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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STUDY AND REPORT ON DEEMING FOR NURSING FACILITIES AND RENAL

DIALYSIS FACILITIES

Pub. L. 104-134, title I, Sec. 101(d) [title V, Sec. 516(d)],

Apr. 26, 1996, 110 Stat. 1321-211, 1321-248; renumbered title I,

Pub. L. 104-140, Sec. 1(a), May 2, 1996, 110 Stat. 1327, provided

that:

"(1) Study. - The Secretary of Health and Human Services shall

provide for -

"(A) a study concerning the effectiveness and appropriateness

of the current mechanisms for surveying and certifying skilled

nursing facilities for compliance with the conditions and

requirements of sections 1819 and 1861(j) of the Social Security

Act [this section and section 1395x(j) of this title] and nursing

facilities for compliance with the conditions of section 1919 of

such Act [section 1396r of this title], and

"(B) a study concerning the effectiveness and appropriateness

of the current mechanisms for surveying and certifying renal

dialysis facilities for compliance with the conditions and

requirements of section 1881(b) of the Social Security Act

[section 1395rr(b) of this title].

"(2) Report. - Not later than July 1, 1997, the Secretary shall

transmit to Congress a report on each of the studies provided for

under paragraph (1). The report on the study under paragraph (1)(A)

shall include (and the report on the study under paragraph (1)(B)

may include) a specific framework, where appropriate, for

implementing a process under which facilities covered under the

respective study may be deemed to meet applicable medicare

conditions and requirements if they are accredited by a national

accreditation body."

MAINTAINING REGULATORY STANDARDS FOR CERTAIN SERVICES

Section 4008(h)(2)(O) of Pub. L. 101-508 provided that: "Any

regulations promulgated and applied by the Secretary of Health and

Human Services after the date of the enactment of the Omnibus

Budget Reconciliation Act of 1987 [Dec. 22, 1987] with respect to

services described in clauses (ii), (iv), and (v) of section

1819(b)(4)(A) of the Social Security Act [subsec. (b)(4)(A)(ii),

(iv), and (v) of this section] shall include requirements for

providers of such services that are at least as strict as the

requirements applicable to providers of such services prior to the

enactment of the Omnibus Budget Reconciliation Act of 1987."

NURSE AIDE TRAINING AND COMPETENCY EVALUATION PROGRAMS; PUBLICATION

OF PROPOSED REGULATIONS

Section 6901(b)(2) of Pub. L. 101-239 provided that: "The

Secretary of Health and Human Services shall issue proposed

regulations to establish the requirements described in sections

1819(f)(2) and 1919(f)(2) of the Social Security Act [subsec.

(f)(2) of this section and section 1396r(f)(2) of this title] by

not later than 90 days after the date of the enactment of this Act

[Dec. 19, 1989]."

NURSE AIDE TRAINING AND COMPETENCY EVALUATION; SATISFACTION OF

REQUIREMENTS; WAIVER

Section 6901(b)(4)(B)-(D) of Pub. L. 101-239 provided that:

"(B) A nurse aide shall be considered to satisfy the requirement

of sections 1819(b)(5)(A) and 1919(b)(5)(A) of the Social Security

Act [subsec. (b)(5)(A) of this section and section 1396r(b)(5)(A)

of this title] (of having completed a training and competency

evaluation program approved by a State under section 1819(e)(1)(A)

or 1919(e)(1)(A) of such Act [subsec. (e)(1)(A) of this section and

section 1396r(e)(1)(A) of this title]), if such aide would have

satisfied such requirement as of July 1, 1989, if a number of hours

(not less than 60 hours) were substituted for '75 hours' in

sections 1819(f)(2) and 1919(f)(2) of such Act [subsec. (f)(2) of

this section and section 1396r(f)(2) of this title], respectively,

and if such aide had received, before July 1, 1989, at least the

difference in the number of such hours in supervised practical

nurse aide training or in regular in-service nurse aide education.

"(C) A nurse aide shall be considered to satisfy the requirement

of sections 1819(b)(5)(A) and 1919(b)(5)(A) of the Social Security

Act (of having completed a training and competency evaluation

program approved by a State under section 1819(e)(1)(A) or

1919(e)(1)(A) of such Act), if such aide was found competent

(whether or not by the State), before July 1, 1989, after the

completion of a course of nurse aide training of at least 100 hours

duration.

"(D) With respect to the nurse aide competency evaluation

requirements described in sections 1819(b)(5)(A) and 1919(b)(5)(A)

of the Social Security Act, a State may waive such requirements

with respect to an individual who can demonstrate to the

satisfaction of the State that such individual has served as a

nurse aide at one or more facilities of the same employer in the

State for at least 24 consecutive months before the date of the

enactment of this Act [Dec. 19, 1989]."

EVALUATION AND REPORT ON IMPLEMENTATION OF RESIDENT ASSESSMENT

PROCESS

Section 4201(c) of Pub. L. 100-203 provided that: "The Secretary

of Health and Human Services shall evaluate, and report to Congress

by not later than January 1, 1992, on the implementation of the

resident assessment process for residents of skilled nursing

facilities under the amendments made by this section [enacting this

section and amending sections 1395x, 1395aa, 1395tt, and 1395yy of

this title]."

ANNUAL REPORT ON STATUTORY COMPLIANCE AND ENFORCEMENT ACTIONS

Section 4205 of Pub. L. 100-203 provided that: "The Secretary of

Health and Human Services shall report to the Congress annually on

the extent to which skilled nursing facilities are complying with

the requirements of subsections (b), (c), and (d) of section 1819

of the Social Security Act [subsecs. (b), (c), and (d) of this

section] (as added by the amendments made by this part) and the

number and type of enforcement actions taken by States and the

Secretary under section 1819(h) of such Act (as added by section

4203 of this Act)."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 296, 1395x, 1395aa,

1395bb, 1395cc, 1395tt, 1395yy, 1396r, 3002 of this title; title 10

section 1074j; title 38 section 3675.

-FOOTNOTE-

(!1) So in original.

(!2) See References in Text note below.

(!3) So in original. Probably should be "as nurse aides".

(!4) So in original. Probably should be "credit".

(!5) So in original. Probably should be followed by a comma.

(!6) So in original. Probably should be "pro rata".

(!7) So in original. The comma probably should not appear.

-End-

-CITE-

42 USC Sec. 1395i-4 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-4. Medicare rural hospital flexibility program

-STATUTE-

(a) Establishment

Any State that submits an application in accordance with

subsection (b) of this section may establish a medicare rural

hospital flexibility program described in subsection (c) of this

section.

(b) Application

A State may establish a medicare rural hospital flexibility

program described in subsection (c) of this section if the State

submits to the Secretary at such time and in such form as the

Secretary may require an application containing -

(1) assurances that the State -

(A) has developed, or is in the process of developing, a

State rural health care plan that -

(i) provides for the creation of 1 or more rural health

networks (as defined in subsection (d) of this section) in

the State;

(ii) promotes regionalization of rural health services in

the State; and

(iii) improves access to hospital and other health services

for rural residents of the State; and

(B) has developed the rural health care plan described in

subparagraph (A) in consultation with the hospital association

of the State, rural hospitals located in the State, and the

State Office of Rural Health (or, in the case of a State in the

process of developing such plan, that assures the Secretary

that the State will consult with its State hospital

association, rural hospitals located in the State, and the

State Office of Rural Health in developing such plan);

(2) assurances that the State has designated (consistent with

the rural health care plan described in paragraph (1)(A)), or is

in the process of so designating, rural nonprofit or public

hospitals or facilities located in the State as critical access

hospitals; and

(3) such other information and assurances as the Secretary may

require.

(c) Medicare rural hospital flexibility program described

(1) In general

A State that has submitted an application in accordance with

subsection (b) of this section, may establish a medicare rural

hospital flexibility program that provides that -

(A) the State shall develop at least 1 rural health network

(as defined in subsection (d) of this section) in the State;

and

(B) at least 1 facility in the State shall be designated as a

critical access hospital in accordance with paragraph (2).

(2) State designation of facilities

(A) In general

A State may designate 1 or more facilities as a critical

access hospital in accordance with subparagraphs (B), (C), and

(D).

(B) Criteria for designation as critical access hospital

A State may designate a facility as a critical access

hospital if the facility -

(i) is a hospital that is located in a county (or

equivalent unit of local government) in a rural area (as

defined in section 1395ww(d)(2)(D) of this title) or is

treated as being located in a rural area pursuant to section

1395ww(d)(8)(E) of this title, and that -

(I) is located more than a 35-mile drive (or, in the case

of mountainous terrain or in areas with only secondary

roads available, a 15-mile drive) from a hospital, or

another facility described in this subsection; or

(II) is certified by the State as being a necessary

provider of health care services to residents in the area;

(ii) makes available 24-hour emergency care services that a

State determines are necessary for ensuring access to

emergency care services in each area served by a critical

access hospital;

(iii) provides not more than 15 (or, in the case of a

facility under an agreement described in subsection (f) of

this section, 25) acute care inpatient beds (meeting such

standards as the Secretary may establish) for providing

inpatient care for a period that does not exceed, as

determined on an annual, average basis, 96 hours per patient;

(iv) meets such staffing requirements as would apply under

section 1395x(e) of this title to a hospital located in a

rural area, except that -

(I) the facility need not meet hospital standards

relating to the number of hours during a day, or days

during a week, in which the facility must be open and fully

staffed, except insofar as the facility is required to make

available emergency care services as determined under

clause (ii) and must have nursing services available on a

24-hour basis, but need not otherwise staff the facility

except when an inpatient is present;

(II) the facility may provide any services otherwise

required to be provided by a full-time, on site dietitian,

pharmacist, laboratory technician, medical technologist,

and radiological technologist on a part-time, off site

basis under arrangements as defined in section 1395x(w)(1)

of this title; and

(III) the inpatient care described in clause (iii) may be

provided by a physician assistant, nurse practitioner, or

clinical nurse specialist subject to the oversight of a

physician who need not be present in the facility; and

(v) meets the requirements of section 1395x(aa)(2)(I) of

this title.

(C) Recently closed facilities

A State may designate a facility as a critical access

hospital if the facility -

(i) was a hospital that ceased operations on or after the

date that is 10 years before November 29, 1999; and

(ii) as of the effective date of such designation, meets

the criteria for designation under subparagraph (B).

(D) Downsized facilities

A State may designate a health clinic or a health center (as

defined by the State) as a critical access hospital if such

clinic or center -

(i) is licensed by the State as a health clinic or a health

center;

(ii) was a hospital that was downsized to a health clinic

or health center; and

(iii) as of the effective date of such designation, meets

the criteria for designation under subparagraph (B).

(d) "Rural health network" defined

(1) In general

In this section, the term "rural health network" means, with

respect to a State, an organization consisting of -

(A) at least 1 facility that the State has designated or

plans to designate as a critical access hospital; and

(B) at least 1 hospital that furnishes acute care services.

(2) Agreements

(A) In general

Each critical access hospital that is a member of a rural

health network shall have an agreement with respect to each

item described in subparagraph (B) with at least 1 hospital

that is a member of the network.

(B) Items described

The items described in this subparagraph are the following:

(i) Patient referral and transfer.

(ii) The development and use of communications systems

including (where feasible) -

(I) telemetry systems; and

(II) systems for electronic sharing of patient data.

(iii) The provision of emergency and non-emergency

transportation among the facility and the hospital.

(C) Credentialing and quality assurance

Each critical access hospital that is a member of a rural

health network shall have an agreement with respect to

credentialing and quality assurance with at least -

(i) 1 hospital that is a member of the network;

(ii) 1 peer review organization or equivalent entity; or

(iii) 1 other appropriate and qualified entity identified

in the State rural health care plan.

(e) Certification by Secretary

The Secretary shall certify a facility as a critical access

hospital if the facility -

(1) is located in a State that has established a medicare rural

hospital flexibility program in accordance with subsection (c) of

this section;

(2) is designated as a critical access hospital by the State in

which it is located; and

(3) meets such other criteria as the Secretary may require.

(f) Permitting maintenance of swing beds

Nothing in this section shall be construed to prohibit a State

from designating or the Secretary from certifying a facility as a

critical access hospital solely because, at the time the facility

applies to the State for designation as a critical access hospital,

there is in effect an agreement between the facility and the

Secretary under section 1395tt of this title under which the

facility's inpatient hospital facilities are used for the provision

of extended care services, so long as the total number of beds that

may be used at any time for the furnishing of either such services

or acute care inpatient services does not exceed 25 beds and the

number of beds used at any time for acute care inpatient services

does not exceed 15 beds. For purposes of the previous sentence, any

bed of a unit of the facility that is licensed as a distinct-part

skilled nursing facility at the time the facility applies to the

State for designation as a critical access hospital shall not be

counted.

(g) Grants

(1) Medicare rural hospital flexibility program

The Secretary may award grants to States that have submitted

applications in accordance with subsection (b) of this section

for -

(A) engaging in activities relating to planning and

implementing a rural health care plan;

(B) engaging in activities relating to planning and

implementing rural health networks; and

(C) designating facilities as critical access hospitals.

(2) Rural emergency medical services

(A) In general

The Secretary may award grants to States that have submitted

applications in accordance with subparagraph (B) for the

establishment or expansion of a program for the provision of

rural emergency medical services.

(B) Application

An application is in accordance with this subparagraph if the

State submits to the Secretary at such time and in such form as

the Secretary may require an application containing the

assurances described in subparagraphs (A)(ii), (A)(iii), and

(B) of subsection (b)(1) of this section and paragraph (3) of

that subsection.

(3) Upgrading data systems

(A) Grants to hospitals

The Secretary may award grants to hospitals that have

submitted applications in accordance with subparagraph (C) to

assist eligible small rural hospitals in meeting the costs of

implementing data systems required to meet requirements

established under the medicare program pursuant to amendments

made by the Balanced Budget Act of 1997.

(B) Eligible small rural hospital defined

For purposes of this paragraph, the term "eligible small

rural hospital" means a non-Federal, short-term general acute

care hospital that -

(i) is located in a rural area (as defined for purposes of

section 1395ww(d) of this title); and

(ii) has less than 50 beds.

(C) Application

A hospital seeking a grant under this paragraph shall submit

an application to the Secretary on or before such date and in

such form and manner as the Secretary specifies.

(D) Amount of grant

A grant to a hospital under this paragraph may not exceed

$50,000.

(E) Use of funds

A hospital receiving a grant under this paragraph may use the

funds for the purchase of computer software and hardware, the

education and training of hospital staff on computer

information systems, and to offset costs related to the

implementation of prospective payment systems.

(F) Reports

(i) Information

A hospital receiving a grant under this section shall

furnish the Secretary with such information as the Secretary

may require to evaluate the project for which the grant is

made and to ensure that the grant is expended for the

purposes for which it is made.

(ii) Timing of submission

(I) Interim reports

The Secretary shall report to the Committee on Ways and

Means of the House of Representatives and the Committee on

Finance of the Senate at least annually on the grant

program established under this section, including in such

report information on the number of grants made, the nature

of the projects involved, the geographic distribution of

grant recipients, and such other matters as the Secretary

deems appropriate.

(II) Final report

The Secretary shall submit a final report to such

committees not later than 180 days after the completion of

all of the projects for which a grant is made under this

section.

(h) Grandfathering of certain facilities

(1) In general

Any medical assistance facility operating in Montana and any

rural primary care hospital designated by the Secretary under

this section prior to August 5, 1997, shall be deemed to have

been certified by the Secretary under subsection (e) of this

section as a critical access hospital if such facility or

hospital is otherwise eligible to be designated by the State as a

critical access hospital under subsection (c) of this section.

(2) Continuation of medical assistance facility and rural primary

care hospital terms

Notwithstanding any other provision of this subchapter, with

respect to any medical assistance facility or rural primary care

hospital described in paragraph (1), any reference in this

subchapter to a "critical access hospital" shall be deemed to be

a reference to a "medical assistance facility" or "rural primary

care hospital".

(i) Waiver of conflicting part A provisions

The Secretary is authorized to waive such provisions of this part

and part D of this subchapter as are necessary to conduct the

program established under this section.

(j) Authorization of appropriations

There are authorized to be appropriated from the Federal Hospital

Insurance Trust Fund for making grants to all States under

subsection (g) of this section, $25,000,000 in each of the fiscal

years 1998 through 2002.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1820, as added Pub. L.

101-239, title VI, Sec. 6003(g)(1)(A), Dec. 19, 1989, 103 Stat.

2145; amended Pub. L. 101-508, title IV, Sec. 4008(d)(1)-(3),

(m)(2)(B), Nov. 5, 1990, 104 Stat. 1388-44, 1388-45, 1388-53; Pub.

L. 103-432, title I, Sec. 102(a)(1), (2), (b)(1)(A), (2), (c), (f),

(h), Oct. 31, 1994, 108 Stat. 4401-4404; Pub. L. 105-33, title IV,

Secs. 4002(f)(1), 4201(a), Aug. 5, 1997, 111 Stat. 329, 369; Pub.

L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec. 321(a), title

IV, Secs. 401(b)(2), 403(a)(1), (b), (c), 409], Nov. 29, 1999, 113

Stat. 1536, 1501A-365, 1501A-369, 1501A-370, 1501A-375.)

-REFTEXT-

REFERENCES IN TEXT

The Balanced Budget Act of 1997, referred to in subsec.

(g)(3)(A), is Pub. L. 105-33, Aug. 5, 1997, 111 Stat. 251. For

complete classification of this Act to the Code, see Tables.

Part D of this subchapter, referred to in subsec. (i), is

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

-MISC1-

AMENDMENTS

1999 - Subsec. (c)(2)(A). Pub. L. 106-113, Sec. 1000(a)(6) [title

IV, Sec. 403(c)(1)], substituted "subparagraphs (B), (C), and (D)"

for "subparagraph (B)".

Subsec. (c)(2)(B)(i). Pub. L. 106-113, Sec. 1000(a)(6) [title IV,

Sec. 403(b)], substituted "hospital" for "nonprofit or public

hospital".

Pub. L. 106-113, Sec. 1000(a)(6) [title IV, Sec. 401(b)(2)],

inserted "or is treated as being located in a rural area pursuant

to section 1395ww(d)(8)(E) of this title" after "section

1395ww(d)(2)(D) of this title)".

Pub. L. 106-113, Sec. 1000(a)(6) [title III, Sec. 321(a)],

substituted "that is located in a county (or equivalent unit of

local government) in a rural area (as defined in section

1395ww(d)(2)(D) of this title), and that" for "and is located in a

county (or equivalent unit of local government) in a rural area (as

defined in section 1395ww(d)(2)(D) of this title) that".

Subsec. (c)(2)(B)(iii). Pub. L. 106-113, Sec. 1000(a)(6) [title

IV, Sec. 403(a)(1)], substituted "for a period that does not

exceed, as determined on an annual, average basis, 96 hours per

patient;" for "for a period not to exceed 96 hours (unless a longer

period is required because transfer to a hospital is precluded

because of inclement weather or other emergency conditions), except

that a peer review organization or equivalent entity may, on

request, waive the 96-hour restriction on a case-by-case basis;".

Subsec. (c)(2)(C), (D). Pub. L. 106-113, Sec. 1000(a)(6) [title

IV, Sec. 403(c)(2)], added subpars. (C) and (D).

Subsec. (g)(3). Pub. L. 106-113, Sec. 1000(a)(6) [title IV, Sec.

409], added par. (3).

1997 - Pub. L. 105-33, Sec. 4201(a), amended section catchline

and text generally, substituting provisions relating to medicare

rural hospital flexibility program for provisions relating to

essential access community hospital program.

Subsec. (j). Pub. L. 105-33, Sec. 4002(f)(1), substituted "part

D" for "part C".

1994 - Subsec. (c)(1). Pub. L. 103-432, Sec. 102(b)(2)(B)(i),

substituted "paragraph (3) or subsection (k) of this section" for

"paragraph (3)".

Subsec. (e)(1). Pub. L. 103-432, Sec. 102(b)(1)(A)(i),

redesignated par. (2) as (1) and struck out former par. (1) which

read as follows: "is located in a rural area (as defined in section

1395ww(d)(2)(D) of this title);".

Subsec. (e)(1)(A). Pub. L. 103-432, Sec. 102(b)(1)(A)(ii),

substituted "except in the case of a hospital located in an urban

area, is located" for "is located" in introductory provisions,

substituted "or (ii)" for ", (ii)", and struck out "or (iii) is

located in an urban area that meets the criteria for classification

as a regional referral center under such section," after "section

1395ww(d)(5)(C) of this title,".

Subsec. (e)(2) to (6). Pub. L. 103-432, Sec. 102(b)(1)(A)(i),

redesignated pars. (2) to (6) as (1) to (5), respectively.

Subsec. (f)(1)(F). Pub. L. 103-432, Sec. 102(a)(1), amended

subpar. (F) generally. Prior to amendment, subpar. (F) read as

follows: "provides not more than 6 inpatient beds (meeting such

conditions as the Secretary may establish) for providing inpatient

care for a period not to exceed 72 hours (unless a longer period is

required because transfer to a hospital is precluded because of

inclement weather or other emergency conditions) to patients

requiring stabilization before discharge or transfer to a

hospital;".

Subsec. (f)(1)(H). Pub. L. 103-432, Sec. 102(f), inserted before

period at end ", except that in determining whether a facility

meets the requirements of this subparagraph, subparagraphs (E) and

(F) of that paragraph shall be applied as if any reference to a

'physician' is a reference to a physician as defined in section

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

Subsec. (f)(3). Pub. L. 103-432, Sec. 102(c), substituted

"because, at the time the facility applies to the State for

designation as a rural primary care hospital, there is in effect an

agreement between the facility and the Secretary under section

1395tt of this title under which the facility's inpatient hospital

facilities are used for the furnishing of extended care services,

except that the number of beds used for the furnishing of such

services may not exceed the total number of licensed inpatient beds

at the time the facility applies to the State for such designation

(minus the number of inpatient beds used for providing inpatient

care pursuant to paragraph (1)(F)). For purposes of the previous

sentence, the number of beds of the facility used for the

furnishing of extended care services shall not include any beds of

a unit of the facility that is licensed as a distinct-part skilled

nursing facility at the time the facility applies to the State for

designation as a rural primary care hospital." for "because the

facility has entered into an agreement with the Secretary under

section 1395tt of this title under which the facility's inpatient

hospital facilities may be used for the furnishing of extended care

services."

Subsec. (f)(4). Pub. L. 103-432, Sec. 102(a)(2), added par. (4).

