(2)(J),

substituted "subsection (f)(2) of this section" for "clause (i) or

(ii) of subsection (f)(2)(A) of this section".

Subsec. (e)(2)(A). Pub. L. 101-508, Sec. 4008(h)(2)(K)(i),

inserted before period at end ", or any individual described in

subsection (f)(2)(B)(ii) of this section or in subparagraph (B),

(C), or (D) of section 6901(b)(4) of the Omnibus Budget

Reconciliation Act of 1989".

Subsec. (e)(2)(C). Pub. L. 101-508, Sec. 4008(h)(2)(K)(ii), added

subpar. (C).

Subsec. (f)(2)(A)(ii). Pub. L. 101-508, Sec. 4008(m)(3)(F)[(E)],

struck out "and" after semicolon at end.

Subsec. (f)(2)(A)(iv). Pub. L. 101-508, Sec. 4008(h)(1)(E),

struck out "and" at end of subcl. (I), inserted "who is employed by

(or who has received an offer of employment from) a facility on the

date on which the aide begins either such program" after "nurse

aide" and substituted ", and" for period at end of subcl. (II), and

added subcl. (III).

Subsec. (f)(2)(B). Pub. L. 101-508, Sec. 4008(h)(1)(G), inserted

"(through subcontract or otherwise)" after "may not delegate" in

second sentence.

Subsec. (f)(2)(B)(iii)(I). Pub. L. 101-508, Sec.

4008(h)(1)(F)(i), amended subcl. (I) generally. Prior to amendment,

subcl. (I) read as follows: "offered by or in a skilled nursing

facility which has been determined to be out of compliance with the

requirements of subsection (b), (c), or (d) of this section, within

the previous 2 years, or".

Subsec. (g)(1)(C). Pub. L. 101-508, Sec. 4008(h)(2)(L), inserted

at end "A State shall not make a finding that an individual has

neglected a resident if the individual demonstrates that such

neglect was caused by factors beyond the control of the

individual."

Subsec. (g)(5)(A)(i). Pub. L. 101-508, Sec. 4008(h)(2)(M),

substituted "deficiencies, within 14 calendar days after such

information is made available to those facilities, and approved

plans" for "deficiencies and plans".

Subsec. (g)(5)(B). Pub. L. 101-508, Sec. 4008(h)(2)(N),

substituted "or of any adverse action taken against a skilled

nursing facility under paragraphs (1), (2), or (4) of subsection

(h) of this section, with respect" for "with respect".

1989 - Subsec. (b)(5)(A). Pub. L. 101-239, Sec. 6901(b)(1)(A),

substituted "October 1, 1990" for "January 1, 1990" in introductory

provisions.

Subsec. (b)(5)(B). Pub. L. 101-239, Sec. 6901(b)(1)(B),

substituted "January 1, 1990" and "October 1, 1990" for "July 1,

1989" and "January 1, 1990", respectively.

Subsec. (c)(1)(A)(ii)(II). Pub. L. 101-239, Sec. 6901(d)(4)(A),

substituted "Secretary until such an order could reasonably be

obtained)" for "Secretary) until such an order could reasonably be

obtained".

Subsec. (c)(1)(A)(v)(I). Pub. L. 101-239, Sec. 6901(d)(4)(B),

substituted "accommodation" for "accommodations".

Subsec. (f)(2)(A)(i)(I). Pub. L. 101-239, Sec. 6901(d)(4)(C),

substituted "and content of the curriculum" for ", content of the

curriculum".

Pub. L. 101-239, Sec. 6901(b)(3)(A), inserted "care of

cognitively impaired residents," after "social service needs,".

Subsec. (f)(2)(A)(ii). Pub. L. 101-239, Sec. 6901(b)(3)(B),

substituted "recognition of mental health and social service needs,

care of cognitively impaired residents" for "cognitive, behavioral

and social care".

Subsec. (f)(2)(A)(iv). Pub. L. 101-239, Sec. 6901(b)(3)(C), (D),

added cl. (iv).