Subsec. (i)(1)(A). Pub. L. 103-432, Sec. 102(b)(2)(B)(ii), in cl.

(i) inserted "(except as provided in subsection (k) of this

section)" and in cl. (ii) inserted "or subsection (k) of this

section".

Subsec. (i)(1)(B). Pub. L. 103-432, Sec. 102(b)(1)(A)(iii),

substituted "paragraph (2)" for "paragraph (3)".

Subsec. (i)(2)(A). Pub. L. 103-432, Sec. 102(b)(2)(B)(ii), in cl.

(i) inserted "(except as provided in subsection (k) of this

section)" and in cl. (ii) inserted "or subsection (k) of this

section".

Subsec. (k). Pub. L. 103-432, Sec. 102(b)(2)(A)(ii), added

subsec. (k). Former subsec. (k) redesignated (l).

Subsec. (l). Pub. L. 103-432, Sec. 102(h), substituted "1990

through 1997" for "1990, 1991, and 1992" in introductory

provisions.

Pub. L. 103-432, Sec. 102(b)(2)(A)(i), redesignated subsec. (k)

as (l).

1990 - Subsec. (d)(1). Pub. L. 101-508, Sec. 4008(m)(2)(B)(i),

struck out "demonstration" before "program".

Subsec. (f)(1)(A). Pub. L. 101-508, Sec. 4008(d)(3), inserted

before semicolon at end ", or is located in a county whose

geographic area is substantially larger than the average geographic

area for urban counties in the United States and whose hospital

service area is characteristic of service areas of hospitals

located in rural areas".

Subsec. (f)(1)(B). Pub. L. 101-508, Sec. 4008(d)(2), which

directed the substitution of "is a hospital (or, in the case of a

facility that closed during the 12-month period that ends on the

date the facility applies for such designation, at the time the

facility closed)," for "is a hospital," was executed by making the

substitution for "is a hospital" to reflect the probable intent of

Congress.

Subsec. (g)(1)(A)(ii). Pub. L. 101-508, Sec. 4008(m)(2)(B)(ii),

substituted "regional referral center" for "rural referral center".

Subsec. (i)(2)(C). Pub. L. 101-508, Sec. 4008(d)(1), inserted at

end "In designating facilities as rural primary care hospitals

under this subparagraph, the Secretary shall give preference to

facilities not meeting the requirements of clause (i) of

subparagraph (A) that have entered into an agreement described in

subsection (g)(2) of this section with a rural health network

located in a State receiving a grant under subsection (a)(1) of

this section."

Subsec. (j). Pub. L. 101-508, Sec. 4008(m)(2)(B)(iii), inserted

"and part C of this subchapter" after "this part".

EFFECTIVE DATE OF 1999 AMENDMENT

Amendment by section 1000(a)(6) [title III, Sec. 321(a)] of Pub.

L. 106-113 effective as if included in the enactment of the

Balanced Budget Act of 1997, Pub. L. 105-33, except as otherwise

provided, see section 1000(a)(6) [title III, Sec. 321(m)] of Pub.

L. 106-113, set out as a note under section 1395d of this title.

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title IV, Sec. 401(c)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-369, provided that: "The

amendments made by this section [amending this section and sections

1395l and 1395ww of this title] shall become effective on January

1, 2000."

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

403(a)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-370, provided

that: "The amendment made by paragraph (1) [amending this section]

takes effect on the date of the enactment of this Act [Nov. 29,

1999]."

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by section 4201(a) 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.

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4008(d)(4) of Pub. L. 101-508 provided that: "The

amendments made by paragraphs (1), (2), and (3) [amending this

section] shall take effect on the date of the enactment of this Act

[Nov. 5, 1990]."

GAO STUDY ON CERTAIN ELIGIBILITY REQUIREMENTS FOR CRITICAL ACCESS

HOSPITALS

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 206], Dec. 21,

2000, 114 Stat. 2763, 2763A-483, provided that:

"(a) Study. - The Comptroller General of the United States shall

conduct a study on the eligibility requirements for critical access

hospitals under section 1820(c) of the Social Security Act (42

U.S.C. 1395i-4(c)) with respect to limitations on average length of

stay and number of beds in such a hospital, including an analysis

of -

"(1) the feasibility of having a distinct part unit as part of

a critical access hospital for purposes of the medicare program

under title XVIII of such Act [this subchapter]; and

"(2) the effect of seasonal variations in patient admissions on

critical access hospital eligibility requirements with respect to

limitations on average annual length of stay and number of beds.

"(b) 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

subsection (a) together with recommendations regarding -

"(1) whether distinct part units should be permitted as part of

a critical access hospital under the medicare program;

"(2) if so permitted, the payment methodologies that should

apply with respect to services provided by such units;

"(3) whether, and to what extent, such units should be included

in or excluded from the bed limits applicable to critical access

hospitals under the medicare program; and

"(4) any adjustments to such eligibility requirements to

account for seasonal variations in patient admissions."

TRANSITION FOR MAF

Section 4201(c)(6) of Pub. L. 105-33 provided that:

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

shall provide for an appropriate transition for a facility that, as

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

as a limited service rural hospital under a demonstration described

in section 4008(i)(1) of the Omnibus Budget Reconciliation Act of

1990 [Pub. L. 101-508] (42 U.S.C. 1395b-1 note) from such

demonstration to the program established under subsection (a)

[amending this section]. At the conclusion of the transition period

described in subparagraph (B), the Secretary shall end such

demonstration.

"(B) Transition period described. -

"(i) Initial period. - Subject to clause (ii), the transition

period described in this subparagraph is the period beginning on

the date of the enactment of this Act and ending on October 1,

1998.

"(ii) Extension. - If the Secretary determines that the

transition is not complete as of October 1, 1998, the Secretary

shall provide for an appropriate extension of the transition

period."

GAO REPORTS

Section 102(a)(4) of Pub. L. 103-432 directed Comptroller General

to submit to Congress, not later than 2 years after Oct. 31, 1994,

reports on application of requirements under subsec. (f) of this

section that rural primary care hospitals provide inpatient care

only to those individuals whose attending physicians certify may

reasonably be expected to be discharged within 72 hours after

admission and maintain average length of inpatient stay during a

year that does not exceed 72 hours, and extent to which such

requirements have resulted in such hospitals providing inpatient

care beyond their capabilities or have limited ability of such

hospitals to provide needed services.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

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

title.

-End-

-CITE-

42 USC Sec. 1395i-5 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-5. Conditions for coverage of religious nonmedical

health care institutional services

-STATUTE-

(a) In general

Subject to subsections (c) and (d) of this section, payment under

this part may be made for inpatient hospital services or

post-hospital extended care services furnished an individual in a

religious nonmedical health care institution only if -

(1) the individual has an election in effect for such benefits

under subsection (b) of this section; and

(2) the individual has a condition such that the individual

would qualify for benefits under this part for inpatient hospital

services or extended care services, respectively, if the

individual were an inpatient or resident in a hospital or skilled

nursing facility that was not such an institution.

(b) Election

(1) In general

An individual may make an election under this subsection in a

form and manner specified by the Secretary consistent with this

subsection. Unless otherwise provided, such an election shall

take effect immediately upon its execution. Such an election,

once made, shall continue in effect until revoked.

(2) Form

The election form under this subsection shall include the

following:

(A) A written statement, signed by the individual (or such

individual's legal representative), that -

(i) the individual is conscientiously opposed to acceptance

of nonexcepted medical treatment; and

(ii) the individual's acceptance of nonexcepted medical

treatment would be inconsistent with the individual's sincere

religious beliefs.

(B) A statement that the receipt of nonexcepted medical

services shall constitute a revocation of the election and may

limit further receipt of services described in subsection (a)

of this section.

(3) Revocation

An election under this subsection by an individual may be

revoked by voluntarily notifying the Secretary in writing of such

revocation and shall be deemed to be revoked if the individual

receives nonexcepted medical treatment for which reimbursement is

made under this subchapter.

(4) Limitation on subsequent elections

Once an individual's election under this subsection has been

made and revoked twice -

(A) the next election may not become effective until the date

that is 1 year after the date of most recent previous

revocation, and

(B) any succeeding election may not become effective until

the date that is 5 years after the date of the most recent

previous revocation.

(5) Excepted medical treatment

For purposes of this subsection:

(A) Excepted medical treatment

The term "excepted medical treatment" means medical care or

treatment (including medical and other health services) -

(i) received involuntarily, or

(ii) required under Federal or State law or law of a

political subdivision of a State.

(B) Nonexcepted medical treatment

The term "nonexcepted medical treatment" means medical care

or treatment (including medical and other health services)

other than excepted medical treatment.

(c) Monitoring and safeguard against excessive expenditures

(1) Estimate of expenditures

Before the beginning of each fiscal year (beginning with fiscal

year 2000), the Secretary shall estimate the level of

expenditures under this part for services described in subsection

(a) of this section for that fiscal year.

(2) Adjustment in payments

(A) Proportional adjustment

If the Secretary determines that the level estimated under

paragraph (1) for a fiscal year will exceed the trigger level

(as defined in subparagraph (C)) for that fiscal year, the

Secretary shall, subject to subparagraph (B), provide for such

a proportional reduction in payment amounts under this part for

services described in subsection (a) of this section for the

fiscal year involved as will assure that such level (taking

into account any adjustment under subparagraph (B)) does not

exceed the trigger level for that fiscal year.

(B) Alternative adjustments

The Secretary may, instead of making some or all of the

reduction described in subparagraph (A), impose such other

conditions or limitations with respect to the coverage of

covered services (including limitations on new elections of

coverage and new facilities) as may be appropriate to reduce

the level of expenditures described in paragraph (1) to the

trigger level.

(C) Trigger level

For purposes of this subsection -

(i) In general

Subject to adjustment under paragraph (3)(B), the "trigger

level" for a year is the unadjusted trigger level described

in clause (ii).

(ii) Unadjusted trigger level

The "unadjusted trigger level" for -

(I) fiscal year 1998, is $20,000,000, or

(II) a succeeding fiscal year is the amount specified

under this clause for the previous fiscal year increased by

the percentage increase in the consumer price index for all

urban consumers (all items; United States city average) for

the 12-month period ending with July preceding the

beginning of the fiscal year.

(D) Prohibition of administrative and judicial review

There shall be no administrative or judicial review under

section 1395ff of this title, 1395oo of this title, or

otherwise of the estimation of expenditures under subparagraph

(A) or the application of reduction amounts under subparagraph

(B).

(E) Effect on billing

Notwithstanding any other provision of this subchapter, in

the case of a reduction in payment provided under this

subsection for services of a religious nonmedical health care

institution provided to an individual, the amount that the

institution is otherwise permitted to charge the individual for

such services is increased by the amount of such reduction.

(3) Monitoring expenditure level

(A) In general

The Secretary shall monitor the expenditure level described

in paragraph (2)(A) for each fiscal year (beginning with fiscal

year 1999).

(B) Adjustment in trigger level

(i) In general

If the Secretary determines that such level for a fiscal

year exceeded, or was less than, the trigger level for that

fiscal year, then, subject to clause (ii), the trigger level

for the succeeding fiscal year shall be reduced, or

increased, respectively, by the amount of such excess or

deficit.

(ii) Limitation on carryforward

In no case may the increase effected under clause (i) for a

fiscal year exceed $50,000,000.

(d) Sunset

If the Secretary determines that the level of expenditures

described in subsection (c)(1) of this section for 3 consecutive

fiscal years (with the first such year being not earlier than

fiscal year 2002) exceeds the trigger level for such expenditures

for such years (as determined under subsection (c)(2) of this

section), benefits shall be paid under this part for services

described in subsection (a) of this section and furnished on or

after the first January 1 that occurs after such 3 consecutive

years only with respect to an individual who has an election in

effect under subsection (b) of this section as of such January 1

and only during the duration of such election.

(e) Annual report

At the beginning of each fiscal year (beginning with fiscal year

1999), the Secretary shall submit to the Committee on Ways and

Means of the House of Representatives and the Committee on Finance

of the Senate an annual report on coverage and expenditures for

services described in subsection (a) of this section under this

part and under State plans under subchapter XIX of this chapter.

Such report shall include -

(1) level of expenditures described in subsection (c)(1) of

this section for the previous fiscal year and estimated for the

fiscal year involved;

(2) trends in such level; and

(3) facts and circumstances of any significant change in such

level from the level in previous fiscal years.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1821, as added Pub. L.

105-33, title IV, Sec. 4454(a)(2), Aug. 5, 1997, 111 Stat. 428.)

-MISC1-

EFFECTIVE DATE

Section 4454(d) of Pub. L. 105-33 provided that: "The amendments

made by this section [enacting this section and amending sections

1320a-1, 1320c-11, 1395x, 1396a, and 1396g of this title] shall

take effect on the date of the enactment of this Act [Aug. 5, 1997]

and shall apply to items and services furnished on or after such

date. By not later than July 1, 1998, the Secretary of Health and

Human Services shall first issue regulations to carry out such

amendments. Such regulations may be issued so they are effective on

an interim basis pending notice and opportunity for public comment.

For periods before the effective date of such regulations, such

regulations shall recognize elections entered into in good faith in

order to comply with the requirements of section 1821(b) of the

Social Security Act [subsec. (b) of this section]."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1395x of this title.

-End-

-CITE-

42 USC Part B - Supplementary Medical 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 B - Supplementary Medical Insurance Benefits for Aged and

Disabled

-HEAD-

PART B - SUPPLEMENTARY MEDICAL INSURANCE BENEFITS FOR AGED AND

DISABLED

-SECREF-

PART REFERRED TO IN OTHER SECTIONS

This part is referred to in sections 300k, 300gg, 300gg-41,

426-1, 1320a-3, 1320a-3a, 1320a-7a, 1320a-7b, 1320d, 1395a,

1395b-1, 1395b-2, 1395b-6, 1395d, 1395i-2, 1395w-21, 1395w-22,

1395w-23, 1395w-24, 1395w-27, 1395w-28, 1395x, 1395y, 1395cc,

1395cc-1, 1395cc-2, 1395ff, 1395ll, 1395mm, 1395nn, 1395pp, 1395qq,

1395rr, 1395ss, 1395uu, 1395xx, 1395yy, 1395eee, 1395ggg, 1396a,

1396b, 1396d, 1396n, 1396u-4 of this title; title 2 section 906;

title 5 sections 8904, 8910; title 10 sections 1079, 1086; title 25

sections 1616m, 1621k; title 26 sections 35, 213, 6103, 9801; title

29 sections 1181, 2918; title 31 section 3806.

-End-

-CITE-

42 USC Sec. 1395j 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part B - Supplementary Medical Insurance Benefits for Aged and

Disabled

-HEAD-

Sec. 1395j. Establishment of supplementary medical insurance

program for aged and disabled

-STATUTE-

There is hereby established a voluntary insurance program to

provide medical insurance benefits in accordance with the

provisions of this part for aged and disabled individuals who elect

to enroll under such program, to be financed from premium payments

by enrollees together with contributions from funds appropriated by

the Federal Government.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1831, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 301; amended

Pub. L. 92-603, title II, Sec. 201(a)(3), Oct. 30, 1972, 86 Stat.

1371.)

-MISC1-

AMENDMENTS

1972 - Pub. L. 92-603 substituted "aged and disabled individuals"

for "individuals 65 years of age or over".

STUDY REGARDING COVERAGE UNDER PART B OF MEDICARE FOR

NONREIMBURSABLE SERVICES PROVIDED BY OPTOMETRISTS FOR PROSTHETIC

LENSES FOR PATIENTS WITH APHAKIA

Pub. L. 94-182, title I, Sec. 109, Dec. 31, 1975, 89 Stat. 1053,

provided that the Secretary of Health, Education, and Welfare

conduct a study on the appropriateness of reimbursement under the

insurance program established by this part for services performed

by optometrists with respect to the provision of prosthetic lenses

for patients with aphakia and submit such study to Congress not

later than 4 months after Dec. 31, 1975.

STUDY TO DETERMINE FEASIBILITY OF INCLUSION OF CERTAIN ADDITIONAL

SERVICES UNDER PART B

Pub. L. 90-248, title I, Sec. 141, Jan. 2, 1968, 81 Stat. 855,

directed Secretary to conduct a study relating to inclusion under

the supplementary medical insurance program under this part of

services of additional types of licensed practitioners performing

health services in independent practice and submit such study to

Congress prior to Jan. 1, 1969.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in title 38 sections 1725, 1729.

-End-

-CITE-

42 USC Sec. 1395k 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part B - Supplementary Medical Insurance Benefits for Aged and

Disabled

-HEAD-

Sec. 1395k. Scope of benefits; definitions

-STATUTE-

(a) Scope of benefits

The benefits provided to an individual by the insurance program

established by this part shall consist of -

(1) entitlement to have payment made to him or on his behalf

(subject to the provisions of this part) for medical and other

health services, except those described in subparagraphs (B) and

(D) of paragraph (2) and subparagraphs (E) and (F) of section

1395u(b)(6) of this title; and

(2) entitlement to have payment made on his behalf (subject to

the provisions of this part) for -

(A) home health services (other than items described in

subparagraph (G) or subparagraph (I));

(B) medical and other health services (other than items

described in subparagraph (G) or subparagraph (I)) furnished by

a provider of services or by others under arrangement with them

made by a provider of services, excluding -

(i) physician services except where furnished by -

(I) a resident or intern of a hospital, or

(II) a physician to a patient in a hospital which has a

teaching program approved as specified in paragraph (6) of

section 1395x(b) of this title (including services in

conjunction with the teaching programs of such hospital

whether or not such patient is an inpatient of such

hospital) where the conditions specified in paragraph (7)

of such section are met,

(ii) services for which payment may be made pursuant to

section 1395n(b)(2) of this title,

(iii) services described by section 1395x(s)(2)(K)(i) of

this title, certified nurse-midwife services, qualified

psychologist services, and services of a certified registered

nurse anesthetist; (!1)

(iv) services of a nurse practitioner or clinical nurse

specialist but only if no facility or other provider charges

or is paid any amounts with respect to the furnishing of such

services; and (!2)

(C) outpatient physical therapy services (other than services

to which the second sentence of section 1395x(p) of this title

applies) and outpatient occupational therapy services (other

than services to which such sentence applies through the

operation of section 1395x(g) of this title);

(D)(i) rural health clinic services and (ii) Federally

qualified health center services;

(E) comprehensive outpatient rehabilitation facility

services;

(F) facility services furnished in connection with surgical

procedures specified by the Secretary -

(i) pursuant to section 1395l(i)(1)(A) of this title and

performed in an ambulatory surgical center (which meets

health, safety, and other standards specified by the

Secretary in regulations) if the center has an agreement in

effect with the Secretary by which the center agrees to

accept the standard overhead amount determined under section

1395l(i)(2)(A) of this title as full payment for such

services (including intraocular lens in cases described in

section 1395l(i)(2)(A)(iii) of this title) and to accept an

assignment described in section 1395u(b)(3)(B)(ii) of this

title with respect to payment for all such services

(including intraocular lens in cases described in section

1395l(i)(2)(A)(iii) of this title) furnished by the center to

individuals enrolled under this part, or

(ii) pursuant to section 1395l(i)(1)(B) of this title and

performed by a physician, described in paragraph (1), (2), or

(3) of section 1395x(r) of this title, in his office, if the

Secretary has determined that -

(I) a quality control and peer review organization

(having a contract with the Secretary under part B of

subchapter XI of this chapter) is willing, able, and has

agreed to carry out a review (on a sample or other

reasonable basis) of the physician's performing such

procedures in the physician's office,

(II) the particular physician involved has agreed to make

available to such organization such records as the

Secretary determines to be necessary to carry out the

review, and

(III) the physician is authorized to perform the

procedure in a hospital located in the area in which the

office is located,

and if the physician agrees to accept the standard overhead

amount determined under section 1395l(i)(2)(B) of this title

as full payment for such services and to accept payment on an

assignment-related basis with respect to payment for all

services (including all pre- and post-operative services)

described in paragraphs (1) and (2)(A) of section 1395x(s) of

this title and furnished in connection with such surgical

procedure to individuals enrolled under this part;

(G) covered items (described in section 1395m(a)(13) of this

title) furnished by a provider of services or by others under

arrangements with them made by a provider of services;

(H) outpatient critical access hospital services (as defined

in section 1395x(mm)(3) of this title);

(I) prosthetic devices and orthotics and prosthetics

(described in section 1395m(h)(4) of this title) furnished by a

provider of services or by others under arrangements with them

made by a provider of services; and

(J) partial hospitalization services provided by a community

mental health center (as described in section 1395x(ff)(2)(B)

of this title).

(b) Definitions

For definitions of "spell of illness", "medical and other health

services", and other terms used in this part, see section 1395x of

this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1832, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 302; amended

Pub. L. 90-248, title I, Secs. 129(c)(6)(B), 133(d), Jan. 2, 1968,

81 Stat. 848, 851; Pub. L. 92-603, title II, Secs. 227(e)(1),

251(a)(4), Oct. 30, 1972, 86 Stat. 1406, 1445; Pub. L. 95-210, Sec.

1(a), Dec. 13, 1977, 91 Stat. 1485; Pub. L. 96-499, title IX, Secs.

930(g), 933(a), 934(a), 948(a)(2), Dec. 5, 1980, 94 Stat. 2631,

2635, 2637, 2643; Pub. L. 97-248, title I, Sec. 148(c), Sept. 3,

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

2341(b), 2354(b)(6), July 18, 1984, 98 Stat. 1094, 1100; Pub. L.

99-509, title IX, Secs. 9320(d), 9337(a), 9343(e)(1), Oct. 21,

1986, 100 Stat. 2013, 2033, 2041; Pub. L. 100-203, title IV, Secs.

4062(d)(2), 4063(e)(2), 4073(b)(1), 4077(b)(2), 4085(i)(22)(A),

Dec. 22, 1987, 101 Stat. 1330-108, 1330-118, 1330-120, as amended

Pub. L. 100-360, title IV, Sec. 411(g)(2)(E), (h)(4)(A), (7)(B),

(i)(4)(C)(vi), July 1, 1988, 102 Stat. 783, 786, 787, 789; Pub. L.

100-360, title I, Sec. 104(d)(3), title II, Secs. 203(a), 205(a),

July 1, 1988, 102 Stat. 689, 721, 729, 783; Pub. L. 101-234, title

I, Sec. 101(a), title II, Sec. 201(a), Dec. 13, 1989, 103 Stat.

1979, 1981; Pub. L. 101-239, title VI, Sec. 6116(a)(2), Dec. 19,

1989, 103 Stat. 2219; Pub. L. 101-508, title IV, Secs.

4153(a)(2)(A), 4155(b)(1), 4157(b), 4161(a)(3)(A), 4162(b)(1), Nov.

5, 1990, 104 Stat. 1388-83, 1388-86, 1388-89, 1388-93, 1388-96;

Pub. L. 105-33, title IV, Secs. 4201(c)(1), 4432(b)(5)(B), 4511(c),

4603(c)(2)(B)(ii), Aug. 5, 1997, 111 Stat. 373, 421, 443, 471; Pub.

L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 227(b)], Nov.

29, 1999, 113 Stat. 1536, 1501A-354; Pub. L. 106-554, Sec. 1(a)(6)

[title I, Sec. 113(b)(1)], Dec. 21, 2000, 114 Stat. 2763,

2763A-473.)

-REFTEXT-

REFERENCES IN TEXT

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

(a)(2)(F)(ii)(I), is classified to section 1320c et seq. of this

title.

-MISC1-

AMENDMENTS

2000 - Subsecs. (b), (c). Pub. L. 106-554 redesignated subsec.

(c) as (b) and struck out former subsec. (b), which related to

extension of coverage of immunosuppressive drugs for individuals

who would exhaust benefits under section 1395x(s)(2)(J)(v) of this

title in a year during the 5-year period beginning with 2000, and

set forth provisions relating to extension periods for each year.

1999 - Subsecs. (b), (c). Pub. L. 106-113 added subsec. (b) and

redesignated former subsec. (b) as (c).

1997 - Subsec. (a)(1). Pub. L. 105-33, Sec. 4603(c)(2)(B)(ii),

substituted "subparagraphs (E) and (F) of section 1395u(b)(6) of

this title;" for "section 1395u(b)(6)(E) of this title;".

Pub. L. 105-33, Sec. 4432(b)(5)(B), substituted "(2) and section

1395u(b)(6)(E) of this title;" for "(2);".

Subsec. (a)(2)(B)(iv). Pub. L. 105-33, Sec. 4511(c), substituted

"but only if no facility or other provider charges or is paid any

amounts with respect to the furnishing of such services" for

"provided in a rural area (as defined in section 1395ww(d)(2)(D) of

this title)".

Subsec. (a)(2)(H). Pub. L. 105-33, Sec. 4201(c)(1), substituted

"critical access" for "rural primary care".

1990 - Subsec. (a)(2)(A), (B). Pub. L. 101-508, Sec.

4153(a)(2)(A)(i), substituted "subparagraph (G) or subparagraph

(I)" for "subparagraph (G)".

Subsec. (a)(2)(B)(iii). Pub. L. 101-508, Sec. 4157(b), amended

cl. (iii) generally. Prior to amendment, cl. (iii) related to

services of a certified registered nurse anesthetist.

Subsec. (a)(2)(B)(iv). Pub. L. 101-508, Sec. 4155(b)(1), added

cl. (iv).

Subsec. (a)(2)(D). Pub. L. 101-508, Sec. 4161(a)(3)(A),

designated existing provisions as cl. (i) and added cl. (ii).

Subsec. (a)(2)(I). Pub. L. 101-508, Sec. 4153(a)(2)(A)(ii)-(iv),

added subpar. (I).

Subsec. (a)(2)(J). Pub. L. 101-508, Sec. 4162(b)(1), added

subpar. (J).

1989 - Subsec. (a). Pub. L. 101-234, Sec. 201(a), repealed Pub.

L. 100-360, Secs. 203(a), 205(a), and provided that the provisions

of law amended or repealed by such sections are restored or revived

as if such sections had not been enacted, see 1988 Amendment notes

below.

Subsec. (a)(2)(H). Pub. L. 101-239 added subpar. (H).

Subsec. (b). Pub. L. 101-234, Sec. 101(a), repealed Pub. L.

100-360, Sec. 104(d)(3), 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. (a). Pub. L. 100-360, Sec. 205(a)(2), inserted

sentence at end relating to in-home care provided to a chronically

dependent individual on any day.

Subsec. (a)(2)(A). Pub. L. 100-360, Sec. 205(a)(1), designated

existing provisions as cl. (i) and added cl. (ii) relating to

in-home care for a chronically dependent individual.

Pub. L. 100-360, Sec. 203(a), inserted "and home intravenous drug

therapy services" before semicolon at end.

Subsec. (a)(2)(B)(iv). Pub. L. 100-360, Sec. 411(h)(7)(B), struck

out Pub. L. 100-203, Sec. 4077(b)(2), see 1987 Amendment note

below.

Pub. L. 100-360, Sec. 411(h)(4)(A), struck out Pub. L. 100-203,

Sec. 4073(b)(1), see 1987 Amendment note below.

Subsec. (a)(2)(F)(i). Pub. L. 100-360, Sec. 411(g)(2)(E), added

Pub. L. 100-203, Sec. 4063(e)(2), see 1987 Amendment note below.

Subsec. (a)(2)(F)(ii). Pub. L. 100-360, Sec. 411(i)(4) (C)(vi),

added Pub. L. 100-203, Sec. 4085(i)(22)(A), see 1987 Amendment note

below.

Subsec. (b). Pub. L. 100-360, Sec. 104(d)(3), substituted

"definitions of 'medical and other health services' and" for

"definitions of 'spell of illness', 'medical and other health

services', and".

1987 - Subsec. (a)(2)(A). Pub. L. 100-203, Sec. 4062(d)(2)(A),

inserted "(other than items described in subparagraph (G))" after

"services".

Subsec. (a)(2)(B). Pub. L. 100-203, Sec. 4062(d)(2)(B), inserted

"(other than items described in subparagraph (G))" after "health

services".

Subsec. (a)(2)(B)(iv). Pub. L. 100-203, Sec. 4077(b)(2), which

directed the addition of cl. (iv) relating to qualified

psychologist services, was repealed by Pub. L. 100-360, Sec.

411(h)(7)(B).

Pub. L. 100-203, Sec. 4073(b)(1), which directed the addition of

cl. (iv) relating to certified nurse-midwife services, was repealed

by Pub. L. 100-360, Sec. 411(h)(4)(A).

Subsec. (a)(2)(F)(i). Pub. L. 100-203, Sec. 4063(e)(2), as added

by Pub. L. 100-360, Sec. 411(g)(2)(E), inserted "(including

intraocular lens in cases described in section 1395l(i)(2)(A)(iii)

of this title)" after "services" in two places.

Subsec. (a)(2)(F)(ii). Pub. L. 100-203, Sec. 4085(i)(22)(A), as

added by Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), substituted

"payment on an assignment-related basis" for "an assignment

described in section 1395u(b)(3)(B)(ii) of this title" in

concluding provisions.

Subsec. (a)(2)(G). Pub. L. 100-203, Sec. 4062(d)(2)(C), added

subpar. (G).

1986 - Subsec. (a)(2)(B)(iii). Pub. L. 99-509, Sec. 9320(d),

added cl. (iii).

Subsec. (a)(2)(C). Pub. L. 99-509, Sec. 9337(a), amended subpar.

(C) generally. Prior to amendment, subpar. (C) read as follows:

"outpatient physical therapy services, other than services to which

the next to last sentence of section 1395x(p) of this title

applies;".

Subsec. (a)(2)(F). Pub. L. 99-509, Sec. 9343(e)(1), inserted

"standard overhead" in cl. (i) and concluding provisions of cl.

(ii).

1984 - Subsec. (a)(2)(F)(ii). Pub. L. 98-369, Sec. 2341(b),

substituted "paragraph (1), (2), or (3) of section 1395x(r) of this

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

Subsec. (a)(2)(F)(ii)(II). Pub. L. 98-369, Sec. 2354(b)(6),

substituted "organization" for "Organization".

1982 - Subsec. (a)(2)(F)(ii)(I). Pub. L. 97-248 substituted

"quality control and peer review organization (having a contract

with the Secretary" for "Professional Standards Review Organization

(designated, conditionally or otherwise,".

1980 - Subsec. (a)(2)(A). Pub. L. 96-499, Sec. 930(g), struck out

restriction on home health services of 100 visits during a calendar

year.

Subsec. (a)(2)(B)(i)(II). Pub. L. 96-499, Sec. 948(a)(2),

substituted "where the conditions specified in paragraph (7) of

such section are met" for ", unless either clause (A) or (B) of

paragraph (7) of such section is met".

Subsec. (a)(2)(E). Pub. L. 96-499, Sec. 933(a), added subpar.

(E).

Subsec. (a)(2)(F). Pub. L. 96-499, Sec. 934(a), added subpar.

(F).

1977 - Subsec. (a)(1). Pub. L. 95-210, Sec. 1(a)(1), substituted

"subparagraphs (B) and (D) of paragraph (2)" for "paragraph

(2)(B)".

Subsec. (a)(2)(D). Pub. L. 95-210, Sec. 1(a)(2), added subpar.

(D).

1972 - Subsec. (a)(2)(B). Pub. L. 92-603, Sec. 227(e)(1),

inserted provisions relating to medical and other health services

performed by a physician to a patient in a hospital which has an

approved teaching program.

Subsec. (a)(2)(C). Pub. L. 92-603, Sec. 251(a)(4), inserted ",

other than services to which the next to last sentence of section

1395x(p) of this title applies".

1968 - Subsec. (a)(2)(B). Pub. L. 90-248, Sec. 129(c)(6)(B),

inserted "and the services for which payment may be made pursuant

to section 1395n(b)(2) of this title" after "hospital".

Subsec. (a)(2)(C). Pub. L. 90-248, Sec. 133(d), added subpar.

(C).

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.

Amendment by section 4432(b)(5)(B) of Pub. L. 105-33 applicable

to items and services furnished on or after July 1, 1998, see

section 4432(d) of Pub. L. 105-33, set out as a note under section

1395i-3 of this title.

Section 4511(e) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and sections 1395l,

1395x, 1395y, 1395cc, and 1395yy of this title] shall apply with

respect to services furnished and supplies provided on and after

January 1, 1998."

Amendment by section 4603(c)(2)(B)(ii) 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.

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4153(a)(3) of Pub. L. 101-508 provided that: "The

amendments made by paragraphs (1) and (2) [amending this section

and sections 1395l and 1395m of this title] shall apply to items

furnished on or after January 1, 1991."

Section 4155(e) of Pub. L. 101-508 provided that: "The amendments

made by this section [amending this section and sections 1395l,

1395u, and 1395x of this title] shall apply to services furnished

on or after January 1, 1991."

Section 4157(d) of Pub. L. 101-508 provided that: "The amendments

made by the preceding subsections [amending this section and

sections 1395x, 1395y, and 1395cc of this title] apply to services

furnished on or after January 1, 1991."

Section 4161(a)(8) of Pub. L. 101-508 provided that:

"(A) Subject to subparagraphs (B) and (C), the amendments made by

this section [probably means this subsection, which amended this

section and sections 1320a-7b, 1395l, 1395x, 1395y, and 1395oo of

this title] shall apply to services furnished on or after October

1, 1991.

"(B) In the case of a Federally qualified health care center that

has elected, as of January 1, 1990, under part B of title XVIII of

the Social Security Act [this part], to have the amount of payments

for services under such part determined on a reasonable-charge

basis, the amendment made by paragraph (3)(A) [amending this

section] shall only apply on and after such date (not earlier than

October 1, 1991) as the center may elect.

"(C) The amendment made by paragraph (6) [amending section 1395oo

of this title] shall apply to cost reports for periods beginning on

or after October 1, 1991."

Section 4162(c) of Pub. L. 101-508 provided that: "The amendments

made by subsections (a) and (b) [amending this section and sections

1395x and 1395cc of this title] shall apply with respect to partial

hospitalization services provided on or after October 1, 1991."

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by section 101(a) of 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.

Amendment by section 201(a) of 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 104(d)(3) 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.

Amendment by section 203(a) 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.

Section 205(f) of Pub. L. 100-360, which provided that the

amendments made by section 205 of Pub. L. 100-360 [amending this

section and sections 1395l, 1395n, 1395x, and 1395y of this title]

were applicable to items and services furnished on or after January

1, 1990, was repealed by Pub. L. 101-234, title II, Sec. 201(a),

Dec. 13, 1989, 103 Stat. 1981.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by section 411(g)(2)(E), (h)(4)(A), (7)(B),

(i)(4)(C)(vi) 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

Amendment by section 4062(d)(2) of Pub. L. 100-203 applicable to

covered items (other than oxygen and oxygen equipment) furnished on

or after Jan. 1, 1989, and to oxygen and oxygen equipment furnished

on or after June 1, 1989, see section 4062(e) of Pub. L. 100-203,

as amended, set out as a note under section 1395f of this title.

Section 4073(e) of Pub. L. 100-203 provided that: "The amendments

made by this section [amending this section and sections 1395l,

1395x, and 1396d of this title] shall be effective with respect to

services performed on or after July 1, 1988."

Section 4077(b)(5), formerly Sec. 4077(b)(6), of Pub. L. 100-203,

as renumbered by Pub. L. 100-360, title IV, Sec. 411(h)(7)(F), July

1, 1988, 102 Stat. 787, provided that: "The amendments made by this

subsection [amending this section and sections 1395l and 1395x of

this title] shall be effective with respect to services performed

on or after July 1, 1988."

EFFECTIVE DATE OF 1986 AMENDMENT

Section 9320(i) of Pub. L. 99-509, as amended by Pub. L. 100-485,

title VI, Sec. 608(c)(1), Oct. 13, 1988, 102 Stat. 2412, provided

that: "Except as provided in subsection (k) [set out below], the

amendments made by this section (other than subsection (a))

[amending this section and sections 1395l, 1395u, 1395x, 1395y,

1395aa, 1395bb, 1395cc, 1395ww, 1396a, and 1396n of this title]

shall apply to services furnished on or after January 1, 1989."

Section 9337(e) of Pub. L. 99-509 provided that: "The amendments

made by this section [amending this section and sections 1395l,

1395n, 1395x, and 1395cc of this title] shall apply to expenses

incurred for outpatient occupational therapy services furnished on

or after July 1, 1987."

EFFECTIVE DATE OF 1984 AMENDMENT

Section 2341(d) of Pub. L. 98-369 provided that: "The amendments

made by this section [amending this section and section 1395x of

this title] apply to services furnished on or after the date of the

enactment of this Act [July 18, 1984]."

Amendment by section 2354(b)(6) 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 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 1980 AMENDMENT

Amendment by section 930(g) 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 933(h) of Pub. L. 96-499 provided that: "The amendments

made by this section [amending this section and sections 1395n,

1395x, 1395z, and 1395aa of this title] shall become effective with

respect to a comprehensive outpatient rehabilitation facility's

first accounting period which begins on or after July 1, 1981."

Amendment by section 948(a)(2) of Pub. L. 96-499 applicable with

respect to cost accounting periods beginning on or after Oct. 1,

1978, see section 948(c)(1) of Pub. L. 96-499, set out as a note

under section 1395x of this title.

EFFECTIVE DATE OF 1977 AMENDMENT

Section 1(j) of Pub. L. 95-210 provided that: "The amendments

made by this section [amending this section and sections 1395l,

1395x, 1395y, and 1395aa of this title and enacting provisions set

out as notes under sections 1395l and 1395x of this title] shall

apply to services rendered on or after the first day of the third

calendar month which begins after the date of enactment of this Act

[Dec. 13, 1977]."

EFFECTIVE DATE OF 1972 AMENDMENT

Amendment by section 227(e)(1) 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.

Amendment by section 251(a)(4) of Pub. L. 92-603 applicable with

respect to services furnished on or after July 1, 1973, see section

251(d)(1) of Pub. L. 92-603, set out as a note under section 1395x

of this title.

EFFECTIVE DATE OF 1968 AMENDMENT

Amendment by section 129(c)(6)(B) 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 133(g) of Pub. L. 90-248 provided that: "The amendments

made by the preceding subsections of this section [amending this

section and sections 1395n, 1395x, 1395aa, and 1395cc of this

title] shall apply to services furnished after June 30, 1968."

REPORT ON IMMUNOSUPPRESSIVE DRUG BENEFIT

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 227(d)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-356, which required the

Secretary of Health and Human Services to submit to Congress not

later than Mar. 1, 2003, a report on the operation of section

1000(a)(6) [title II, Sec. 227] of Pub. L. 106-113, amending this

section and section 1395x of this title, including an analysis of

impact and recommendations regarding an appropriate cost-effective

method for providing coverage of immunosuppressive drugs under the

medicare program on a permanent basis, was repealed by Pub. L.

106-554, Sec. 1(a)(6) [title I, Sec. 113(b)(2)], Dec. 21, 2000, 114

Stat. 2763, 2763A-473.

CONSTRUCTION OF SECTION 9320 OF PUB. L. 99-509

Section 9320(j) of Pub. L. 99-509 provided that: "Nothing in this

section or the amendments made by this section [amending this

section and sections 1395l, 1395u, 1395x, 1395y, 1395aa, 1395bb,

1395cc, 1395ww, 1396a, and 1396n of this title, enacting provisions

set out as notes under this section, and amending provisions set

out as a note under section 1395ww of this title] shall contravene

provisions of State law relating to the practice of medicine or

nursing or State law requirements or institutional requirements

regarding the administration of anesthesia and its medical

direction or supervision."

QUALITY AND UTILIZATION OF IN-HOME CARE FOR CHRONICALLY DEPENDENT

INDIVIDUALS

Section 205(e)(2) of Pub. L. 100-360 directed Secretary of Health

and Human Services to take appropriate efforts to assure quality

and provide for appropriate utilization of in-home care for

chronically dependent individuals under the amendments made by

section 205 of Pub. L. 100-360 [amending this section and sections

1395l, 1395n, 1395x, and 1395y of this title], prior to repeal by

Pub. L. 101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat.

1981.

STUDY OF ALTERNATIVE OUT-OF-HOME SERVICES

Section 205(g) of Pub. L. 100-360, which required Secretary of

Health and Human Services to study, and report to Congress, not

later than 18 months after July 1, 1988, on advisability of

providing, to chronically dependent individuals eligible for

in-home care under amendments made by section 205 of Pub. L.

100-360 [amending this section and sections 1395l, 1395n, 1395x,

and 1395y of this title], out-of-home services as alternative

services to in-home care, was repealed by Pub. L. 101-234, title

II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981.

CONTINUATION OF COST PASS-THROUGH FOR CERTIFIED REGISTERED NURSE

ANESTHETISTS

Section 9320(k) of Pub. L. 99-509, as added by Pub. L. 100-485,

title VI, Sec. 608(c)(2), Oct. 13, 1988, 102 Stat. 2412, and

amended by Pub. L. 101-239, title VI, Sec. 6132(a), Dec. 19, 1989,

103 Stat. 2222, provided that:

"(1) Subject to paragraph (2), the amendments made by this

section [amending this section and sections 1395l, 1395u, 1395x,

1395y, 1395aa, 1395bb, 1395cc, 1395ww, 1396a, and 1396n of this

title and provisions set out as a note under section 1395ww of this

title] shall not apply during a year (beginning with 1989) to a

hospital located in a rural area (as defined for purposes of

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

this title]) if the hospital establishes, at any time before the

year[,] to the satisfaction of the Secretary of Health and Human

Services that -

"(A) as of January 1, 1988, the hospital employed or contracted

with a certified registered nurse anesthetist (but not more than

one full-time equivalent certified registered nurse anesthetist),

"(B) in 1987 the hospital had a volume of surgical procedures

(including inpatient and outpatient procedures) requiring

anesthesia services that did not exceed 500 (or such higher

number as the Secretary determines to be appropriate), and

"(C) each certified registered nurse anesthetist employed by,

or under contract with, the hospital has agreed not to bill under

part B of title XVIII of such Act [this part] for professional

services furnished by the anesthetist at the hospital.

"(2) Paragraph (1) shall not apply in a year (after 1989) to a

hospital unless the hospital establishes, before the beginning of

the year, that the hospital has had a volume of surgical procedures

(including inpatient and outpatient procedures) requiring

anesthesia services in the previous year that did not exceed 500

(or such higher number as the Secretary determines to be

appropriate)."

[Section 6132(b) of Pub. L. 101-239 provided that: "The

amendments made by this section [amending section 9320(k) of Pub.

L. 99-509, set out above] shall apply to services furnished on or

after January 1, 1990."]

PAYMENT FOR SERVICES OF PHYSICIANS RENDERED IN A TEACHING HOSPITAL

FOR ACCOUNTING PERIODS BEGINNING AFTER JUNE 30, 1975, AND PRIOR TO

OCTOBER 1, 1978; STUDIES, REPORTS, ETC.; EFFECTIVE DATES

Pub. L. 93-233, Sec. 15(a)(2), Dec. 31, 1973, 87 Stat. 966,

provided that for the cost accounting periods beginning after June

30, 1975, and prior to Oct. 1, 1978, subsec. (a)(2)(B)(i) of this

section will be administered as if subclause II of subsec.

(a)(2)(B)(i) read as follows: "(II) a physician to a patient in a

hospital which has a teaching program approved as specified in

paragraph (6) of section 1861(b) [section 1395x(b)(6) of this

title] (including services in conjunction with the teaching

programs of such hospital whether or not such patient is an

inpatient of such hospital), where the conditions specified in

paragraph (7) of such section [section 1395x(b)(7) of this title]

are met and".

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395l, 1395n, 1395x,

1395z, 1395aa, 1395gg of this title.

-FOOTNOTE-

(!1) So in original. The semicolon probably should be a comma.

(!2) So in original. The word "and" probably should not appear.