Subsec. (h)(2)(C). Pub. L. 101-239, Sec. 6901(d)(4)(D), inserted

"after the effective date of the findings" after "6 months" in

introductory provisions.

1988 - Subsec. (b)(3)(A)(iii). Pub. L. 100-360, Sec.

411(l)(2)(B), struck out "in the case of a resident eligible for

benefits under subchapter XIX of this chapter," before "uses an

instrument".

Subsec. (b)(3)(A)(iv). Pub. L. 100-360, Sec. 411(l)(2)(A), as

amended by Pub. L. 100-485, Sec. 608(d)(27)(C), struck out "in the

case of a resident eligible for benefits under this part," before

"includes the identification".

Subsec. (b)(3)(B)(ii)(III). Pub. L. 100-360, Sec. 411(l)(2)(C),

amended subcl. (III) generally. Prior to amendment, subcl. (III)

read as follows: "The Secretary shall provide for imposition of

civil money penalties under this clause in a manner similar to that

for the imposition of civil money penalties under section 1320a-7a

of this title."

Subsec. (b)(3)(C)(i)(I). Pub. L. 100-360, Sec. 411(l)(1)(A)(i),

substituted "than January 1, 1991" for "than October 1, 1990".

Subsec. (b)(4)(C)(i). Pub. L. 100-360, Sec. 411(l)(1)(A)(ii),

substituted "24-hour licensed nursing" for "24-hour nursing", "must

use" for "must employ", and "at least 8 consecutive hours a day,"

for "during the day tour of duty (of at least 8 hours a day)".

Subsec. (b)(5)(A). Pub. L. 100-360, Sec. 411(l)(2)(D)(i), as

amended by Pub. L. 100-485, Sec. 608(d)(27)(D), struck out ", who

is not a licensed health professional (as defined in subparagraph

(E))," after "any individual".

Pub. L. 100-360, Sec. 411(l)(1)(A)(iii), substituted "January 1,

1990" for "October 1, 1989, (or January 1, 1990, in the case of an

individual used by the facility as a nurse aide before July 1,

1989)".

Subsec. (b)(5)(A)(ii). Pub. L. 100-360, Sec. 411(l)(2)(D)(ii),

substituted "nursing or nursing-related services" for "such

services".

Subsec. (b)(5)(G). Pub. L. 100-360, Sec. 411(l)(2)(D)(iii),

inserted "physical or occupational therapy assistant," after

"occupational therapist,".

Subsec. (c)(1)(D). Pub. L. 100-360, Sec. 411(l)(1)(A)(iv), as

added by Pub. L. 100-485, Sec. 608(d)(27)(A), added subpar. (D).

Subsec. (c)(2)(A)(v). Pub. L. 100-360, Sec. 411(l)(2)(F),

substituted "for a stay at the facility" for "an allowable charge

imposed by the facility for an item or service requested by the

resident and for which a charge may be imposed consistent with this

subchapter and subchapter XIX of this chapter".

Subsec. (c)(6). Pub. L. 100-360, Sec. 411(l)(2)(G), substituted

"upon the written" for "once the facility accepts the written" in

subpar. (A)(ii), and "Upon written" for "Upon a facility's

acceptance of written" in subpar. (B).

Subsec. (e)(1)(A). Pub. L. 100-360, Sec. 411(l)(1)(A)(v),

formerly Sec. 411(l)(1)(A)(iv), as redesignated by Pub. L. 100-485,

Sec. 608(d)(27)(A), substituted "January" for "March".

Subsec. (e)(1)(B). Pub. L. 100-360, Sec. 411(l)(1)(A)(vi),

formerly Sec. 411(l)(1)(A)(v), as redesignated by Pub. L. 100-485,

Sec. 608(d)(27)(A), substituted "January" for "March".

Subsec. (e)(2)(A). Pub. L. 100-360, Sec. 411(l)(1)(A)(vii),

formerly Sec. 411(l)(1)(A)(vi), as redesignated by Pub. L. 100-485,

Sec. 608(d)(27)(A), substituted "January" for "March".

Subsec. (e)(2)(B). Pub. L. 100-360, Sec. 411(l)(2)(H), inserted

after first sentence "The State shall make available to the public

information in the registry."

Subsec. (e)(3). Pub. L. 100-360, Sec. 411(l)(2)(I), inserted "and

discharges" after "transfers" in heading and in two places in text.

Pub. L. 100-360, Sec. 411(l)(1)(A)(viii), formerly Sec.

411(l)(1)(A)(vii), as redesignated by Pub. L. 100-485, Sec.

608(d)(27)(A), substituted "1989" for "1990".

Subsec. (e)(5). Pub. L. 100-360, Sec. 411(l)(1)(A)(ix), formerly

Sec. 411(l)(1)(A)(viii), as redesignated by Pub. L. 100-485, Sec.

608(d)(27)(A), substituted "1990" for "1989" in introductory

provisions.

Subsec. (f)(2)(A)(i)(I). Pub. L. 100-360, Sec. 411(l)(2)(J),

substituted "recognition of mental health and social service needs"

for "cognitive, behavioral and social care".

Subsec. (f)(3). Pub. L. 100-360, Sec. 411(l)(2)(I), inserted "and

discharges" after "transfers" in heading and in text.

Pub. L. 100-360, Sec. 411(l)(1)(A)(x), formerly Sec.

411(l)(1)(A)(ix), as redesignated by Pub. L. 100-485, Sec.

608(d)(27)(A), substituted "1988" for "1989".

Subsec. (f)(6)(A). Pub. L. 100-360, Sec. 411(l)(1)(A)(xi),

formerly Sec. 411(l)(1)(A)(x), as redesignated by Pub. L. 100-485,

Sec. 608(d)(27)(A), substituted "January" for "July".

Subsec. (f)(6)(B). Pub. L. 100-360, Sec. 411(l)(1)(A)(xii),

formerly Sec. 411(l)(1)(A)(xi), as redesignated by Pub. L. 100-485,

Sec. 608(d)(27)(A), substituted "April" for "October".

Subsec. (f)(7)(A). Pub. L. 100-360, Sec. 411(l)(2)(K),

substituted "residents" for "patients".

Subsec. (f)(7)(B). Pub. L. 100-360, Sec. 411(l)(2)(L)(i),

substituted "shall include" for "shall not include".

Subsec. (g)(1)(C). Pub. L. 100-360, Sec. 411(l)(5)(A)-(C),

substituted "and timely review" for ", review,", inserted "or by

another individual used by the facility in providing services to

such a resident" after "a nursing facility", and substituted "The

State shall, after notice to the individual involved and a

reasonable opportunity for a hearing for the individual to rebut

allegations, make a finding as to the accuracy of the allegations.

If the State finds that a nurse aide has neglected or abused a

resident or misappropriated resident property in a facility, the

State shall notify the nurse aide and the registry of such finding.

If the State finds that any other individual used by the facility

has neglected or abused a resident or misappropriated resident

property in a facility, the State shall notify the appropriate

licensure authority." for "If the State finds, after notice to the

nurse aide involved and a reasonable opportunity for a hearing for

the nurse aide to rebut allegations, that a nurse aide whose name

is contained in a nurse aide registry has neglected or abused a

resident or misappropriated resident property in a facility, the

State shall notify the nurse aide and the registry of such

finding."

Subsec. (g)(1)(D). Pub. L. 100-360, Sec. 411(l)(5)(D),

substituted "to issue regulations to carry out this subsection" for

"to establish standards under subsection (f) of this section".

Subsec. (g)(2)(A)(i). Pub. L. 100-360, Sec. 411(l)(5)(E), amended

third sentence generally. Prior to amendment, third sentence read

as follows: "The Secretary shall provide for imposition of civil

money penalties under this clause in a manner similar to that for

the imposition of civil money penalties under section 1320a-7a of

this title."