-End-

-CITE-

42 USC Sec. 1395l 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part B - Supplementary Medical Insurance Benefits for Aged and

Disabled

-HEAD-

Sec. 1395l. Payment of benefits

-STATUTE-

(a) Amounts

Except as provided in section 1395mm of this title, and subject

to the succeeding provisions of this section, there shall be paid

from the Federal Supplementary Medical Insurance Trust Fund, in the

case of each individual who is covered under the insurance program

established by this part and incurs expenses for services with

respect to which benefits are payable under this part, amounts

equal to -

(1) in the case of services described in section 1395k(a)(1) of

this title - 80 percent of the reasonable charges for the

services; except that (A) an organization which provides medical

and other health services (or arranges for their availability) on

a prepayment basis (and either is sponsored by a union or

employer, or does not provide, or arrange for the provision of,

any inpatient hospital services) may elect to be paid 80 percent

of the reasonable cost of services for which payment may be made

under this part on behalf of individuals enrolled in such

organization in lieu of 80 percent of the reasonable charges for

such services if the organization undertakes to charge such

individuals no more than 20 percent of such reasonable cost plus

any amounts payable by them as a result of subsection (b) of this

section, (B) with respect to items and services described in

section 1395x(s)(10)(A) of this title, the amounts paid shall be

100 percent of the reasonable charges for such items and

services, (C) with respect to expenses incurred for those

physicians' services for which payment may be made under this

part that are described in section 1395y(a)(4) of this title, the

amounts paid shall be subject to such limitations as may be

prescribed by regulations, (D) with respect to clinical

diagnostic laboratory tests for which payment is made under this

part (i) on the basis of a fee schedule under subsection (h)(1)

of this section or section 1395m(d)(1) of this title, the amount

paid shall be equal to 80 percent (or 100 percent, in the case of

such tests for which payment is made on an assignment-related

basis) of the lesser of the amount determined under such fee

schedule, the limitation amount for that test determined under

subsection (h)(4)(B) of this section, or the amount of the

charges billed for the tests, or (ii) on the basis of a

negotiated rate established under subsection (h)(6) of this

section, the amount paid shall be equal to 100 percent of such

negotiated rate, (E) with respect to services furnished to

individuals who have been determined to have end stage renal

disease, the amounts paid shall be determined subject to the

provisions of section 1395rr of this title, (F) with respect to

clinical social worker services under section 1395x(s)(2)(N) of

this title, the amounts paid shall be 80 percent of the lesser of

(i) the actual charge for the services or (ii) 75 percent of the

amount determined for payment of a psychologist under clause (L),

[(G) Repealed. Pub. L. 103-432, title I, Sec. 156(a)(2)(B)(ii),

Oct. 31, 1994, 108 Stat. 4440,] (H) with respect to services of a

certified registered nurse anesthetist under section 1395x(s)(11)

of this title, the amounts paid shall be 80 percent of the least

of the actual charge, the prevailing charge that would be

recognized (or, for services furnished on or after January 1,

1992, the fee schedule amount provided under section 1395w-4 of

this title) if the services had been performed by an

anesthesiologist, or the fee schedule for such services

established by the Secretary in accordance with subsection (l) of

this section, (I) with respect to covered items (described in

section 1395m(a)(13) of this title), the amounts paid shall be

the amounts described in section 1395m(a)(1) of this title, and

(!1) (J) with respect to expenses incurred for radiologist

services (as defined in section 1395m(b)(6) of this title),

subject to section 1395w-4 of this title, the amounts paid shall

be 80 percent of the lesser of the actual charge for the services

or the amount provided under the fee schedule established under

section 1395m(b) of this title, (K) with respect to certified

nurse-midwife services under section 1395x(s)(2)(L) of this

title, the amounts paid shall be 80 percent of the lesser of the

actual charge for the services or the amount determined by a fee

schedule established by the Secretary for the purposes of this

subparagraph (but in no event shall such fee schedule exceed 65

percent of the prevailing charge that would be allowed for the

same service performed by a physician, or, for services furnished

on or after January 1, 1992, 65 percent of the fee schedule

amount provided under section 1395w-4 of this title for the same

service performed by a physician), (L) with respect to qualified

psychologist services under section 1395x(s)(2)(M) of this title,

the amounts paid shall be 80 percent of the lesser of the actual

charge for the services or the amount determined by a fee

schedule established by the Secretary for the purposes of this

subparagraph, (M) with respect to prosthetic devices and

orthotics and prosthetics (as defined in section 1395m(h)(4) of

this title), the amounts paid shall be the amounts described in

section 1395m(h)(1) of this title, (N) with respect to expenses

incurred for physicians' services (as defined in section

1395w-4(j)(3) of this title), the amounts paid shall be 80

percent of the payment basis determined under section

1395w-4(a)(1) of this title, (O) with respect to services

described in section 1395x(s)(2)(K) of this title (relating to

services furnished by physician assistants, nurse practitioners,

or clinic nurse specialists), the amounts paid shall be equal to

80 percent of (i) the lesser of the actual charge or 85 percent

of the fee schedule amount provided under section 1395w-4 of this

title, or (ii) in the case of services as an assistant at

surgery, the lesser of the actual charge or 85 percent of the

amount that would otherwise be recognized if performed by a

physician who is serving as an assistant at surgery, (P) with

respect to surgical dressings, the amounts paid shall be the

amounts determined under section 1395m(i) of this title, (Q) with

respect to items or services for which fee schedules are

established pursuant to section 1395u(s) of this title, the

amounts paid shall be 80 percent of the lesser of the actual

charge or the fee schedule established in such section, (R) with

respect to ambulance services, (i) the amounts paid shall be 80

percent of the lesser of the actual charge for the services or

the amount determined by a fee schedule established by the

Secretary under section 1395m(l) of this title and (ii) with

respect to ambulance services described in section 1395m(l)(8) of

this title, the amounts paid shall be the amounts determined

under section 1395m(g) of this title for outpatient critical

access hospital services, (S) with respect to drugs and

biologicals not paid on a cost or prospective payment basis as

otherwise provided in this part (other than items and services

described in subparagraph (B)), the amounts paid shall be 80

percent of the lesser of the actual charge or the payment amount

established in section 1395u(o) of this title, (T) with respect

to medical nutrition therapy services (as defined in section

1395x(vv) of this title), the amount paid shall be 80 percent of

the lesser of the actual charge for the services or 85 percent of

the amount determined under the fee schedule established under

section 1395w-4(b) of this title for the same services if

furnished by a physician, and (U) with respect to facility fees

described in section 1395m(m)(2)(B) of this title, the amounts

paid shall be 80 percent of the lesser of the actual charge or

the amounts specified in such section;

(2) in the case of services described in section 1395k(a)(2) of

this title (except those services described in subparagraphs (C),

(D), (E), (F), (G), (H), and (I) of such section and unless

otherwise specified in section 1395rr of this title) -

(A) with respect to home health services (other than a

covered osteoporosis drug) (as defined in section 1395x(kk) of

this title), the amount determined under the prospective

payment system under section 1395fff of this title;

(B) with respect to other items and services (except those

described in subparagraph (C), (D), or (E) of this paragraph

and except as may be provided in section 1395ww of this title

or section 1395yy(e)(9) of this title) -

(i) furnished before January 1, 1999, the lesser of -

(I) the reasonable cost of such services, as determined

under section 1395x(v) of this title, or

(II) the customary charges with respect to such services,

less the amount a provider may charge as described in clause

(ii) of section 1395cc(a)(2)(A) of this title, but in no case

may the payment for such other services exceed 80 percent of

such reasonable cost, or

(ii) if such services are furnished before January 1, 1999,

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 clause), free of

charge or at nominal charges to the public, 80 percent of the

amount determined in accordance with section 1395f(b)(2) of

this title, or

(iii) if such services are furnished on or after January 1,

1999, the amount determined under subsection (t) of this

section, or

(iv) if (and for so long as) the conditions described in

section 1395f(b)(3) of this title are met, the amounts

determined under the reimbursement system described in such

section;

(C) with respect to services described in the second sentence

of section 1395x(p) of this title, 80 percent of the reasonable

charges for such services;

(D) with respect to clinical diagnostic laboratory tests for

which payment is made under this part (i) on the basis of a fee

schedule determined under subsection (h)(1) of this section or

section 1395m(d)(1) of this title, the amount paid shall be

equal to 80 percent (or 100 percent, in the case of such tests

for which payment is made on an assignment-related basis or to

a provider having an agreement under section 1395cc of this

title) of the lesser of the amount determined under such fee

schedule, the limitation amount for that test determined under

subsection (h)(4)(B) of this section, or the amount of the

charges billed for the tests, or (ii) on the basis of a

negotiated rate established under subsection (h)(6) of this

section, the amount paid shall be equal to 100 percent of such

negotiated rate for such tests;

(E) with respect to -

(i) outpatient hospital radiology services (including

diagnostic and therapeutic radiology, nuclear medicine and

CAT scan procedures, magnetic resonance imaging, and

ultrasound and other imaging services, but excluding

screening mammography), and

(ii) effective for procedures performed on or after October

1, 1989, diagnostic procedures (as defined by the Secretary)

described in section 1395x(s)(3) of this title (other than

diagnostic x-ray tests and diagnostic laboratory tests),

the amount determined under subsection (n) of this section or,

for services or procedures performed on or after January 1,

1999, subsection (t) of this section;

(F) with respect to a covered osteoporosis drug (as defined

in section 1395x(kk) of this title) furnished by a home health

agency, 80 percent of the reasonable cost of such service, as

determined under section 1395x(v) of this title; and

(G) with respect to items and services described in section

1395x(s)(10)(A) of this title, the lesser of -

(i) the reasonable cost of such services, as determined

under section 1395x(v) of this title, or

(ii) the customary charges with respect to such services,

or, 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 provision), free of charge or at nominal charges to

the public, the amount determined in accordance with section

1395f(b)(2) of this title;

(3) in the case of services described in section 1395k(a)(2)(D)

of this title, the costs which are reasonable and related to the

cost of furnishing such services 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, less the amount a provider may

charge as described in clause (ii) of section 1395cc(a)(2)(A) of

this title, but in no case may the payment for such services

(other than for items and services described in section

1395x(s)(10)(A) of this title) exceed 80 percent of such costs;

(4) in the case of facility services described in section

1395k(a)(2)(F) of this title, and outpatient hospital facility

services furnished in connection with surgical procedures

specified by the Secretary pursuant to subsection (i)(1)(A) of

this section, the applicable amount as determined under paragraph

(2) or (3) of subsection (i) of this section or subsection (t) of

this section;

(5) in the case of covered items (described in section

1395m(a)(13) of this title) the amounts described in section

1395m(a)(1) of this title;

(6) in the case of outpatient critical access hospital

services, the amounts described in section 1395m(g) of this

title;

(7) in the case of prosthetic devices and orthotics and

prosthetics (as described in section 1395m(h)(4) of this title),

the amounts described in section 1395m(h) of this title;

(8) in the case of -

(A) outpatient physical therapy services (which includes

outpatient speech-language pathology services) and outpatient

occupational therapy services furnished -

(i) by a rehabilitation agency, public health agency,

clinic, comprehensive outpatient rehabilitation facility, or

skilled nursing facility,

(ii) by a home health agency to an individual who is not

homebound, or

(iii) by another entity under an arrangement with an entity

described in clause (i) or (ii); and

(B) outpatient physical therapy services (which includes

outpatient speech-language pathology services) and outpatient

occupational therapy services furnished -

(i) by a hospital to an outpatient or to a hospital

inpatient who is entitled to benefits under part A of this

subchapter but has exhausted benefits for inpatient hospital

services during a spell of illness or is not so entitled to

benefits under part A of this subchapter, or

(ii) by another entity under an arrangement with a hospital

described in clause (i),

the amounts described in section 1395m(k) of this title; and

(9) in the case of services described in section 1395k(a)(2)(E)

of this title that are not described in paragraph (8), the

amounts described in section 1395m(k) of this title.

(b) Deductible provision

Before applying subsection (a) of this section with respect to

expenses incurred by an individual during any calendar year, the

total amount of the expenses incurred by such individual during

such year (which would, except for this subsection, constitute

incurred expenses from which benefits payable under subsection (a)

of this section are determinable) shall be reduced by a deductible

of $75 for calendar years before 1991 and $100 for 1991 and

subsequent years; except that (1) such total amount shall not

include expenses incurred for items and services described in

section 1395x(s)(10)(A) of this title, (2) such deductible shall

not apply with respect to home health services (other than a

covered osteoporosis drug (as defined in section 1395x(kk) of this

title)), (3) such deductible shall not apply with respect to

clinical diagnostic laboratory tests for which payment is made

under this part (A) under subsection (a)(1)(D)(i) or (a)(2)(D)(i)

of this section on an assignment-related basis, or to a provider

having an agreement under section 1395cc of this title, or (B) on

the basis of a negotiated rate determined under subsection (h)(6)

of this section, (4) such deductible shall not apply to Federally

qualified health center services, (5) such deductible shall not

apply with respect to screening mammography (as described in

section 1395x(jj) of this title), and (6) such deductible shall not

apply with respect to screening pap smear and screening pelvic exam

(as described in section 1395x(nn) of this title). The total amount

of the expenses incurred by an individual as determined under the

preceding sentence shall, after the reduction specified in such

sentence, be further reduced by an amount 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 the 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. The deductible under the previous sentence 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

1395e(a)(2) of this title to blood or blood cells furnished the

individual in the year.

(c) Mental disorders

Notwithstanding any other provision of this part, with respect to

expenses incurred in any calendar year in connection with the

treatment of mental, psychoneurotic, and personality disorders of

an individual who is not an inpatient of a hospital at the time

such expenses are incurred, there shall be considered as incurred

expenses for purposes of subsections (a) and (b) of this section

only 62 1/2 percent of such expenses. For purposes of this

subsection, the term "treatment" does not include brief office

visits (as defined by the Secretary) for the sole purpose of

monitoring or changing drug prescriptions used in the treatment of

such disorders or partial hospitalization services that are not

directly provided by a physician.

(d) Nonduplication of payments

No payment may be made under this part with respect to any

services furnished an individual to the extent that such individual

is entitled (or would be entitled except for section 1395e of this

title) to have payment made with respect to such services under

part A of this subchapter.

(e) Information for determination of amounts due

No payment shall be made to any provider of services or other

person under this part unless there has been furnished such

information as may be necessary in order to determine the amounts

due such provider or other person under this part for the period

with respect to which the amounts are being paid or for any prior

period.

(f) Maximum rate of payment per visit for independent rural health

clinics

In establishing limits under subsection (a) of this section on

payment for rural health clinic services provided by rural health

clinics (other than such clinics in hospitals with less than 50

beds), the Secretary shall establish such limit, for services

provided -

(1) in 1988, after March 31, at $46 per visit, and

(2) in a subsequent year, at the limit established under this

subsection for the previous year increased by the percentage

increase in the MEI (as defined in section 1395u(i)(3) of this

title) applicable to primary care services (as defined in section

1395u(i)(4) of this title) furnished as of the first day of that

year.

(g) Physical therapy services

(1) Subject to paragraph (4), in the case of physical therapy

services of the type described in section 1395x(p) of this title,

but not described in subsection (a)(8)(B) of this section, and

physical therapy services of such type which are furnished by a

physician or as incident to physicians' services, with respect to

expenses incurred in any calendar year, no more than the amount

specified in paragraph (2) for the year shall be considered as

incurred expenses for purposes of subsections (a) and (b) of this

section.

(2) The amount specified in this paragraph -

(A) for 1999, 2000, and 2001, is $1,500, and

(B) for a subsequent year is the amount specified in this

paragraph for the preceding year increased by the percentage

increase in the MEI (as defined in section 1395u(i)(3) of this

title) for such subsequent year;

except that if an increase under subparagraph (B) for a year is not

a multiple of $10, it shall be rounded to the nearest multiple of

$10.

(3) Subject to paragraph (4), in the case of occupational therapy

services (of the type that are described in section 1395x(p) of

this title (but not described in subsection (a)(8)(B) of this

section) through the operation of section 1395x(g) of this title

and of such type which are furnished by a physician or as incident

to physicians' services), with respect to expenses incurred in any

calendar year, no more than the amount specified in paragraph (2)

for the year shall be considered as incurred expenses for purposes

of subsections (a) and (b) of this section.

(4) This subsection shall not apply to expenses incurred with

respect to services furnished during 2000, 2001, and 2002.

(h) Fee schedules for clinical diagnostic laboratory tests;

percentage of prevailing charge level; nominal fee for samples;

adjustments; recipients of payments; negotiated payment rate

(1)(A) Subject to section 1395m(d)(1) of this title, the

Secretary shall establish fee schedules for clinical diagnostic

laboratory tests (including prostate cancer screening tests under

section 1395x(oo) of this title consisting of prostate-specific

antigen blood tests) for which payment is made under this part,

other than such tests performed by a provider of services for an

inpatient of such provider.

(B) In the case of clinical diagnostic laboratory tests performed

by a physician or by a laboratory (other than tests performed by a

qualified hospital laboratory (as defined in subparagraph (D)) for

outpatients of such hospital), the fee schedules established under

subparagraph (A) shall be established on a regional, statewide, or

carrier service area basis (as the Secretary may determine to be

appropriate) for tests furnished on or after July 1, 1984.

(C) In the case of clinical diagnostic laboratory tests performed

by a qualified hospital laboratory (as defined in subparagraph (D))

for outpatients of such hospital, the fee schedules established

under subparagraph (A) shall be established on a regional,

statewide, or carrier service area basis (as the Secretary may

determine to be appropriate) for tests furnished on or after July

1, 1984.

(D) In this subsection, the term "qualified hospital laboratory"

means a hospital laboratory, in a sole community hospital (as

defined in section 1395ww(d)(5)(D)(iii) of this title), which

provides some clinical diagnostic laboratory tests 24 hours a day

in order to serve a hospital emergency room which is available to

provide services 24 hours a day and 7 days a week.

(2)(A)(i) Except as provided in paragraph (4), the Secretary

shall set the fee schedules at 60 percent (or, in the case of a

test performed by a qualified hospital laboratory (as defined in

paragraph (1)(D)) for outpatients of such hospital, 62 percent) of

the prevailing charge level determined pursuant to the third and

fourth sentences of section 1395u(b)(3) of this title for similar

clinical diagnostic laboratory tests for the applicable region,

State, or area for the 12-month period beginning July 1, 1984,

adjusted annually (to become effective on January 1 of each year)

by a percentage increase or decrease equal to the percentage

increase or decrease in the Consumer Price Index for All Urban

Consumers (United States city average), and subject to such other

adjustments as the Secretary determines are justified by

technological changes.

(ii) Notwithstanding clause (i) -

(I) any change in the fee schedules which would have become

effective under this subsection for tests furnished on or after

January 1, 1988, shall not be effective for tests furnished

during the 3-month period beginning on January 1, 1988,

(II) the Secretary shall not adjust the fee schedules under

clause (i) to take into account any increase in the consumer

price index for 1988,

(III) the annual adjustment in the fee schedules determined

under clause (i) for each of the years 1991, 1992, and 1993 shall

be 2 percent, and

(IV) the annual adjustment in the fee schedules determined

under clause (i) for each of the years 1994 and 1995 and 1998

through 2002 shall be 0 percent.

(iii) In establishing fee schedules under clause (i) with respect

to automated tests and tests (other than cytopathology tests) which

before July 1, 1984, the Secretary made subject to a limit based on

lowest charge levels under the sixth sentence of section

1395u(b)(3) of this title performed after March 31, 1988, the

Secretary shall reduce by 8.3 percent the fee schedules otherwise

established for 1988, and such reduced fee schedules shall serve as

the base for 1989 and subsequent years.

(B) The Secretary may make further adjustments or exceptions to

the fee schedules to assure adequate reimbursement of (i) emergency

laboratory tests needed for the provision of bona fide emergency

services, and (ii) certain low volume high-cost tests where highly

sophisticated equipment or extremely skilled personnel are

necessary to assure quality.

(3) In addition to the amounts provided under the fee schedules,

the Secretary shall provide for and establish (A) a nominal fee to

cover the appropriate costs in collecting the sample on which a

clinical diagnostic laboratory test was performed and for which

payment is made under this part, except that not more than one such

fee may be provided under this paragraph with respect to samples

collected in the same encounter, and (B) a fee to cover the

transportation and personnel expenses for trained personnel to

travel to the location of an individual to collect the sample,

except that such a fee may be provided only with respect to an

individual who is homebound or an inpatient in an inpatient

facility (other than a hospital). In establishing a fee to cover

the transportation and personnel expenses for trained personnel to

travel to the location of an individual to collect a sample, the

Secretary shall provide a method for computing the fee based on the

number of miles traveled and the personnel costs associated with

the collection of each individual sample, but the Secretary shall

only be required to apply such method in the case of tests

furnished during the period beginning on April 1, 1989, and ending

on December 31, 1990, by a laboratory that establishes to the

satisfaction of the Secretary (based on data for the 12-month

period ending June 30, 1988) that (i) the laboratory is dependent

upon payments under this subchapter for at least 80 percent of its

collected revenues for clinical diagnostic laboratory tests, (ii)

at least 85 percent of its gross revenues for such tests are

attributable to tests performed with respect to individuals who are

homebound or who are residents in a nursing facility, and (iii) the

laboratory provided such tests for residents in nursing facilities

representing at least 20 percent of the number of such facilities

in the State in which the laboratory is located.

(4)(A) In establishing any fee schedule under this subsection,

the Secretary may provide for an adjustment to take into account,

with respect to the portion of the expenses of clinical diagnostic

laboratory tests attributable to wages, the relative difference

between a region's or local area's wage rates and the wage rate

presumed in the data on which the schedule is based.

(B) For purposes of subsections (a)(1)(D)(i) and (a)(2)(D)(i) of

this section, the limitation amount for a clinical diagnostic

laboratory test performed -

(i) on or after July 1, 1986, and before April 1, 1988, is

equal to 115 percent of the median of all the fee schedules

established for that test for that laboratory setting under

paragraph (1),

(ii) after March 31, 1988, and before January 1, 1990, is equal

to the median of all the fee schedules established for that test

for that laboratory setting under paragraph (1),

(iii) after December 31, 1989, and before January 1, 1991, is

equal to 93 percent of the median of all the fee schedules

established for that test for that laboratory setting under

paragraph (1),

(iv) after December 31, 1990, and before January 1, 1994, is

equal to 88 percent of such median,

(v) after December 31, 1993, and before January 1, 1995, is

equal to 84 percent of such median,

(vi) after December 31, 1994, and before January 1, 1996, is

equal to 80 percent of such median,

(vii) after December 31, 1995, and before January 1, 1998, is

equal to 76 percent of such median, and

(viii) after December 31, 1997, is equal to 74 percent of such

median (or 100 percent of such median in the case of a clinical

diagnostic laboratory test performed on or after January 1, 2001,

that the Secretary determines is a new test for which no

limitation amount has previously been established under this

subparagraph).

(5)(A) In the case of a bill or request for payment for a

clinical diagnostic laboratory test for which payment may otherwise

be made under this part on an assignment-related basis or under a

provider agreement under section 1395cc of this title, payment may

be made only to the person or entity which performed or supervised

the performance of such test; except that -

(i) if a physician performed or supervised the performance of

such test, payment may be made to another physician with whom he

shares his practice,

(ii) in the case of a test performed at the request of a

laboratory by another laboratory, payment may be made to the

referring laboratory but only if -

(I) the referring laboratory is located in, or is part of, a

rural hospital,

(II) the referring laboratory is wholly owned by the entity

performing such test, the referring laboratory wholly owns the

entity performing such test, or both the referring laboratory

and the entity performing such test are wholly-owned by a third

entity, or

(III) not more than 30 percent of the clinical diagnostic

laboratory tests for which such referring laboratory (but not

including a laboratory described in subclause (II)),(!2)

receives requests for testing during the year in which the test

is performed (!2) are performed by another laboratory, and

(iii) in the case of a clinical diagnostic laboratory test

provided under an arrangement (as defined in section 1395x(w)(1)

of this title) made by a hospital, critical access hospital, or

skilled nursing facility, payment shall be made to the hospital

or skilled nursing facility.

(B) In the case of such a bill or request for payment for a

clinical diagnostic laboratory test for which payment may otherwise

be made under this part, and which is not described in subparagraph

(A), payment may be made to the beneficiary only on the basis of

the itemized bill of the person or entity which performed or

supervised the performance of the test.

(C) Payment for a clinical diagnostic laboratory test, including

a test performed in a physician's office but excluding a test

performed by a rural health clinic may only be made on an

assignment-related basis or to a provider of services with an

agreement in effect under section 1395cc of this title.

(D) A person may not bill for a clinical diagnostic laboratory

test, including a test performed in a physician's office but

excluding a test performed by a rural health clinic,,(!3) other

than on an assignment-related basis. If a person knowingly and

willfully and on a repeated basis bills for a clinical diagnostic

laboratory test in violation of the previous sentence, the

Secretary may apply sanctions against the person in the same manner

as the Secretary may apply sanctions against a physician in

accordance with paragraph (2) of section 1395u(j) of this title in

the same manner such paragraphs apply (!4) with respect to a

physician. Paragraph (4) of such section shall apply in this

subparagraph in the same manner as such paragraph applies to such

section.

(6) In the case of any diagnostic laboratory test payment for

which is not made on the basis of a fee schedule under paragraph

(1), the Secretary may establish a payment rate which is acceptable

to the person or entity performing the test and which would be

considered the full charge for such tests. Such negotiated rate

shall be limited to an amount not in excess of the total payment

that would have been made for the services in the absence of such

rate.

(7) Notwithstanding paragraphs (1) and (4), the Secretary shall

establish a national minimum payment amount under this subsection

for a diagnostic or screening pap smear laboratory test (including

all cervical cancer screening technologies that have been approved

by the Food and Drug Administration as a primary screening method

for detection of cervical cancer) equal to $14.60 for tests

furnished in 2000. For such tests furnished in subsequent years,

such national minimum payment amount shall be adjusted annually as

provided in paragraph (2).

(i) Outpatient surgery

(1) The Secretary shall, in consultation with appropriate medical

organizations -

(A) specify those surgical procedures which are appropriately

(when considered in terms of the proper utilization of hospital

inpatient facilities) performed on an inpatient basis in a

hospital but which also can be performed safely on an ambulatory

basis in an ambulatory surgical center (meeting the standards

specified under section 1395k(a)(2)(F)(i) of this title),

critical access hospital, or hospital outpatient department, and

(B) specify those surgical procedures which are appropriately

(when considered in terms of the proper utilization of hospital

inpatient facilities) performed on an inpatient basis in a

hospital but which also can be performed safely on an ambulatory

basis in a physician's office.

The lists of procedures established under subparagraphs (A) and (B)

shall be reviewed and updated not less often than every 2 years, in

consultation with appropriate trade and professional organizations.

(2)(A) The amount of payment to be made for facility services

furnished in connection with a surgical procedure specified

pursuant to paragraph (1)(A) and furnished to an individual in an

ambulatory surgical center described in such paragraph shall be

equal to 80 percent of a standard overhead amount established by

the Secretary (with respect to each such procedure) on the basis of

the Secretary's estimate of a fair fee which -

(i) takes into account the costs incurred by such centers, or

classes of centers, generally in providing services furnished in

connection with the performance of such procedure, as determined

in accordance with a survey (based upon a representative sample

of procedures and facilities) taken not later than January 1,

1995, and every 5 years thereafter, of the actual audited costs

incurred by such centers in providing such services,

(ii) takes such costs into account in such a manner as will

assure that the performance of the procedure in such a center

will result in substantially less amounts paid under this

subchapter than would have been paid if the procedure had been

performed on an inpatient basis in a hospital, and

(iii) in the case of insertion of an intraocular lens during or

subsequent to cataract surgery includes payment which is

reasonable and related to the cost of acquiring the class of lens

involved.

Each amount so established shall be reviewed and updated not later

than July 1, 1987, and annually thereafter to take account of

varying conditions in different areas.

(B) The amount of payment to be made under this part for facility

services furnished, in connection with a surgical procedure

specified pursuant to paragraph (1)(B), in a physician's office

shall be equal to 80 percent of a standard overhead amount

established by the Secretary (with respect to each such procedure)

on the basis of the Secretary's estimate of a fair fee which -

(i) takes into account additional costs, not usually included

in the professional fee, incurred by physicians in securing,

maintaining, and staffing the facilities and ancillary services

appropriate for the performance of such procedure in the

physician's office, and

(ii) takes such items into account in such a manner which will

assure that the performance of such procedure in the physician's

office will result in substantially less amounts paid under this

subchapter than would have been paid if the services had been

furnished on an inpatient basis in a hospital.

Each amount so established shall be reviewed and updated not later

than July 1, 1987, and annually thereafter to take account of

varying conditions in different areas.

(C) Notwithstanding the second sentence of subparagraph (A) or

the second sentence of subparagraph (B), if the Secretary has not

updated amounts established under such subparagraphs with respect

to facility services furnished during a fiscal year (beginning with

fiscal year 1996), such amounts shall be increased by the

percentage increase in the consumer price index for all urban

consumers (U.S. city average) as estimated by the Secretary for the

12-month period ending with the midpoint of the year involved. In

each of the fiscal years 1998 through 2002, the increase under this

subparagraph shall be reduced (but not below zero) by 2.0

percentage points.

(3)(A) The aggregate amount of the payments to be made under this

part for outpatient hospital facility services or critical access

hospital services furnished before January 1, 1999, in connection

with surgical procedures specified under paragraph (1)(A) shall be

equal to the lesser of -

(i) the amount determined with respect to such services under

subsection (a)(2)(B) of this section; or

(ii) the blend amount (described in subparagraph (B)).

(B)(i) The blend amount for a cost reporting period is the sum of

-

(I) the cost proportion (as defined in clause (ii)(I)) of the

amount described in subparagraph (A)(i), and

(II) the ASC proportion (as defined in clause (ii)(II)) of the

standard overhead amount payable with respect to the same

surgical procedure as if it were provided in an ambulatory

surgical center in the same area, as determined under paragraph

(2)(A), less the amount a provider may charge as described in

clause (ii) of section 1395cc(a)(2)(A) of this title.

(ii) Subject to paragraph (4), in this paragraph:

(I) The term "cost proportion" means 75 percent for cost

reporting periods beginning in fiscal year 1988, 50 percent for

portions of cost reporting periods beginning on or after October

1, 1988, and ending on or before December 31, 1990, and 42

percent for portions of cost reporting periods beginning on or

after January 1, 1991.

(II) The term "ASC proportion" means 25 percent for cost

reporting periods beginning in fiscal year 1988, 50 percent for

portions of cost reporting periods beginning on or after October

1, 1988, and ending on or before December 31, 1990, and 58

percent for portions of cost reporting periods beginning on or

after January 1, 1991.

(4)(A) In the case of a hospital that -

(i) makes application to the Secretary and demonstrates that it

specializes in eye services or eye and ear services (as

determined by the Secretary),

(ii) receives more than 30 percent of its total revenues from

outpatient services, and

(iii) on October 1, 1987 -

(I) was an eye specialty hospital or an eye and ear specialty

hospital, or

(II) was operated as an eye or eye and ear unit (as defined

in subparagraph (B)) of a general acute care hospital which, on

the date of the application described in clause (i), operates

less than 20 percent of the beds that the hospital operated on

October 1, 1987, and has sold or otherwise disposed of a

substantial portion of the hospital's other acute care

operations,

the cost proportion and ASC proportion in effect under subclauses

(I) and (II) of paragraph (3)(B)(ii) for cost reporting periods

beginning in fiscal year 1988 shall remain in effect for cost

reporting periods beginning on or after October 1, 1988, and before

January 1, 1995.

(B) For purposes of this (!5) subparagraph (A)(iii)(II), the term

"eye or eye and ear unit" means a physically separate or distinct

unit containing separate surgical suites devoted solely to eye or

eye and ear services.

(5)(A) The Secretary is authorized to provide by regulations that

in the case of a surgical procedure, specified by the Secretary

pursuant to paragraph (1)(A), performed in an ambulatory surgical

center described in such paragraph, there shall be paid (in lieu of

any amounts otherwise payable under this part) with respect to the

facility services furnished by such center and with respect to all

related services (including physicians' services, laboratory,

X-ray, and diagnostic services) a single all-inclusive fee

established pursuant to subparagraph (B), if all parties furnishing

all such services agree to accept such fee (to be divided among the

parties involved in such manner as they shall have previously

agreed upon) as full payment for the services furnished.

(B) In implementing this paragraph, the Secretary shall establish

with respect to each surgical procedure specified pursuant to

paragraph (1)(A) the amount of the all-inclusive fee for such

procedure, taking into account such factors as may be appropriate.

The amount so established with respect to any surgical procedure

shall be reviewed periodically and may be adjusted by the

Secretary, when appropriate, to take account of varying conditions

in different areas.

(6) Any person, including a facility having an agreement under

section 1395k(a)(2)(F)(i) of this title, who knowingly and

willfully presents, or causes to be presented, a bill or request

for payment, for an intraocular lens inserted during or subsequent

to cataract surgery for which payment may be made under paragraph

(2)(A)(iii), 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.

(j) 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 either to a provider of services or to another

person pursuant to an assignment under section 1395u(b)(3)(B)(ii)

of this title 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.

(k) Hepatitis B vaccine

With respect to services described in section 1395x(s)(10)(B) of

this title, the Secretary may provide, instead of the amount of

payment otherwise provided under this part, for payment of such an

amount or amounts as reasonably reflects the general cost of

efficiently providing such services.

(l) Fee schedule for services of certified registered nurse

anesthetists

(1)(A) The Secretary shall establish a fee schedule for services

of certified registered nurse anesthetists under section

1395x(s)(11) of this title.

(B) In establishing the fee schedule under this paragraph the

Secretary may utilize a system of time units, a system of base and

time units, or any appropriate methodology.

(C) The provisions of this subsection shall not apply to certain

services furnished in certain hospitals in rural areas under the

provisions of section 9320(k) of the Omnibus Budget Reconciliation

Act of 1986, as amended by section 6132 of the Omnibus Budget

Reconciliation Act of 1989.

(2) Except as provided in paragraph (3), the fee schedule

established under paragraph (1) shall be initially based on audited

data from cost reporting periods ending in fiscal year 1985 and

such other data as the Secretary determines necessary.

(3)(A) In establishing the initial fee schedule for those

services, the Secretary shall adjust the fee schedule to the extent

necessary to ensure that the estimated total amount which will be

paid under this subchapter for those services plus applicable

coinsurance in 1989 will equal the estimated total amount which

would be paid under this subchapter for those services in 1989 if

the services were included as inpatient hospital services and

payment for such services was made under part A of this subchapter

in the same manner as payment was made in fiscal year 1987,

adjusted to take into account changes in prices and technology

relating to the administration of anesthesia.

(B) The Secretary shall also reduce the prevailing charge of

physicians for medical direction of a certified registered nurse

anesthetist, or the fee schedule for services of certified

registered nurse anesthetists, or both, to the extent necessary to

ensure that the estimated total amount which will be paid under

this subchapter plus applicable coinsurance for such medical

direction and such services in 1989 and 1990 will not exceed the

estimated total amount which would have been paid plus applicable

coinsurance but for the enactment of the amendments made by section

9320 of the Omnibus Budget Reconciliation Act of 1986. A reduced

prevailing charge under this subparagraph shall become the

prevailing charge but for subsequent years for purposes of applying

the economic index under the fourth sentence of section 1395u(b)(3)

of this title.

(4)(A) Except as provided in subparagraphs (C) and (D), in

determining the amount paid under the fee schedule under this

subsection for services furnished on or after January 1, 1991, by a

certified registered nurse anesthetist who is not medically

directed -

(i) the conversion factor shall be -

(I) for services furnished in 1991, $15.50,

(II) for services furnished in 1992, $15.75,

(III) for services furnished in 1993, $16.00,

(IV) for services furnished in 1994, $16.25,

(V) for services furnished in 1995, $16.50,

(VI) for services furnished in 1996, $16.75, and

(VII) for services furnished in calendar years after 1996,

the previous year's conversion factor increased by the update

determined under section 1395w-4(d) of this title for physician

anesthesia services for that year;

(ii) the payment areas to be used shall be the fee schedule

areas used under section 1395w-4 of this title (or, in the case

of services furnished during 1991, the localities used under

section 1395u(b) of this title) for purposes of computing

payments for physicians' services that are anesthesia services;

(iii) the geographic adjustment factors to be applied to the

conversion factor under clause (i) for services in a fee schedule

area or locality is - (!6)

(I) in the case of services furnished in 1991, the geographic

work index value and the geographic practice cost index value

specified in section 1395u(q)(1)(B) of this title for

physicians' services that are anesthesia services furnished in

the area or locality, and

(II) in the case of services furnished after 1991, the

geographic work index value, the geographic practice cost index

value, and the geographic malpractice index value used for

determining payments for physicians' services that are

anesthesia services under section 1395w-4 of this title,

with 70 percent of the conversion factor treated as attributable

to work and 30 percent as attributable to overhead for services

furnished in 1991 (and the portions attributable to work,

practice expenses, and malpractice expenses in 1992 and

thereafter being the same as is applied under section 1395w-4 of

this title).

(B)(i) Except as provided in clause (ii) and subparagraph (D), in

determining the amount paid under the fee schedule under this

subsection for services furnished on or after January 1, 1991, and

before January 1, 1994, by a certified registered nurse anesthetist

who is medically directed, the Secretary shall apply the same

methodology specified in subparagraph (A).

(ii) The conversion factor used under clause (i) shall be -

(I) for services furnished in 1991, $10.50,

(II) for services furnished in 1992, $10.75, and

(III) for services furnished in 1993, $11.00.

(iii) In the case of services of a certified registered nurse

anesthetist who is medically directed or medically supervised by a

physician which are furnished on or after January 1, 1994, the fee

schedule amount shall be one-half of the amount described in

section 1395w-4(a)(5)(B) of this title with respect to the

physician.

(C) Notwithstanding subclauses (I) through (V) of subparagraph

(A)(i) -

(i) in the case of a 1990 conversion factor that is greater

than $16.50, the conversion factor for a calendar year after 1990

and before 1996 shall be the 1990 conversion factor reduced by

the product of the last digit of the calendar year and one-fifth

of the amount by which the 1990 conversion factor exceeds $16.50;

and

(ii) in the case of a 1990 conversion factor that is greater

than $15.49 but less than $16.51, the conversion factor for a

calendar year after 1990 and before 1996 shall be the greater of

-

(I) the 1990 conversion factor, or

(II) the conversion factor specified in subparagraph (A)(i)

for the year involved.

(D) Notwithstanding subparagraph (C), in no case may the

conversion factor used to determine payment for services in a fee

schedule area or locality under this subsection, as adjusted by the

adjustment factors specified in subparagraphs (!7) (A)(iii), exceed

the conversion factor used to determine the amount paid for

physicians' services that are anesthesia services in the area or

locality.

(5)(A) Payment for the services of a certified registered nurse

anesthetist (for which payment may otherwise be made under this

part) may be made on the basis of a claim or request for payment

presented by the certified registered nurse anesthetist furnishing

such services, or by a hospital, critical access hospital,

physician, group practice, or ambulatory surgical center with which

the certified registered nurse anesthetist furnishing such services

has an employment or contractual relationship that provides for

payment to be made under this part for such services to such

hospital, critical access hospital, physician, group practice, or

ambulatory surgical center.

(B) No hospital or critical access hospital that presents a claim

or request for payment for services of a certified nurse

anesthetist under this part may treat any uncollected coinsurance

amount imposed under this part with respect to such services as a

bad debt of such hospital or critical access hospital for purposes

of this subchapter.

(6) If an adjustment under paragraph (3)(B) results in a

reduction in the reasonable charge for a physicians' service and a

nonparticipating physician furnishes the service to an individual

entitled to benefits under this part after the effective date of

the reduction, the physician's actual charge is subject to a limit

under section 1395u(j)(1)(D) of this title.

(m) Incentive payments for physicians' services furnished in

underserved areas

In the case of physicians' services furnished to an individual,

who is covered under the insurance program established by this part

and who incurs expenses for such services, in an area that is

designated (under section 254e(a)(1)(A) of this title) as a health

professional shortage area, in addition to the amount otherwise

paid under this part, there also shall be paid to the physician (or

to an employer or facility in the cases described in clause (A) of

section 1395u(b)(6) of this title) (on a monthly or quarterly

basis) from the Federal Supplementary Medical Insurance Trust Fund

an amount equal to 10 percent of the payment amount for the service

under this part.

(n) Payments to hospital outpatient departments for radiology;

amount; definitions

(1)(A) (!8) The aggregate amount of the payments to be made for

all or part of a cost reporting period for services described in

subsection (a)(2)(E)(i) of this section furnished under this part

on or after October 1, 1988, and before January 1, 1999, and for

services described in subsection (a)(2)(E)(ii) of this section

furnished under this part on or after October 1, 1989, and before

January 1, 1999, shall be equal to the lesser of -

(i) the amount determined with respect to such services under

subsection (a)(2)(B) of this section, or

(ii) the blend amount for radiology services and diagnostic

procedures determined in accordance with subparagraph (B).

(B)(i) The blend amount for radiology services and diagnostic

procedures for a cost reporting period is the sum of -

(I) the cost proportion (as defined in clause (ii)) of the

amount described in subparagraph (A)(i); and

(II) the charge proportion (as defined in clause (ii)(II)) of

62 percent (for services described in subsection (a)(2)(E)(i) of

this section), or (for procedures described in subsection

(a)(2)(E)(ii) of this section), 42 percent or such other percent

established by the Secretary (or carriers acting pursuant to

guidelines issued by the Secretary) based on prevailing charges

established with actual charge data, of the prevailing charge or

(for services described in subsection (a)(2)(E)(i) of this

section furnished on or after April 1, 1989 and for services

described in subsection (a)(2)(E)(ii) of this section furnished

on or after January 1, 1992) the fee schedule amount established

for participating physicians for the same services as if they

were furnished in a physician's office in the same locality as

determined under section 1395u(b) of this title (or, in the case

of services furnished on or after January 1, 1992, under section

1395w-4 of this title), less the amount a provider may charge as

described in clause (ii) of section 1395cc(a)(2)(A) of this

title.

(ii) In this subparagraph:

(I) The term "cost proportion" means 50 percent, except that

such term means 65 percent in the case of outpatient radiology

services for portions of cost reporting periods which occur in

fiscal year 1989 and in the case of diagnostic procedures

described in subsection (a)(2)(E)(ii) of this section for

portions of cost reporting periods which occur in fiscal year

1990, and such term means 42 percent in the case of outpatient

radiology services for portions of cost reporting periods

beginning on or after January 1, 1991.

(II) The term "charge proportion" means 100 percent minus the

cost proportion.

(o) Limitation on benefit for payment for therapeutic shoes for

individuals with severe diabetic foot disease

(1) In the case of shoes described in section 1395x(s)(12) of

this title -

(A) no payment may be made under this part, with respect to any

individual for any year, for the furnishing of -

(i) more than one pair of custom molded shoes (including

inserts provided with such shoes) and 2 additional pairs of

inserts for such shoes, or

(ii) more than one pair of extra-depth shoes (not including

inserts provided with such shoes) and 3 pairs of inserts for

such shoes, and

(B) with respect to expenses incurred in any calendar year, no

more than the limits established under paragraph (2) shall be

considered as incurred expenses for purposes of subsections (a)

and (b) of this section.

Payment for shoes (or inserts) under this part shall be considered

to include payment for any expenses for the fitting of such shoes

(or inserts).

(2)(A) Except as provided by the Secretary under subparagraphs

(B) and (C), the limits established under this paragraph -

(i) for the furnishing of -

(I) one pair of custom molded shoes (including any inserts

that are provided initially with the shoes) is $300, and

(II) any additional pair of inserts with respect to such

shoes is $50; and

(ii) for the furnishing of extra-depth shoes and inserts is -

(I) $100 for the pair of shoes itself, and

(II) $50 for any pairs of inserts for a pair of shoes.

(B) The Secretary or a carrier may establish limits for shoes

that are lower than the limits established under subparagraph (A)

if the Secretary finds that shoes and inserts of an appropriate

quality are readily available at or below such lower limits.

(C) For each year after 1988, each dollar amount under

subparagraph (A) or (B) (as previously adjusted under this

subparagraph) shall be increased by the same percentage increase as

the Secretary provides with respect to durable medical equipment

for that year, except that if such increase is not a multiple of

$1, it shall be rounded to the nearest multiple of $1.

(D) In accordance with procedures established by the Secretary,

an individual entitled to benefits with respect to shoes described

in section 1395x(s)(12) of this title may substitute modification

of such shoes instead of obtaining one (or more, as specified by

the Secretary) pairs (!9) of inserts (other than the original pair

of inserts with respect to such shoes). In such case, the Secretary

shall substitute, for the limits established under subparagraph

(A), such limits as the Secretary estimates will assure that there

is no net increase in expenditures under this subsection as a

result of this subparagraph.

(3) In this subchapter, the term "shoes" includes, except for

purposes of subparagraphs (A)(ii) and (B) of paragraph (2), inserts

for extra-depth shoes.

(p) Repealed. Pub. L. 103-432, title I, Sec. 123(b)(2)(A)(ii), Oct.

31, 1994, 108 Stat. 4411

(q) Requests for payment to include information on referring

physician

(1) Each request for payment, or bill submitted, for an item or

service furnished by an entity for which payment may be made under

this part and for which the entity knows or has reason to believe

there has been a referral by a referring physician (within the

meaning of section 1395nn of this title) shall include the name and

unique physician identification number for the referring physician.