Subsec. (g)(2)(B)(ii). Pub. L. 100-360, Sec. 411(l)(5)(F), as

added by Pub. L. 100-485, Sec. 608(d)(27)(I), substituted

"practicable" for "practical".

Subsec. (g)(2)(C)(i). Pub. L. 100-360, Sec. 411(l)(4),

substituted "January" for "October".

Subsec. (g)(3)(D). Pub. L. 100-360, Sec. 411(l)(5)(G), formerly

Sec. 411(l)(5)(F), as redesignated by Pub. L. 100-485, Sec.

608(d)(27)(I), substituted "on the basis of that survey" for "on

that basis".

Subsec. (g)(4). Pub. L. 100-360, Sec. 411(l)(5)(H), formerly Sec.

411(l)(5)(G), as redesignated by Pub. L. 100-485, Sec.

608(d)(27)(I), struck out "chronically" after "enforcement actions

against" in last sentence.

Subsec. (h)(2)(B)(ii). Pub. L. 100-360, Sec. 411(l)(7)(A),

substituted ". The provisions of section 1320a-7a of this title

(other than subsections (a) and (b)) shall apply to a civil money

penalty under the previous sentence in the same manner as such

provisions apply to a penalty or proceeding under section

1320a-7a(a) of this title." for "and the Secretary shall impose and

collect such a penalty in the same manner as civil money penalties

are imposed and collected under section 1320a-7a of this title."

Subsec. (h)(5). Pub. L. 100-360, Sec. 411(l)(11), as added by

Pub. L. 100-485, Sec. 608(d)(27)(L), substituted "clauses (i), and

(iii) of paragraph (2)(B)" for "clauses (i), (iii), and (iv) of

paragraph (2)(A)".

Subsec. (h)(6). Pub. L. 100-360, Sec. 411(l)(7)(B), inserted "by

such facilities" after "be made available".

1987 - Subsecs. (g) to (i). Pub. L. 100-203, Secs. 4202(a)(2),

4203(a)(2), 4206, added subsecs. (g), (h), and (i), respectively.

EFFECTIVE DATE OF 2000 AMENDMENT

Pub. L. 106-554, Sec. 1(a)(6) [title IX, Sec. 941(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-586, provided that: "The amendments

made by this section [amending this section and section 1396r of

this title] shall take effect on January 1, 2003."

EFFECTIVE DATE OF 1997 AMENDMENT

Section 4432(d) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and sections 1395k,

1395l, 1395u, 1395x, 1395y, 1395cc, 1395tt, and 1395yy of this

title] are effective for cost reporting periods beginning on or

after July 1, 1998; except that the amendments made by subsection

(b) [amending this section and sections 1395k, 1395l, 1395u, 1395x,

1395y, 1395cc, 1395tt, and 1395yy of this title] shall apply to

items and services furnished on or after July 1, 1998."

EFFECTIVE DATE OF 1994 AMENDMENT

Section 106(c)(1)(B) of Pub. L. 103-432 provided that: "The

amendment made by subparagraph (A) [amending this section] shall

take effect as if included in the enactment of OBRA-1990 [Pub. L.

101-508]."

Section 106(c)(2)(B) of Pub. L. 103-432 provided that: "The

amendment made by subparagraph (A) [amending this section] shall

take effect as if included in the enactment of OBRA-1987 [Pub. L.

100-203]."

Section 106(c)(3)(B) of Pub. L. 103-432 provided that: "The

amendment made by subparagraph (A) [amending this section] shall

take effect January 1, 1995."

Section 106(c)(4)(C) of Pub. L. 103-432 provided that: "The

amendments made by this paragraph [amending this section] shall

take effect January 1, 1995."

Section 106(d)(7) of Pub. L. 103-432 provided that: "The

amendments made by this subsection [amending this section and

provisions set out as a note below] shall take effect as if

included in the enactment of OBRA-1990 [Pub. L. 101-508]."

EFFECTIVE DATE OF 1992 AMENDMENT

Amendment by Pub. L. 102-375 inapplicable with respect to fiscal

year 1993, see section 4(b) of Pub. L. 103-171, set out as a note

under section 3001 of this title.