(2)(A) In the case of a request for payment for an item or

service furnished by an entity under this part on an

assignment-related basis and for which information is required to

be provided under paragraph (1) but not included, payment may be

denied under this part.

(B) In the case of a request for payment for an item or service

furnished by an entity under this part not submitted on an

assignment-related basis and for which information is required to

be provided under paragraph (1) but not included -

(i) if the entity knowingly and willfully fails to provide such

information promptly upon request of the Secretary or a carrier,

the entity may be subject to a civil money penalty in an amount

not to exceed $2,000, and

(ii) if the entity knowingly, willfully, and in repeated cases

fails, after being notified by the Secretary of the obligations

and requirements of this subsection to provide the information

required under paragraph (1), the entity may be subject to

exclusion from participation in the programs under this chapter

for a period not to exceed 5 years, in accordance with the

procedures of subsections (c), (f), and (g) of section 1320a-7 of

this title.

The provisions of section 1320a-7a of this title (other than

subsections (a) and (b)) shall apply to civil money penalties under

clause (i) in the same manner as they apply to a penalty or

proceeding under section 1320a-7a(a) of this title.

(r) Cap on prevailing charge; billing on assignment-related basis

(1) With respect to services described in section

1395x(s)(2)(K)(ii) of this title (relating to nurse practitioner or

clinical nurse specialist services), payment may be made on the

basis of a claim or request for payment presented by the nurse

practitioner or clinical nurse specialist furnishing such services,

or by a hospital, critical access hospital, skilled nursing

facility or nursing facility (as defined in section 1396r(a) of

this title), physician, group practice, or ambulatory surgical

center with which the nurse practitioner or clinical nurse

specialist has an employment or contractual relationship that

provides for payment to be made under this part for such services

to such hospital, physician, group practice, or ambulatory surgical

center.

(2) No hospital or critical access hospital that presents a claim

or request for payment under this part for services described in

section 1395x(s)(2)(K)(ii) of this title may treat any uncollected

coinsurance amount imposed under this part with respect to such

services as a bad debt of such hospital for purposes of this

subchapter.

(s) Other prepaid organizations

The Secretary may not provide for payment under subsection

(a)(1)(A) of this section with respect to an organization unless

the organization provides assurances satisfactory to the Secretary

that the organization meets the requirement of section 1395cc(f) of

this title (relating to maintaining written policies and procedures

respecting advance directives).

(t) Prospective payment system for hospital outpatient department

services

(1) Amount of payment

(A) In general

With respect to covered OPD services (as defined in

subparagraph (B)) furnished during a year beginning with 1999,

the amount of payment under this part shall be determined under

a prospective payment system established by the Secretary in

accordance with this subsection.

(B) Definition of covered OPD services

For purposes of this subsection, the term "covered OPD

services" -

(i) means hospital outpatient services designated by the

Secretary;

(ii) subject to clause (iv), includes inpatient hospital

services designated by the Secretary that are covered under

this part and furnished to a hospital inpatient who (I) is

entitled to benefits under part A of this subchapter but has

exhausted benefits for inpatient hospital services during a

spell of illness, or (II) is not so entitled;

(iii) includes implantable items described in paragraph

(3), (6), or (8) of section 1395x(s) of this title; but

(iv) does not include any therapy services described in

subsection (a)(8) of this section or ambulance services, for

which payment is made under a fee schedule described in

section 1395m(k) of this title or section 1395m(l) of this

title.

(2) System requirements

Under the payment system -

(A) the Secretary shall develop a classification system for

covered OPD services;

(B) the Secretary may establish groups of covered OPD

services, within the classification system described in

subparagraph (A), so that services classified within each group

are comparable clinically and with respect to the use of

resources and so that an implantable item is classified to the

group that includes the service to which the item relates;

(C) the Secretary shall, using data on claims from 1996 and

using data from the most recent available cost reports,

establish relative payment weights for covered OPD services

(and any groups of such services described in subparagraph (B))

based on median (or, at the election of the Secretary, mean)

hospital costs and shall determine projections of the frequency

of utilization of each such service (or group of services) in

1999;

(D) the Secretary shall determine a wage adjustment factor to

adjust the portion of payment and coinsurance attributable to

labor-related costs for relative differences in labor and

labor-related costs across geographic regions in a budget

neutral manner;

(E) the Secretary shall establish, in a budget neutral

manner, outlier adjustments under paragraph (5) and

transitional pass-through payments under paragraph (6) and

other adjustments as determined to be necessary to ensure

equitable payments, such as adjustments for certain classes of

hospitals;

(F) the Secretary shall develop a method for controlling

unnecessary increases in the volume of covered OPD services;

and

(G) the Secretary shall create additional groups of covered

OPD services that classify separately those procedures that

utilize contrast agents from those that do not.

For purposes of subparagraph (B), items and services within a

group shall not be treated as "comparable with respect to the use

of resources" if the highest median cost (or mean cost, if

elected by the Secretary under subparagraph (C)) for an item or

service within the group is more than 2 times greater than the

lowest median cost (or mean cost, if so elected) for an item or

service within the group; except that the Secretary may make

exceptions in unusual cases, such as low volume items and

services, but may not make such an exception in the case of a

drug or biological that has been designated as an orphan drug

under section 360bb of title 21.

(3) Calculation of base amounts

(A) Aggregate amounts that would be payable if deductibles were

disregarded

The Secretary shall estimate the sum of -

(i) the total amounts that would be payable from the Trust

Fund under this part for covered OPD services in 1999,

determined without regard to this subsection, as though the

deductible under subsection (b) of this section did not

apply, and

(ii) the total amounts of copayments estimated to be paid

under this subsection by beneficiaries to hospitals for

covered OPD services in 1999, as though the deductible under

subsection (b) of this section did not apply.

(B) Unadjusted copayment amount

(i) In general

For purposes of this subsection, subject to clause (ii),

the "unadjusted copayment amount" applicable to a covered OPD

service (or group of such services) is 20 percent of the

national median of the charges for the service (or services

within the group) furnished during 1996, updated to 1999

using the Secretary's estimate of charge growth during the

period.

(ii) Adjusted to be 20 percent when fully phased in

If the pre-deductible payment percentage for a covered OPD

service (or group of such services) furnished in a year would

be equal to or exceed 80 percent, then the unadjusted

copayment amount shall be 20 percent of amount determined

under subparagraph (D).

(iii) Rules for new services

The Secretary shall establish rules for establishment of an

unadjusted copayment amount for a covered OPD service not

furnished during 1996, based upon its classification within a

group of such services.

(C) Calculation of conversion factors

(i) For 1999

(I) In general

The Secretary shall establish a 1999 conversion factor

for determining the medicare OPD fee schedule amounts for

each covered OPD service (or group of such services)

furnished in 1999. Such conversion factor shall be

established on the basis of the weights and frequencies

described in paragraph (2)(C) and in such a manner that the

sum for all services and groups of the products (described

in subclause (II) for each such service or group) equals

the total projected amount described in subparagraph (A).

(II) Product described

The Secretary shall determine for each service or group

the product of the medicare OPD fee schedule amounts

(taking into account appropriate adjustments described in

paragraphs (2)(D) and (2)(E)) and the estimated frequencies

for such service or group.

(ii) Subsequent years

Subject to paragraph (8)(B), the Secretary shall establish

a conversion factor for covered OPD services furnished in

subsequent years in an amount equal to the conversion factor

established under this subparagraph and applicable to such

services furnished in the previous year increased by the OPD

fee schedule increase factor specified under clause (iii)

(!10) for the year involved.

(iii) Adjustment for service mix changes

Insofar as the Secretary determines that the adjustments

for service mix under paragraph (2) for a previous year (or

estimates that such adjustments for a future year) did (or

are likely to) result in a change in aggregate payments under

this subsection during the year that are a result of changes

in the coding or classification of covered OPD services that

do not reflect real changes in service mix, the Secretary may

adjust the conversion factor computed under this subparagraph

for subsequent years so as to eliminate the effect of such

coding or classification changes.

(iv) OPD fee schedule increase factor

For purposes of this subparagraph, the "OPD fee schedule

increase factor" for services furnished in a year is equal to

the market basket percentage increase applicable under

section 1395ww(b)(3)(B)(iii) of this title to hospital

discharges occurring during the fiscal year ending in such

year, reduced by 1 percentage point for such factor for

services furnished in each of 2000 and 2002. In applying the

previous sentence for years beginning with 2000, the

Secretary may substitute for the market basket percentage

increase an annual percentage increase that is computed and

applied with respect to covered OPD services furnished in a

year in the same manner as the market basket percentage

increase is determined and applied to inpatient hospital

services for discharges occurring in a fiscal year.

(D) Calculation of medicare OPD fee schedule amounts

The Secretary shall compute a medicare OPD fee schedule

amount for each covered OPD service (or group of such services)

furnished in a year, in an amount equal to the product of -

(i) the conversion factor computed under subparagraph (C)

for the year, and

(ii) the relative payment weight (determined under

paragraph (2)(C)) for the service or group.

(E) Pre-deductible payment percentage

The pre-deductible payment percentage for a covered OPD

service (or group of such services) furnished in a year is

equal to the ratio of -

(i) the medicare OPD fee schedule amount established under

subparagraph (D) for the year, minus the unadjusted copayment

amount determined under subparagraph (B) for the service or

group, to

(ii) the medicare OPD fee schedule amount determined under

subparagraph (D) for the year for such service or group.

(4) Medicare payment amount

The amount of payment made from the Trust Fund under this part

for a covered OPD service (and such services classified within a

group) furnished in a year is determined, subject to paragraph

(7), as follows:

(A) Fee schedule adjustments

The medicare OPD fee schedule amount (computed under

paragraph (3)(D)) for the service or group and year is adjusted

for relative differences in the cost of labor and other factors

determined by the Secretary, as computed under paragraphs

(2)(D) and (2)(E).

(B) Subtract applicable deductible

Reduce the adjusted amount determined under subparagraph (A)

by the amount of the deductible under subsection (b) of this

section, to the extent applicable.

(C) Apply payment proportion to remainder

The amount of payment is the amount so determined under

subparagraph (B) multiplied by the pre-deductible payment

percentage (as determined under paragraph (3)(E)) for the

service or group and year involved, plus the amount of any

reduction in the copayment amount attributable to paragraph

(8)(C).

(5) Outlier adjustment

(A) In general

Subject to subparagraph (D), the Secretary shall provide for

an additional payment for each covered OPD service (or group of

services) for which a hospital's charges, adjusted to cost,

exceed -

(i) a fixed multiple of the sum of -

(I) the applicable medicare OPD fee schedule amount

determined under paragraph (3)(D), as adjusted under

paragraph (4)(A) (other than for adjustments under this

paragraph or paragraph (6)); and

(II) any transitional pass-through payment under

paragraph (6); and

(ii) at the option of the Secretary, such fixed dollar

amount as the Secretary may establish.

(B) Amount of adjustment

The amount of the additional payment under subparagraph (A)

shall be determined by the Secretary and shall approximate the

marginal cost of care beyond the applicable cutoff point under

such subparagraph.

(C) Limit on aggregate outlier adjustments

(i) In general

The total of the additional payments made under this

paragraph for covered OPD services furnished in a year (as

estimated by the Secretary before the beginning of the year)

may not exceed the applicable percentage (specified in clause

(ii)) of the total program payments estimated to be made

under this subsection for all covered OPD services furnished

in that year. If this paragraph is first applied to less than

a full year, the previous sentence shall apply only to the

portion of such year.

(ii) Applicable percentage

For purposes of clause (i), the term "applicable

percentage" means a percentage specified by the Secretary up

to (but not to exceed) -

(I) for a year (or portion of a year) before 2004, 2.5

percent; and

(II) for 2004 and thereafter, 3.0 percent.

(D) Transitional authority

In applying subparagraph (A) for covered OPD services

furnished before January 1, 2002, the Secretary may -

(i) apply such subparagraph to a bill for such services

related to an outpatient encounter (rather than for a

specific service or group of services) using OPD fee schedule

amounts and transitional pass-through payments covered under

the bill; and

(ii) use an appropriate cost-to-charge ratio for the

hospital involved (as determined by the Secretary), rather

than for specific departments within the hospital.

(6) Transitional pass-through for additional costs of innovative

medical devices, drugs, and biologicals

(A) In general

The Secretary shall provide for an additional payment under

this paragraph for any of the following that are provided as

part of a covered OPD service (or group of services):

(i) Current orphan drugs

A drug or biological that is used for a rare disease or

condition with respect to which the drug or biological has

been designated as an orphan drug under section 360bb of

title 21 if payment for the drug or biological as an

outpatient hospital service under this part was being made on

the first date that the system under this subsection is

implemented.

(ii) Current cancer therapy drugs and biologicals and

brachytherapy

A drug or biological that is used in cancer therapy,

including (but not limited to) a chemotherapeutic agent, an

antiemetic, a hematopoietic growth factor, a colony

stimulating factor, a biological response modifier, a

bisphosphonate, and a device of brachytherapy or temperature

monitored cryoablation, if payment for such drug, biological,

or device as an outpatient hospital service under this part

was being made on such first date.

(iii) Current radiopharmaceutical drugs and biological

products

A radiopharmaceutical drug or biological product used in

diagnostic, monitoring, and therapeutic nuclear medicine

procedures if payment for the drug or biological as an

outpatient hospital service under this part was being made on

such first date.

(iv) New medical devices, drugs, and biologicals

A medical device, drug, or biological not described in

clause (i), (ii), or (iii) if -

(I) payment for the device, drug, or biological as an

outpatient hospital service under this part was not being

made as of December 31, 1996; and

(II) the cost of the drug or biological or the average

cost of the category of devices is not insignificant in

relation to the OPD fee schedule amount (as calculated

under paragraph (3)(D)) payable for the service (or group

of services) involved.

(B) Use of categories in determining eligibility of a device

for pass-through payments

The following provisions apply for purposes of determining

whether a medical device qualifies for additional payments

under clause (ii) or (iv) of subparagraph (A):

(i) Establishment of initial categories

(I) In general

The Secretary shall initially establish under this clause

categories of medical devices based on type of device by

April 1, 2001. Such categories shall be established in a

manner such that each medical device that meets the

requirements of clause (ii) or (iv) of subparagraph (A) as

of January 1, 2001, is included in such a category and no

such device is included in more than one category. For

purposes of the preceding sentence, whether a medical

device meets such requirements as of such date shall be

determined on the basis of the program memoranda issued

before such date.

(II) Authorization of implementation other than through

regulations

The categories may be established under this clause by

program memorandum or otherwise, after consultation with

groups representing hospitals, manufacturers of medical

devices, and other affected parties.

(ii) Establishing criteria for additional categories

(I) In general

The Secretary shall establish criteria that will be used

for creation of additional categories (other than those

established under clause (i)) through rulemaking (which may

include use of an interim final rule with comment period).

(II) Standard

Such categories shall be established under this clause in

a manner such that no medical device is described by more

than one category. Such criteria shall include a test of

whether the average cost of devices that would be included

in a category and are in use at the time the category is

established is not insignificant, as described in

subparagraph (A)(iv)(II).

(III) Deadline

Criteria shall first be established under this clause by

July 1, 2001. The Secretary may establish in compelling

circumstances categories under this clause before the date

such criteria are established.

(IV) Adding categories

The Secretary shall promptly establish a new category of

medical devices under this clause for any medical device

that meets the requirements of subparagraph (A)(iv) and for

which none of the categories in effect (or that were

previously in effect) is appropriate.

(iii) Period for which category is in effect

A category of medical devices established under clause (i)

or (ii) shall be in effect for a period of at least 2 years,

but not more than 3 years, that begins -

(I) in the case of a category established under clause

(i), on the first date on which payment was made under this

paragraph for any device described by such category

(including payments made during the period before April 1,

2001); and

(II) in the case of any other category, on the first date

on which payment is made under this paragraph for any

medical device that is described by such category.

(iv) Requirements treated as met

A medical device shall be treated as meeting the

requirements of subparagraph (A)(iv), regardless of whether

the device meets the requirement of subclause (I) of such

subparagraph, if -

(I) the device is described by a category established and

in effect under clause (i); or

(II) the device is described by a category established

and in effect under clause (ii) and an application under

section 360e of title 21 has been approved with respect to

the device, or the device has been cleared for market under

section 360(k) of title 21, or the device is exempt from

the requirements of section 360(k) of title 21 pursuant to

subsection (l) or (m) of section 360 of title 21 or section

360j(g) of title 21.

Nothing in this clause shall be construed as requiring an

application or prior approval (other than that described in

subclause (II)) in order for a covered device described by a

category to qualify for payment under this paragraph.

(C) Limited period of payment

(i) Drugs and biologicals

The payment under this paragraph with respect to a drug or

biological shall only apply during a period of at least 2

years, but not more than 3 years, that begins -

(I) on the first date this subsection is implemented in

the case of a drug or biological described in clause (i),

(ii), or (iii) of subparagraph (A) and in the case of a

drug or biological described in subparagraph (A)(iv) and

for which payment under this part is made as an outpatient

hospital service before such first date; or

(II) in the case of a drug or biological described in

subparagraph (A)(iv) not described in subclause (I), on the

first date on which payment is made under this part for the

drug or biological as an outpatient hospital service.

(ii) Medical devices

Payment shall be made under this paragraph with respect to

a medical device only if such device -

(I) is described by a category of medical devices

established and in effect under subparagraph (B); and

(II) is provided as part of a service (or group of

services) paid for under this subsection and provided

during the period for which such category is in effect

under such subparagraph.

(D) Amount of additional payment

Subject to subparagraph (E)(iii), the amount of the payment

under this paragraph with respect to a device, drug, or

biological provided as part of a covered OPD service is -

(i) in the case of a drug or biological, the amount by

which the amount determined under section 1395u(o) of this

title for the drug or biological exceeds the portion of the

otherwise applicable medicare OPD fee schedule that the

Secretary determines is associated with the drug or

biological; or

(ii) in the case of a medical device, the amount by which

the hospital's charges for the device, adjusted to cost,

exceeds the portion of the otherwise applicable medicare OPD

fee schedule that the Secretary determines is associated with

the device.

(E) Limit on aggregate annual adjustment

(i) In general

The total of the additional payments made under this

paragraph for covered OPD services furnished in a year (as

estimated by the Secretary before the beginning of the year)

may not exceed the applicable percentage (specified in clause

(ii)) of the total program payments estimated to be made

under this subsection for all covered OPD services furnished

in that year. If this paragraph is first applied to less than

a full year, the previous sentence shall apply only to the

portion of such year.

(ii) Applicable percentage

For purposes of clause (i), the term "applicable

percentage" means -

(I) for a year (or portion of a year) before 2004, 2.5

percent; and

(II) for 2004 and thereafter, a percentage specified by

the Secretary up to (but not to exceed) 2.0 percent.

(iii) Uniform prospective reduction if aggregate limit

projected to be exceeded

If the Secretary estimates before the beginning of a year

that the amount of the additional payments under this

paragraph for the year (or portion thereof) as determined

under clause (i) without regard to this clause will exceed

the limit established under such clause, the Secretary shall

reduce pro rata the amount of each of the additional payments

under this paragraph for that year (or portion thereof) in

order to ensure that the aggregate additional payments under

this paragraph (as so estimated) do not exceed such limit.

(7) Transitional adjustment to limit decline in payment

(A) Before 2002

Subject to subparagraph (D), for covered OPD services

furnished before January 1, 2002, for which the PPS amount (as

defined in subparagraph (E)) is -

(i) at least 90 percent, but less than 100 percent, of the

pre-BBA amount (as defined in subparagraph (F)), the amount

of payment under this subsection shall be increased by 80

percent of the amount of such difference;

(ii) at least 80 percent, but less than 90 percent, of the

pre-BBA amount, the amount of payment under this subsection

shall be increased by the amount by which (I) the product of

0.71 and the pre-BBA amount, exceeds (II) the product of 0.70

and the PPS amount;

(iii) at least 70 percent, but less than 80 percent, of the

pre-BBA amount, the amount of payment under this subsection

shall be increased by the amount by which (I) the product of

0.63 and the pre-BBA amount, exceeds (II) the product of 0.60

and the PPS amount; or

(iv) less than 70 percent of the pre-BBA amount, the amount

of payment under this subsection shall be increased by 21

percent of the pre-BBA amount.

(B) 2002

Subject to subparagraph (D), for covered OPD services

furnished during 2002, for which the PPS amount is -

(i) at least 90 percent, but less than 100 percent, of the

pre-BBA amount, the amount of payment under this subsection

shall be increased by 70 percent of the amount of such

difference;

(ii) at least 80 percent, but less than 90 percent, of the

pre-BBA amount, the amount of payment under this subsection

shall be increased by the amount by which (I) the product of

0.61 and the pre-BBA amount, exceeds (II) the product of 0.60

and the PPS amount; or

(iii) less than 80 percent of the pre-BBA amount, the

amount of payment under this subsection shall be increased by

13 percent of the pre-BBA amount.

(C) 2003

Subject to subparagraph (D), for covered OPD services

furnished during 2003, for which the PPS amount is -

(i) at least 90 percent, but less than 100 percent, of the

pre-BBA amount, the amount of payment under this subsection

shall be increased by 60 percent of the amount of such

difference; or

(ii) less than 90 percent of the pre-BBA amount, the amount

of payment under this subsection shall be increased by 6

percent of the pre-BBA amount.

(D) Hold harmless provisions

(i) Temporary treatment for small rural hospitals

In the case of a hospital located in a rural area and that

has not more than 100 beds, for covered OPD services

furnished before January 1, 2004, for which the PPS amount is

less than the pre-BBA amount, the amount of payment under

this subsection shall be increased by the amount of such

difference.

(ii) Permanent treatment for cancer hospitals and children's

hospitals

In the case of a hospital described in clause (iii) or (v)

of section 1395ww(d)(1)(B) of this title, for covered OPD

services for which the PPS amount is less than the pre-BBA

amount, the amount of payment under this subsection shall be

increased by the amount of such difference.

(E) PPS amount defined

In this paragraph, the term "PPS amount" means, with respect

to covered OPD services, the amount payable under this

subchapter for such services (determined without regard to this

paragraph), including amounts payable as copayment under

paragraph (8), coinsurance under section 1395cc(a)(2)(A)(ii) of

this title, and the deductible under subsection (b) of this

section.