Amendment by Pub. L. 102-375 inapplicable with respect to fiscal

year 1992, see section 905(b)(6) of Pub. L. 102-375, set out as a

note under section 3001 of this title.

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4008(h)(1)(F)(ii) of Pub. L. 101-508, as amended by Pub.

L. 103-432, title I, Sec. 106(d)(6), Oct. 31, 1994, 108 Stat. 4407,

provided that:

"(I) The amendments made by clause (i) [amending this section]

shall take effect as if included in the enactment of the Omnibus

Budget Reconciliation Act of 1987 [Pub. L. 100-203], except that a

State may not approve a training and competency evaluation program

or a competency evaluation program offered by or in a skilled

nursing facility which, pursuant to any Federal or State law within

the 2-year period beginning on October 1, 1988 -

"(aa) had its participation terminated under title XVIII of the

Social Security Act [this subchapter] or under the State plan

under title XIX of such Act [subchapter XIX of this chapter];

"(bb) was subject to a denial of payment under either such

title;

"(cc) was assessed a civil money penalty not less than $5,000

for deficiencies in skilled nursing facility standards;

"(dd) operated under a temporary management appointed to

oversee the operation of the facility and to ensure the health

and safety of the facility's residents; or

"(ee) pursuant to State action, was closed or had its residents

transferred.

"(II) Notwithstanding subclause (I) and subject to section

1819(f)(2)(B)(iii)(I) of the Social Security Act [subsec.

(f)(2)(B)(iii)(I) of this section] (as amended by clause (i)), a

State may approve a training and competency evaluation program or a

competency evaluation program offered by or in a skilled nursing

facility described in subclause (I) if, during the previous 2

years, item (aa), (bb), (cc), (dd), or (ee) of subclause (I) did

not apply to the facility."

Section 4008(h)(1)(H) of Pub. L. 101-508 provided that: "Except

as provided in subparagraph (F) [amending this section and enacting

provisions set out as a note above], the amendments made by this

subsection [probably means this paragraph, amending this section]

shall take effect as if they were included in the enactment of the

Omnibus Budget Reconciliation Act of 1987 [Pub. L. 100-203]."

Section 4008(h)(2)(P) of Pub. L. 101-508 provided that: "The

amendments made by this paragraph [amending this section and

sections 1395x and 1395yy of this title] shall take effect as if

they were included in the enactment of the Omnibus Budget

Reconciliation Act of 1987 [Pub. L. 100-203]."

Section 4206(e)(1) of Pub. L. 101-508 provided that: "The

amendments made by subsections (a) and (d) [amending this section

and sections 1395cc and 1395bbb of this title] shall apply with

respect to services furnished on or after the first day of the

first month beginning more than 1 year after the date of the

enactment of this Act [Nov. 5, 1990]."

EFFECTIVE DATE OF 1989 AMENDMENT

Section 6901(b)(6) of Pub. L. 101-239 provided that:

"(A) In general. - Except as provided in subparagraph (B), the

amendments made by this subsection [amending this section and

sections 1396b and 1396r of this title] shall take effect as if

they were included in the enactment of the Omnibus Budget

Reconciliation Act of 1987 [Pub. L. 100-203].

"(B) Exception. - The amendments made by paragraph (3) [amending

this section and section 1396r of this title] shall apply to nurse

aide training and competency evaluation programs, and nurse aide

competency evaluation programs, offered on or after the end of the

90-day period beginning on the date of the enactment of this Act

[Dec. 19, 1989], but shall not affect competency evaluations

conducted under programs offered before the end of such period."

Section 6901(d)(6) of Pub. L. 101-239 provided that:

"(A) In general. - Except as provided in subparagraph (B), the

amendments made by this subsection [amending this section and

sections 1396i and 1396r of this title] shall take effect as if

they were included in the enactment of the Omnibus Budget

Reconciliation Act of 1987 [Pub. L. 100-203].