(F) Pre-BBA amount defined

(i) In general

In this paragraph, the "pre-BBA amount" means, with respect

to covered OPD services furnished by a hospital in a year, an

amount equal to the product of the reasonable cost of the

hospital for such services for the portions of the hospital's

cost reporting period (or periods) occurring in the year and

the base OPD payment-to-cost ratio for the hospital (as

defined in clause (ii)).

(ii) Base payment-to-cost ratio defined

For purposes of this subparagraph, the "base

payment-to-cost ratio" for a hospital means the ratio of -

(I) the hospital's reimbursement under this part for

covered OPD services furnished during the cost reporting

period ending in 1996 (or in the case of a hospital that

did not submit a cost report for such period, during the

first subsequent cost reporting period ending before 2001

for which the hospital submitted a cost report), including

any reimbursement for such services through cost-sharing

described in subparagraph (E), to

(II) the reasonable cost of such services for such

period.

The Secretary shall determine such ratios as if the

amendments made by section 4521 of the Balanced Budget Act of

1997 were in effect in 1996.

(G) Interim payments

The Secretary shall make payments under this paragraph to

hospitals on an interim basis, subject to retrospective

adjustments based on settled cost reports.

(H) No effect on copayments

Nothing in this paragraph shall be construed to affect the

unadjusted copayment amount described in paragraph (3)(B) or

the copayment amount under paragraph (8).

(I) Application without regard to budget neutrality

The additional payments made under this paragraph -

(i) shall not be considered an adjustment under paragraph

(2)(E); and

(ii) shall not be implemented in a budget neutral manner.

(8) Copayment amount

(A) In general

Except as provided in subparagraphs (B) and (C), the

copayment amount under this subsection is the amount by which

the amount described in paragraph (4)(B) exceeds the amount of

payment determined under paragraph (4)(C).

(B) Election to offer reduced copayment amount

The Secretary shall establish a procedure under which a

hospital, before the beginning of a year (beginning with 1999),

may elect to reduce the copayment amount otherwise established

under subparagraph (A) for some or all covered OPD services to

an amount that is not less than 20 percent of the medicare OPD

fee schedule amount (computed under paragraph (3)(D)) for the

service involved. Under such procedures, such reduced copayment

amount may not be further reduced or increased during the year

involved and the hospital may disseminate information on the

reduction of copayment amount effected under this subparagraph.

(C) Limitation on copayment amount

(i) To inpatient hospital deductible amount

In no case shall the copayment amount for a procedure

performed in a year exceed the amount of the inpatient

hospital deductible established under section 1395e(b) of

this title for that year.

(ii) To specified percentage

The Secretary shall reduce the national unadjusted

copayment amount for a covered OPD service (or group of such

services) furnished in a year in a manner so that the

effective copayment rate (determined on a national unadjusted

basis) for that service in the year does not exceed the

following percentage:

(I) For procedures performed in 2001, on or after April

1, 2001, 57 percent.

(II) For procedures performed in 2002 or 2003, 55

percent.

(III) For procedures performed in 2004, 50 percent.

(IV) For procedures performed in 2005, 45 percent.

(V) For procedures performed in 2006 and thereafter, 40

percent.

(D) No impact on deductibles

Nothing in this paragraph shall be construed as affecting a

hospital's authority to waive the charging of a deductible

under subsection (b) of this section.

(E) Computation ignoring outlier and pass-through adjustments

The copayment amount shall be computed under subparagraph (A)

as if the adjustments under paragraphs (5) and (6) (and any

adjustment made under paragraph (2)(E) in relation to such

adjustments) had not occurred.

(9) Periodic review and adjustments components of prospective

payment system

(A) Periodic review

The Secretary shall review not less often than annually and

revise the groups, the relative payment weights, and the wage

and other adjustments described in paragraph (2) to take into

account changes in medical practice, changes in technology, the

addition of new services, new cost data, and other relevant

information and factors. The Secretary shall consult with an

expert outside advisory panel composed of an appropriate

selection of representatives of providers to review (and advise

the Secretary concerning) the clinical integrity of the groups

and weights. Such panel may use data collected or developed by

entities and organizations (other than the Department of Health

and Human Services) in conducting such review.

(B) Budget neutrality adjustment

If the Secretary makes adjustments under subparagraph (A),

then the adjustments for a year may not cause the estimated

amount of expenditures under this part for the year to increase

or decrease from the estimated amount of expenditures under

this part that would have been made if the adjustments had not

been made.

(C) Update factor

If the Secretary determines under methodologies described in

paragraph (2)(F) that the volume of services paid for under

this subsection increased beyond amounts established through

those methodologies, the Secretary may appropriately adjust the

update to the conversion factor otherwise applicable in a

subsequent year.

(10) Special rule for ambulance services

The Secretary shall pay for hospital outpatient services that

are ambulance services on the basis described in section

1395x(v)(1)(U) of this title, or, if applicable, the fee schedule

established under section 1395m(l) of this title.

(11) Special rules for certain hospitals

In the case of hospitals described in clause (iii) or (v) of

section 1395ww(d)(1)(B) of this title -

(A) the system under this subsection shall not apply to

covered OPD services furnished before January 1, 2000; and

(B) the Secretary may establish a separate conversion factor

for such services in a manner that specifically takes into

account the unique costs incurred by such hospitals by virtue

of their patient population and service intensity.

(12) Limitation on review

There shall be no administrative or judicial review under

section 1395ff of this title, 1395oo of this title, or otherwise

of -

(A) the development of the classification system under

paragraph (2), including the establishment of groups and

relative payment weights for covered OPD services, of wage

adjustment factors, other adjustments, and methods described in

paragraph (2)(F);

(B) the calculation of base amounts under paragraph (3);

(C) periodic adjustments made under paragraph (6);

(D) the establishment of a separate conversion factor under

paragraph (8)(B); and

(E) the determination of the fixed multiple, or a fixed

dollar cutoff amount, the marginal cost of care, or applicable

percentage under paragraph (5) or the determination of

insignificance of cost, the duration of the additional

payments, the determination and deletion of initial and new

categories (consistent with subparagraphs (B) and (C) of

paragraph (6)), the portion of the medicare OPD fee schedule

amount associated with particular devices, drugs, or

biologicals, and the application of any pro rata reduction

under paragraph (6).

(13) Miscellaneous provisions

(A) (!11) Application of reclassification of certain hospitals

If a hospital is being treated as being located in a rural

area under section 1395ww(d)(8)(E) of this title, that hospital

shall be treated under this subsection as being located in that

rural area.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1833, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 302; amended

Pub. L. 90-248, title I, Secs. 129(c)(7), (8), 131(a), (b), 132(b),

135(c), Jan. 2, 1968, 81 Stat. 848-850, 853; Pub. L. 92-603, title

II, Secs. 204(a), 211(c)(4), 226(c)(2), 233(b), 245(d), 251(a)(2),

(3), 279, 299K(a), Oct. 30, 1972, 86 Stat. 1377, 1384, 1404, 1411,

1424, 1445, 1454, 1464; Pub. L. 95-142, Sec. 16(a), Oct. 25, 1977,

91 Stat. 1200; Pub. L. 95-210, Sec. 1(b), Dec. 13, 1977, 91 Stat.

1485; Pub. L. 95-292, Sec. 4(b), (c), June 13, 1978, 92 Stat. 315;

Pub. L. 96-473, Sec. 6(j), Oct. 19, 1980, 94 Stat. 2266; Pub. L.

96-499, title IX, Secs. 918(a)(4), 930(h), 932(a)(1), 934(b),

(d)(1), (3), 935(a), 942, 943(a), Dec. 5, 1980, 94 Stat. 2626,

2631, 2634, 2637, 2639, 2641; Pub. L. 96-611, Sec. 1(b)(1), (2),

Dec. 28, 1980, 94 Stat. 3566; Pub. L. 97-35, title XXI, Secs.

2106(a), 2133(a), 2134(a), Aug. 13, 1981, 95 Stat. 792, 797; Pub.

L. 97-248, title I, Secs. 101(c)(2), 112(a), (b), 117(a)(2),

148(d), Sept. 3, 1982, 96 Stat. 336, 340, 355, 394; Pub. L. 98-369,

div. B, title III, Secs. 2303(a)-(d), 2305(a)-(d), 2308(b)(2)(B),

2321(b), (d)(4)(A), 2323(b)(1), (2), (4), 2354(b)(5), (7), July 18,

1984, 98 Stat. 1064, 1069, 1070, 1074, 1084-1086, 1100; Pub. L.

98-617, Sec. 3(b)(2), (3), Nov. 8, 1984, 98 Stat. 3295; Pub. L.

99-272, title IX, Secs. 9303(a)(1), (b)(1)-(3), 9401(b)-(2)(E),

Apr. 7, 1986, 100 Stat. 188, 189, 198, 199; Pub. L. 99-509, title

IX, Secs. 9320(e)(1), (2), 9337(b), 9339(a)(1), (b)(1), (2),

(c)(1), 9343(a), (b), (e)(2), Oct. 21, 1986, 100 Stat. 2014, 2033,

2036, 2039-2041; Pub. L. 100-203, title IV, Secs. 4042(b)(2)(B),

4043(a), 4045(c)(2)(A), 4049(a)(1), 4055(a), formerly 4054(a),

4062(d)(3), 4063(b), (e)(1), 4064(a), (b)(1), (2), (c)(1), formerly

(c), 4066(a), (b), 4067(a), 4068(a), 4070(a), (b)(4), 4072(b),

4073(b), formerly (b)(2), (3), 4077(b)(2), (3), formerly (b)(3),

(4), 4084(a), (c)(2), 4085(b)(1), (i)(1)-(3), (21)(D)(i), (22)(B),

(23), Dec. 22, 1987, 101 Stat. 1330-85, 1330-88, 1330-90, 1330-108

to 1330-115, 1330-117, 1330-118, 1330-120, 1330-121, 1330-129 to

1330-133, as amended Pub. L. 100-360, title IV, Sec. 411(f)(2)(D),

(8)(B)(i), (12)(A), (14), (g)(2)(E), (3)(A)-(C), (E), (F),

(h)(3)(B), (4)(B), (C), (7)(C), (D), (F), (i)(3), (4)(C)(i), (ii),

(iv), (vi), July 1, 1988, 102 Stat. 777, 779, 781, 783, 784,

786-789; Pub. L. 100-360, title I, Sec. 104(d)(7), title II, Secs.

201(a), 202(b)(1)-(3), 203(c)(1)(A)-(E), 204(d)(1), 205(c),

212(c)(2), title IV, Sec. 411(f)(8)(C), (g)(1)(E), (2)(D), (3)(D),

(4)(C), (5), (h)(1)(A), (i)(4)(B), July 1, 1988, 102 Stat. 699,

704, 722, 729, 730, 741, 779, 782-785, 789, as amended Pub. L.

100-485, title VI, Sec. 608(d)(3)(G), Oct. 13, 1988, 102 Stat.

2414; Pub. L. 100-485, title VI, Sec. 608(d)(4), (22)(B), (D),

(23)(A), Oct. 13, 1988, 102 Stat. 2414, 2420, 2421; Pub. L.

100-647, title VIII, Secs. 8421(a), 8422(a), Nov. 10, 1988, 102

Stat. 3802; Pub. L. 101-234, title II, Secs. 201(a), 202(a), Dec.

13, 1989, 103 Stat. 1981; Pub. L. 101-239, title VI, Secs.

6003(e)(2)(A), (g)(3)(D)(vii), 6102(c)(1), (e)(1), (5), (6)(A),

(7), (f)(2), 6111(a), (b)(1), 6113(b)(3), (d), 6116(b)(1),

6131(a)(1), (b), 6133(a), 6204(b), Dec. 19, 1989, 103 Stat. 2143,

2153, 2184, 2187-2189, 2213, 2214, 2217, 2219, 2221, 2222, 2241;

Pub. L. 101-508, title IV, Secs. 4008(m)(2)(C), 4104(b)(1),

4118(f)(2)(D), 4151(c)(1), (2), 4153(a)(2)(B), (C), 4154(a),

(b)(1), (c)(1), (e)(1), 4155(b)(2), (3), 4160, 4161(a)(3)(B),

4163(d)(1), 4206(b)(2), 4302, Nov. 5, 1990, 104 Stat. 1388-53,

1388-59, 1388-70, 1388-73, 1388-83 to 1388-87, 1388-91, 1388-93,

1388-100, 1388-116, 1388-125; Pub. L. 101-597, title IV, Sec.

401(c)(2), Nov. 16, 1990, 104 Stat. 3035; Pub. L. 103-66, title

XIII, Secs. 13516(b), 13532(a), 13544(b)(2), 13551, 13555(a), Aug.

10, 1993, 107 Stat. 584, 586, 590, 592; Pub. L. 103-432, title I,

Secs. 123(b)(2)(A), (e), 141(a), (c)(1), 147(a), (d), (e)(2), (3),

(f)(6)(C), (D), 156(a)(2)(B), 160(d)(1), Oct. 31, 1994, 108 Stat.

4411, 4412, 4424, 4425, 4429, 4430, 4432, 4440, 4443; Pub. L.

105-33, title IV, Secs. 4002(j)(1)(A), 4101(b), 4102(b), 4103(b),

4104(c)(1), (2), 4201(c)(1), 4205(a)(1)(A), (2), 4315(b),

4432(b)(5)(C), 4511(b), 4512(b)(1), 4521(a), (b), 4523(a),

(d)(1)(A)(i), (B)-(3), 4531(b)(1), 4541(a)(1), (c), (d)(1),

4553(a), (b), 4555, 4556(b), 4603(c)(2)(A), Aug. 5, 1997, 111 Stat.

330, 360-362, 365, 373, 376, 390, 421, 442-445, 449, 450, 454, 456,

460, 462, 463, 470; Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title

II, Secs. 201(a)-(e)(1), (f)-(h)(1), (i), (j), 202(a), 204(a),(b),

211(a)(3)(B), 221(a)(1), 224(a), title III, Sec. 321(g)(2), (k)(2),

title IV, Secs. 401(b)(1), 403(e)(1)], Nov. 29, 1999, 113 Stat.

1536, 1501A-336 to 1501A-342, 1501A-345, 1501A-348, 1501A-351,

1501A-353, 1501A-366, 1501A-369, 1501A-371; Pub. L. 106-554, Sec.

1(a)(6) [title I, Secs. 105(c), 111(a)(1), title II, Secs.

201(b)(1), 205(b), 223(c), 224(a), title IV, Secs. 401(a), (b)(1),

402(a), (b), 403(a), 405(a), 406(a), 421(a), 430(a), title V, Sec.

531(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A-472, 2763A-481,

2763A-483, 2763A-489, 2763A-490, 2763A-502, 2763A-503, 2763A-505 to

2763A-508, 2763A-516, 2763A-524, 2763A-547.)

-REFTEXT-

REFERENCES IN TEXT

Part A of this subchapter, referred to in subsecs. (a)(8)(B)(i),

(d), (l)(3)(A), and (t)(1)(B)(ii)(I), is classified to section

1395c et seq. of this title.

Section 9320(k) of the Omnibus Budget Reconciliation Act of 1986,

as amended by section 6132 of the Omnibus Budget Reconciliation Act

of 1989, referred to in subsec. (l)(1)(C), is section 9320(k) of

Pub. L. 99-509, as amended, which is set out as a note under

section 1395k of this title.

The amendments made by section 9320 of the Omnibus Budget

Reconciliation Act of 1986, referred to in subsec. (l)(3)(B), are

amendments made by section 9320 of Pub. L. 99-509, which amended

sections 1395k, 1395l, 1395u, 1395x, 1395y, 1395aa, 1395bb, 1395cc,

1395ww, 1396a, and 1396n of this title and provisions set out as a

note under section 1395ww of this title.

Clause (iii), referred to in subsec. (t)(3)(C)(ii), was

redesignated cl. (iv), and a new cl. (iii) was added, by Pub. L.

106-554, Sec. 1(a)(6) [title IV, Sec. 401(b)(1)], Dec. 21, 2000,

114 Stat. 2763, 2763A-502.

Section 4521 of The Balanced Budget Act of 1997, referred to in

subsec. (t)(7)(F), is section 4521 of Pub. L. 105-33, Aug. 5, 1997,

111 Stat. 444, which amended this section and enacted provisions

set out as a note under this section.

-MISC1-

AMENDMENTS

2000 - Subsec. (a)(1)(D)(i). Pub. L. 106-554, Sec. 1(a)(6) [title

II, Sec. 201(b)(1)], struck out "or which are furnished on an

outpatient basis by a critical access hospital" after "on an

assignment-related basis".

Subsec. (a)(1)(R). Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec.

205(b)], substituted "ambulance services, (i)" for "ambulance

service," and inserted before comma at end "and (ii) with respect

to ambulance services described in section 1395m(l)(8) of this

title, the amounts paid shall be the amounts determined under

section 1395m(g) of this title for outpatient critical access

hospital services".

Subsec. (a)(1)(T). Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec.

105(c)], added cl. (T).

Subsec. (a)(1)(U). Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec.

223(c)], added cl. (U).

Subsec. (a)(2)(D)(i). Pub. L. 106-554, Sec. 1(a)(6) [title II,

Sec. 201(b)(1)], struck out "or which are furnished on an

outpatient basis by a critical access hospital" after "on an

assignment-related basis".

Subsec. (f). Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec.

224(a)], substituted "hospitals" for "rural hospitals" in

introductory provisions.

Subsec. (g)(4). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

421(a)], substituted "2000, 2001, and 2002." for "2000 and 2001."

Subsec. (h)(4)(B)(viii). Pub. L. 106-554, Sec. 1(a)(6) [title V,

Sec. 531(a)], inserted before period at end "(or 100 percent of

such median in the case of a clinical diagnostic laboratory test

performed on or after January 1, 2001, that the Secretary

determines is a new test for which no limitation amount has

previously been established under this subparagraph)".

Subsec. (t)(2)(G). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

430(a)], added subpar. (G).

Subsec. (t)(3)(C)(iii). Pub. L. 106-554, Sec. 1(a)(6) [title IV,

Sec. 401(b)(1)(B)], added cl. (iii). Former cl. (iii) redesignated

(iv).

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 401(a)],

substituted "in each of 2000 and 2002" for "in each of 2000, 2001,

and 2002".

Subsec. (t)(3)(C)(iv). Pub. L. 106-554, Sec. 1(a)(6) [title IV,

Sec. 401(b)(1)(A)], redesignated cl. (iii) as (iv).

Subsec. (t)(6)(A)(ii). Pub. L. 106-554, Sec. 1(a)(6) [title IV,

Sec. 406(a)], inserted "or temperature monitored cryoablation"

after "device of brachytherapy".

Subsec. (t)(6)(A)(iv)(II). Pub. L. 106-554, Sec. 1(a)(6) [title

IV, Sec. 402(b)(1)], substituted "the cost of the drug or

biological or the average cost of the category of devices" for "the

cost of the device, drug, or biological".

Subsec. (t)(6)(B). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

402(a)(2)], added subpar. (B) and struck out heading and text of

former subpar. (B). Text read as follows: "The payment under this

paragraph with respect to a medical device, drug, or biological

shall only apply during a period of at least 2 years, but not more

than 3 years, that begins -

"(i) on the first date this subsection is implemented in the

case of a drug, biological, or device described in clause (i),

(ii), or (iii) of subparagraph (A) and in the case of a device,

drug, or biological described in subparagraph (A)(iv) and for

which payment under this part is made as an outpatient hospital

service before such first date; or

"(ii) in the case of a device, drug, or biological described in

subparagraph (A)(iv) not described in clause (i), on the first

date on which payment is made under this part for the device,

drug, or biological as an outpatient hospital service."

Subsec. (t)(6)(C). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

402(a)(2)], added subpar. (C). Former subpar. (C) redesignated (D).

Subsec. (t)(6)(D). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

402(b)(2)], substituted "subparagraph (E)(iii)" for "subparagraph

(D)(iii)" in introductory provisions.

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 402(a)(1)],

redesignated subpar. (C) as (D). Former subpar. (D) redesignated

(E).

Subsec. (t)(6)(E). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

402(a)(1)], redesignated subpar. (D) as (E).

Subsec. (t)(7)(D)(ii). Pub. L. 106-554, Sec. 1(a)(6) [title IV,

Sec. 405(a)], in heading, inserted "and children's hospitals" after

"cancer hospitals" and in text, substituted "clause (iii) or (v) of

section 1395ww(d)(1)(B) of this title" for "section

1395ww(d)(1)(B)(v) of this title".

Subsec. (t)(7)(F)(ii)(I). Pub. L. 106-554, Sec. 1(a)(6) [title

IV, Sec. 403(a)], inserted "(or in the case of a hospital that did

not submit a cost report for such period, during the first

subsequent cost reporting period ending before 2001 for which the

hospital submitted a cost report)" after "1996".

Subsec. (t)(8)(C). Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec.

111(a)(1)], amended heading and text of subpar. (C) generally.

Prior to amendment, text read as follows: "In no case shall the

copayment amount for a procedure performed in a year exceed the

amount of the inpatient hospital deductible established under

section 1395e(b) of this title for that year."

Subsec. (t)(11). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

405(a)(2)], substituted "clause (iii) or (v) of section

1395ww(d)(1)(B) of this title" for "section 1395ww(d)(1)(B)(v) of

this title" in introductory provisions.

Subsec. (t)(12)(E). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

402(b)(3)], substituted "additional payments, the determination and

deletion of initial and new categories (consistent with

subparagraphs (B) and (C) of paragraph (6))" for "additional

payments (consistent with paragraph (6)(B))".

1999 - Subsec. (a)(1)(D)(i). Pub. L. 106-113, Sec. 1000(a)(6)

[title IV, Sec. 403(e)(1)], inserted "or which are furnished on an

outpatient basis by a critical access hospital" after "on an

assignment-related basis".

Subsec. (a)(1)(O). Pub. L. 106-113, Sec. 1000(a)(6) [title III,

Sec. 321(k)(2)], substituted a comma for the semicolon at end.

Subsec. (a)(2)(D)(i). Pub. L. 106-113, Sec. 1000(a)(6) [title IV,

Sec. 403(e)(1)], inserted "or which are furnished on an outpatient

basis by a critical access hospital" after "on an

assignment-related basis".

Subsec. (g)(1), (3). Pub. L. 106-113, Sec. 1000(a)(6) [title II,

Sec. 221(a)(1)(A)], substituted "Subject to paragraph (4), in the

case" for "In the case".

Subsec. (g)(4). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

221(a)(1)(B)], added par. (4).