"(B) Exception. - The amendment made by paragraph (1) [amending

section 1396r of this title] shall take effect on the date of the

enactment of this Act [Dec. 19, 1989]."

EFFECTIVE DATE OF 1988 AMENDMENTS

Amendment by Pub. L. 100-485 effective as if originally included

in the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100-360,

see section 608(g)(1) of Pub. L. 100-485, set out as a note under

section 704 of this title.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by Pub. L. 100-360, as it relates to a provision

in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203,

effective as if included in the enactment of that provision in Pub.

L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a

Reference to OBRA; Effective Date note under section 106 of Title

1, General Provisions.

EFFECTIVE DATE

Section 4204 of title IV of Pub. L. 100-203, as amended by Pub.

L. 100-360, title IV, Sec. 411(l)(9), July 1, 1988, 102 Stat. 805;

Pub. L. 100-485, title VI, Sec. 608(d)(27)(K), Oct. 13, 1988, 102

Stat. 2423, provided that:

"(a) New Requirements and Survey and Certification Process. -

Except as otherwise specifically provided in section 1819 of the

Social Security Act [this section], the amendments made by sections

4201 and 4202 [enacting and amending this section and amending

sections 1395x, 1395aa, 1395tt, and 1395yy of this title] (relating

to skilled nursing facility requirements and survey and

certification requirements) shall apply to services furnished on or

after October 1, 1990, without regard to whether regulations to

implement such amendments are promulgated by such date.

"(b) Enforcement. - (1) Except as otherwise specifically provided

in section 1819 of the Social Security Act [this section], the

amendments made by section 4203 of this Act [amending this section

and section 1395aa of this title] apply January 1, 1988, without

regard to whether regulations to implement such amendments are

promulgated by such date.

"(2) In applying the amendments made by section 4203 of this Act

for services furnished by a skilled nursing facility before October

1, 1990, any reference to a requirement of subsection (b), (c), or

(d), of section 1819 of the Social Security Act is deemed a

reference to the provisions of section 1861(j) of such Act [section

1395x(j) of this title].

"(c) Waiver of Paperwork Reduction. - Chapter 35 of title 44,

United States Code, shall not apply to information required for

purposes of carrying out this part [part 1 of subtitle C (Secs.

4201-4206), enacting this section, amending this section and

sections 1395x, 1395aa, 1395tt, and 1395yy of this title, and

enacting provisions set out as notes under this section] and

implementing the amendments made by this part."

STUDY AND REPORT REGARDING STATE LICENSURE AND CERTIFICATION

STANDARDS AND RESPIRATORY THERAPY COMPETENCY EXAMINATIONS

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title I, Sec. 107],

Nov. 29, 1999, 113 Stat. 1536, 1501A-328, provided that:

"(a) Study. - The Secretary of Health and Human Services shall

conduct a study that -

"(1) identifies variations in State licensure and certification

standards for health care providers (including nursing and allied

health professionals) and other individuals providing respiratory

therapy in skilled nursing facilities;

"(2) examines State requirements relating to respiratory

therapy competency examinations for such providers and

individuals; and

"(3) determines whether regular respiratory therapy competency

examinations or certifications should be required under the

medicare program under title XVIII of the Social Security Act (42

U.S.C. 1395 et seq.) for such providers and individuals.

"(b) Report. - Not later than 18 months after the date of

enactment of this Act [Nov. 29, 1999], the Secretary of Health and

Human Services shall submit to Congress a report on the results of

the study conducted under this section, together with any

recommendations for legislation that the Secretary determines to be

appropriate as a result of such study."

RETROACTIVE REVIEW

Section 4755(c) of Pub. L. 105-33 provided that: "The procedures

developed by a State under the amendments made by subsection[s] (a)

and (b) [amending this section and section 1396r of this title]

shall permit an individual to petition for a review of any finding

made by a State under section 1819(g)(1)(C) or 1919(g)(1)(C) of the

Social Security Act (42 U.S.C. 1395i-3(g)(1)(C) or 1396r(g)(1)(C))

after January 1, 1995."