Subsec. (h)(5)(A)(iii). Pub. L. 106-113, Sec. 1000(a)(6) [title

III, Sec. 321(g)(2)], substituted ", critical access hospital, or

skilled nursing facility," for "or critical access hospital," and

inserted "or skilled nursing facility" before period at end.

Subsec. (h)(7). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

224(a)], added par. (7).

Subsec. (l)(4)(A)(i)(VII). Pub. L. 106-113, Sec. 1000(a)(6)

[title II, Sec. 211(a)(3)(B)], substituted "1395w-4(d) of this

title" for "1395w-4(d)(3) of this title".

Subsec. (t)(1)(B)(ii). Pub. L. 106-113, Sec. 1000(a)(6) [title

II, Sec. 201(e)(1)(A)], substituted "clause (iv)" for "clause

(iii)" and directed the striking out of "but" which was executed by

striking out "but" after semicolon at end to reflect the probable

intent of Congress.

Subsec. (t)(1)(B)(iii), (iv). Pub. L. 106-113, Sec. 1000(a)(6)

[title II, Sec. 201(e)(1)(B)], added cl. (iii) and redesignated

former cl. (iii) as (iv).

Subsec. (t)(2). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

201(g)], inserted concluding provisions.

Subsec. (t)(2)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title II,

Sec. 201(e)(1)(C)], inserted "and so that an implantable item is

classified to the group that includes the service to which the item

relates" before semicolon at end.

Subsec. (t)(2)(C). Pub. L. 106-113, Sec. 1000(a)(6) [title II,

Sec. 201(f)], inserted "(or, at the election of the Secretary,

mean)" after "median".

Subsec. (t)(2)(E). Pub. L. 106-113, Sec. 1000(a)(6) [title II,

Sec. 201(c)], substituted ", in a budget neutral manner, outlier

adjustments under paragraph (5) and transitional pass-through

payments under paragraph (6) and other adjustments as determined to

be necessary to ensure equitable payments, such as" for "other

adjustments, in a budget neutral manner, as determined to be

necessary to ensure equitable payments, such as outlier adjustments

or".

Subsec. (t)(4). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

202(a)(1)], inserted ", subject to paragraph (7)," after "is

determined" in introductory provisions.

Subsec. (t)(4)(C). Pub. L. 106-113, Sec. 1000(a)(6) [title II,

Sec. 204(b)], inserted ", plus the amount of any reduction in the

copayment amount attributable to paragraph (8)(C)" before period at

end.

Subsec. (t)(5). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

201(a)(2)], added par. (5). Former par. (5) redesignated (7).

Subsec. (t)(6). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

201(b)], added par. (6). Former par. (6) redesignated (8).

Subsec. (t)(7). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

202(a)(3)], added par. (7). Former par. (7) redesignated (8).

Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec. 201(a)(1)],

redesignated par. (5) as (7). Former par. (7) redesignated (9).

Subsec. (t)(7)(D). Pub. L. 106-113, Sec. 1000(a)(6) [title II,

Sec. 201(i)], added subpar. (D).

Subsec. (t)(8). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

202(a)(2)], redesignated par. (7) as (8). Former par. (8)

redesignated (9).

Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec. 201(a)(1)],

redesignated par. (6) as (8). Former par. (8) redesignated (10).

Subsec. (t)(8)(A). Pub. L. 106-113, Sec. 1000(a)(6) [title II,

Sec. 204(a)(1)], substituted "subparagraphs (B) and (C)" for

"subparagraph (B)".

Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec. 201(h)(1)(B)],

inserted at end "The Secretary shall consult with an expert outside

advisory panel composed of an appropriate selection of

representatives of providers to review (and advise the Secretary

concerning) the clinical integrity of the groups and weights. Such

panel may use data collected or developed by entities and

organizations (other than the Department of Health and Human

Services) in conducting such review."

Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec. 201(h)(1)(A)],

substituted "shall review not less often than annually" for "may

periodically review".

Subsec. (t)(8)(C) to (E). Pub. L. 106-113, Sec. 1000(a)(6) [title

II, Sec. 204(a)(2), (3)], added subpar. (C) and redesignated former

subpars. (C) and (D) as (D) and (E), respectively.

Subsec. (t)(9). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

202(a)(2)], redesignated par. (8) as (9). Former par. (9)

redesignated (10).

Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec. 201(j)],

substituted "section 1395x(v)(1)(U) of this title" for "the matter

in subsection (a)(1) of this section preceding subparagraph (A)".

Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec. 201(a)(1)],

redesignated par. (7) as (9). Former par. (9) redesignated (11).

Subsec. (t)(10). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

202(a)(2)], redesignated par. (9) as (10). Former par. (10)

redesignated (11).

Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec. 201(a)(1)],

redesignated par. (8) as (10).

Subsec. (t)(11). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

202(a)(2)], redesignated par. (10) as (11). Former par. (11)

redesignated (12).

Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec. 201(a)(1)],

redesignated par. (9) as (11).

Subsec. (t)(11)(E). Pub. L. 106-113, Sec. 1000(a)(6) [title II,

Sec. 201(d)], added subpar. (E).

Subsec. (t)(12). Pub. L. 106-113, Sec. 1000(a)(6) [title II, Sec.

202(a)(2)], redesignated par. (11) as (12).

Subsec. (t)(13). Pub. L. 106-113, Sec. 1000(a)(6) [title IV, Sec.

401(b)(1)], added par. (13).

1997 - Subsec. (a)(1)(A). Pub. L. 105-33, Sec. 4002(j)(1)(A),

inserted "(and either is sponsored by a union or employer, or does

not provide, or arrange for the provision of, any inpatient

hospital services)" after "prepayment basis".

Subsec. (a)(1)(D). Pub. L. 105-33, Sec. 4104(c), inserted "or

section 1395m(d)(1) of this title" after "subsection (h)(1) of this

section".

Subsec. (a)(1)(O). Pub. L. 105-33, Sec. 4512(b)(1), substituted

"section 1395x(s)(2)(K) of this title" for "section

1395x(s)(2)(K)(ii) of this title" and "services furnished by

physician assistants, nurse practitioners, or clinic nurse

specialists" for "nurse practitioner or clinical nurse specialist

services".

Pub. L. 105-33, Sec. 4511(b)(1), amended cl. (O) generally. Prior

to amendment, cl. (O) read as follows: "with respect to services

described in section 1395x(s)(2)(K)(iii) of this title (relating to

nurse practitioner or clinical nurse specialist services provided

in a rural area), the amounts paid shall be 80 percent of the

lesser of the actual charge or the prevailing charge that would be

recognized (or, for services furnished on or after January 1, 1992,

the fee schedule amount provided under section 1395w-4 of this

title) if the services had been performed by a physician (subject

to the limitation described in subsection (r)(2) of this

section),".

Subsec. (a)(1)(Q). Pub. L. 105-33, Sec. 4315(b), added cl. (Q).

Subsec. (a)(1)(R). Pub. L. 105-33, Sec. 4531(b)(1), added cl.

(R).

Subsec. (a)(1)(S). Pub. L. 105-33, Sec. 4556(b), added cl. (S).

Subsec. (a)(2). Pub. L. 105-33, Sec. 4541(a)(1)(A), inserted

"(C)," before "(D)" in introductory provisions.

Subsec. (a)(2)(A). Pub. L. 105-33, Sec. 4603(c)(2)(A)(i), amended

subpar. (A) generally. Prior to amendment, subpar. (A) read as

follows: "with respect to home health services (other than a

covered osteoporosis drug (as defined in section 1395x(kk) of this

title)) and to items and services described in section

1395x(s)(10)(A) of this title, the lesser of -

"(i) the reasonable cost of such services, as determined under

section 1395x(v) of this title, or

"(ii) the customary charges with respect to such services,

or, 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 provision), free of charge or at nominal charges to the

public, the amount determined in accordance with section

1395f(b)(2) of this title;".

Subsec. (a)(2)(B). Pub. L. 105-33, Sec. 4432(b)(5)(C), inserted

"or section 1395yy(e)(9) of this title" after "1395ww of this

title" in introductory provisions.

Pub. L. 105-33, Sec. 4523(d)(3), inserted "furnished before

January 1, 1999," after "(i)" in cl. (i), inserted "before January

1, 1999," after "furnished" in cl. (ii), added cl. (iii), and

redesignated former cl. (iii) as (iv).

Subsec. (a)(2)(D). Pub. L. 105-33, Sec. 4104(c)(1), inserted "or

section 1395m(d)(1) of this title" after "subsection (h)(1) of this

section".

Subsec. (a)(2)(E). Pub. L. 105-33, Sec. 4523(d)(2)(B), inserted

"or, for services or procedures performed on or after January 1,

1999, subsection (t) of this section" before semicolon at end.

Subsec. (a)(2)(G). Pub. L. 105-33, Sec. 4603(c)(2)(A)(ii)-(iv),

added subpar. (G).

Subsec. (a)(3). Pub. L. 105-33, Sec. 4541(a)(1)(B), substituted

"section 1395k(a)(2)(D) of this title" for "subparagraphs (D) and

(E) of section 1395k(a)(2) of this title".

Subsec. (a)(4). Pub. L. 105-33, Sec. 4523(d)(1)(B), inserted "or

subsection (t) of this section" before semicolon at end.

Subsec. (a)(6). Pub. L. 105-33, Sec. 4201(c)(1), substituted

"critical access" for "rural primary care".

Subsec. (a)(8), (9). Pub. L. 105-33, Sec. 4541(a)(1)(C)-(E),

added pars. (8) and (9).

Subsec. (b)(5). Pub. L. 105-33, Sec. 4101(b), added cl. (5) at

end of first sentence.

Subsec. (b)(6). Pub. L. 105-33, Sec. 4102(b), added cl. (6) at

end of first sentence.

Subsec. (f). Pub. L. 105-33, Sec. 4205(a)(1)(A), substituted

"rural health clinics (other than such clinics in rural hospitals

with less than 50 beds)" for "independent rural health clinics" in

introductory provisions.

Subsec. (f)(1). Pub. L. 105-33, Sec. 4205(a)(2), inserted "per

visit" after "$46".

Subsec. (g). Pub. L. 105-33, Sec. 4541(d)(1), substituted "the

amount specified in paragraph (2) for the year" for "$900" in two

places, redesignated first sentence as par. (1) and last sentence

as par. (3), and added par. (2).

Pub. L. 105-33, Sec. 4541(c), (d)(1)(A), substituted, in first

sentence, "physical therapy services of the type described in

section 1395x(p) of this title, but not described in subsection

(a)(8)(B) of this section, and physical therapy services of such

type which are furnished by a physician or as incident to

physicians' services" for "services described in the second

sentence of section 1395x(p) of this title", and substituted, in

last sentence, "occupational therapy services (of the type that are

described in section 1395x(p) of this title (but not described in

subsection (a)(8)(B) of this section) through the operation of

section 1395x(g) of this title and of such type which are furnished

by a physician or as incident to physicians' services)" for

"outpatient occupational therapy services which are described in

the second sentence of section 1395x(p) of this title through the

operation of section 1395x(g) of this title".

Subsec. (h)(1)(A). Pub. L. 105-33, Sec. 4104(c)(2), substituted

"Subject to section 1395m(d)(1) of this title, the Secretary" for

"The Secretary".

Pub. L. 105-33, Sec. 4103(b), inserted "(including prostate

cancer screening tests under section 1395x(oo) of this title

consisting of prostate-specific antigen blood tests)" after

"laboratory tests".

Subsec. (h)(2)(A)(ii)(IV). Pub. L. 105-33, Sec. 4553(a), inserted

"and 1998 through 2002" after "1995".

Subsec. (h)(4)(B)(vii). Pub. L. 105-33, Sec. 4553(b)(2)(A),

inserted "and before January 1, 1998," after "December 31, 1995,".

Subsec. (h)(4)(B)(viii). Pub. L. 105-33, Sec. 4553(b)(1), (2)(B),

(3), added cl. (viii).

Subsec. (h)(5)(A)(iii). Pub. L. 105-33, Sec. 4201(c)(1),

substituted "critical access" for "rural primary care".

Subsec. (i)(1)(A). Pub. L. 105-33, Sec. 4201(c)(1), substituted

"critical access" for "rural primary care".

Subsec. (i)(2)(C). Pub. L. 105-33, Sec. 4555, inserted at end "In

each of the fiscal years 1998 through 2002, the increase under this

subparagraph shall be reduced (but not below zero) by 2.0

percentage points."

Subsec. (i)(3)(A). Pub. L. 105-33, Sec. 4523(d)(1)(A)(i),

inserted "before January 1, 1999," after "furnished" and struck out

"in a cost reporting period" after "paragraph (1)(A)".

Pub. L. 105-33, Sec. 4201(c)(1), substituted "critical access"

for "rural primary care".

Subsec. (i)(3)(B)(i)(II). Pub. L. 105-33, Sec. 4521(a), struck

out "of 80 percent" before "of the standard overhead amount" and

inserted before period at end ", less the amount a provider may

charge as described in clause (ii) of section 1395cc(a)(2)(A) of

this title".

Subsec. (l)(5). Pub. L. 105-33, Sec. 4201(c)(1), substituted

"critical access" for "rural primary care" wherever appearing.

Subsec. (n)(1)(A). Pub. L. 105-33, Sec. 4523(d)(2)(A), inserted

"and before January 1, 1999," after "October 1, 1988," and after

"October 1, 1989,".

Subsec. (n)(1)(B)(i)(II). Pub. L. 105-33, Sec. 4521(b), struck

out "of 80 percent" before "of the prevailing charge" and inserted

before period at end ", less the amount a provider may charge as

described in clause (ii) of section 1395cc(a)(2)(A) of this title".

Subsec. (r)(1). Pub. L. 105-33, Sec. 4511(b)(2)(A), substituted

"section 1395x(s)(2)(K)(ii) of this title (relating to nurse

practitioner or clinical nurse specialist services)" for "section

1395x(s)(2)(K)(iii) of this title (relating to nurse practitioner

or clinical nurse specialist services provided in a rural area)".

Pub. L. 105-33, Sec. 4201(c)(1), substituted "critical access"

for "rural primary care".

Subsec. (r)(2). Pub. L. 105-33, Sec. 4511(b)(2)(B), (D),

redesignated par. (3) as (2) and struck out former par. (2) which

read as follows:

"(2)(A) For purposes of subsection (a)(1)(O) of this section, the

prevailing charge for services described in section

1395x(s)(2)(K)(iii) of this title may not exceed the applicable

percentage (as defined in subparagraph (B)) of the prevailing

charge (or, for services furnished on or after January 1, 1992, the

fee schedule amount provided under section 1395w-4 of this title)

determined for such services performed by physicians who are not

specialists.

"(B) In subparagraph (A), the term 'applicable percentage' means

-

"(i) 75 percent in the case of services performed in a

hospital, and

"(ii) 85 percent in the case of other services."

Subsec. (r)(3). Pub. L. 105-33, Sec. 4511(b)(2)(C), (D),

redesignated par. (3) as (2) and substituted "section

1395x(s)(2)(K)(ii) of this title" for "section 1395x(s)(2)(K)(iii)

of this title".

Pub. L. 105-33, Sec. 4201(c)(1), substituted "critical access"

for "rural primary care".

Subsec. (t). Pub. L. 105-33, Sec. 4523(a), added subsec. (t).

1994 - Subsec. (a)(1)(D)(i). Pub. L. 103-432, Sec.

156(a)(2)(B)(i), struck out ", or for tests furnished in connection

with obtaining a second opinion required under section

1320c-13(c)(2) of this title (or a third opinion, if the second

opinion was in disagreement with the first opinion)" after

"assignment-related basis".

Subsec. (a)(1)(G). Pub. L. 103-432, Sec. 156(a)(2)(B)(ii), struck

out cl. (G) which read as follows: "with respect to items and

services (other than clinical diagnostic laboratory tests)

furnished in connection with obtaining a second opinion required

under section 1320c-13(c)(2) of this title (or a third opinion, if

the second opinion was in disagreement with the first opinion), the

amounts paid shall be 100 percent of the reasonable charges for

such items and services,".

Subsec. (a)(2)(A). Pub. L. 103-432, Sec. 156(a)(2)(B)(iii),

struck out ", to items and services (other than clinical diagnostic

laboratory tests) furnished in connection with obtaining a second

opinion required under section 1320c-13(c)(2) of this title (or a

third opinion, if the second opinion was in disagreement with the

first opinion)," before "and to items and services" in introductory

provisions.

Pub. L. 103-432, Sec. 147(f)(6)(C)(i), substituted "health

services (other than a covered osteoporosis drug (as defined in

section 1395x(kk) of this title))" for "health services" in

introductory provisions.

Subsec. (a)(2)(D)(i). Pub. L. 103-432, Sec. 156(a)(2)(B)(iv),

substituted "assignment-related basis or" for "assignment-related

basis," and struck out ", or for tests furnished in connection with

obtaining a second opinion required under section 1320c-13(c)(2) of

this title (or a third opinion, if the second opinion was in

disagreement with the first opinion)" after "section 1395cc of this

title".

Subsec. (a)(2)(F). Pub. L. 103-432, Sec. 147(f)(6)(C)(ii)-(iv),

added subpar. (F).

Subsec. (a)(3). Pub. L. 103-432, Sec. 156(a)(2)(B)(v), struck out

"and for items and services furnished in connection with obtaining

a second opinion required under section 1320c-13(c)(2) of this

title, or a third opinion, if the second opinion was in

disagreement with the first opinion)" after "section

1395x(s)(10)(A) of this title".

Subsec. (b)(2). Pub. L. 103-432, Sec. 147(f)(6)(D), inserted

"(other than a covered osteoporosis drug (as defined in section

1395x(kk) of this title))" after "services".

Subsec. (b)(4), (5). Pub. L. 103-432, Sec. 156(a)(2)(B)(vi),

redesignated par. (5) as (4) and struck out former par. (4) which

read as follows: "such deductible shall not apply with respect to

items and services furnished in connection with obtaining a second

opinion required under section 1320c-13(c)(2) of this title (or a

third opinion, if the second opinion was in disagreement with the

first opinion),".

Subsec. (h)(5)(D). Pub. L. 103-432, Sec. 123(e), substituted

"paragraph (2) of section 1395u(j)" for "paragraphs (2) and (3) of

section 1395u(j)" and inserted at end "Paragraph (4) of such

section shall apply in this subparagraph in the same manner as such

paragraph applies to such section."

Subsec. (i)(1). Pub. L. 103-432, Sec. 141(a)(3), inserted before

period at end of last sentence ", in consultation with appropriate

trade and professional organizations".

Subsec. (i)(2)(A). Pub. L. 103-432, Sec. 141(a)(2)(A), struck out

"and may be adjusted by the Secretary, when appropriate," after

"annually thereafter" in last sentence.

Subsec. (i)(2)(A)(i). Pub. L. 103-432, Sec. 141(a)(1), inserted

before comma at end ", as determined in accordance with a survey

(based upon a representative sample of procedures and facilities)

taken not later than January 1, 1995, and every 5 years thereafter,

of the actual audited costs incurred by such centers in providing

such services".

Subsec. (i)(2)(B). Pub. L. 103-432, Sec. 141(a)(2)(A), struck out

"and may be adjusted by the Secretary, when appropriate," after

"annually thereafter" in last sentence.

Subsec. (i)(2)(C). Pub. L. 103-432, Sec. 141(a)(2)(B), added

subpar. (C).

Subsec. (i)(3)(B)(ii). Pub. L. 103-432, Sec. 141(c)(1), in

subcls. (I) and (II) substituted "for portions of cost reporting

periods" for "for reporting periods" and "and ending on or before

December 31, 1990" for "and on or before December 31, 1990".

Subsec. (l)(5)(B), (C). Pub. L. 103-432, Sec. 123(b)(2)(A)(i),

redesignated subpar. (C) as (B) and struck out former subpar. (B)

which read as follows:

"(B)(i) Payment for the services of a certified registered nurse

anesthetist under this part may be made only on an

assignment-related basis, and any such assignment agreed to by a

certified registered nurse anesthetist shall be binding upon any

other person presenting a claim or request for payment for such

services.

"(ii) Except for deductible and coinsurance amounts applicable

under this section, any person who knowingly and willfully

presents, or causes to be presented, to an individual enrolled

under this part a bill or request for payment for services of a

certified registered nurse anesthetist for which payment may be

made under this part only on an assignment-related basis is subject

to a civil money penalty of not to exceed $2,000 for each such bill

or request. 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."

Subsec. (n)(1)(B)(i)(II). Pub. L. 103-432, Sec. 147(d)(2),

substituted "April 1, 1989" for "January 1, 1989".

Pub. L. 103-432, Sec. 147(d)(1), inserted "and for services

described in subsection (a)(2)(E)(ii) of this section furnished on

or after January 1, 1992" after "January 1, 1989" and "(or, in the

case of services furnished on or after January 1, 1992, under

section 1395w-4 of this title)" before period at end.

Subsec. (p). Pub. L. 103-432, Sec. 123(b)(2)(A)(ii), struck out

subsec. (p) which read as follows: "In the case of certified

nurse-midwife services for which payment may be made under this

part only pursuant to section 1395x(s)(2)(L) of this title, in the

case of qualified psychologists services for which payment may be

made under this part only pursuant to section 1395x(s)(2)(M) of

this title, and in the case of clinical social worker services for

which payment may be made under this part only pursuant to section

1395x(s)(2)(N) of this title, payment may only be made under this

part for such services on an assignment-related basis. Except for

deductible and coinsurance amounts applicable under this section,

whoever knowingly and willfully presents, or causes to be

presented, to an individual enrolled under this part a bill or

request for payment for services described in the previous

sentence, is subject to a civil money penalty of not to exceed

$2,000 for each such bill or request. 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."

Subsec. (q)(1). Pub. L. 103-432, Sec. 147(a), substituted "unique

physician identification number" for "provider number" and struck

out "and indicate whether or not the referring physician is an

interested investor (within the meaning of section 1395nn(h)(5) of

this title)" after "for the referring physician".

Subsec. (r). Pub. L. 103-432, Sec. 160(d)(1), redesignated

subsec. (r), relating to other prepaid organizations, as (s).

Subsec. (r)(1). Pub. L. 103-432, Sec. 147(e)(2), substituted "or

ambulatory" for "ambulatory" in two places and "center" for

"center," before "with which the nurse".

Subsec. (r)(2)(A). Pub. L. 103-432, Sec. 147(e)(3), substituted

"subsection (a)(1)(O) of this section" for "subsection (a)(1)(M) of

this section".

Subsec. (r)(3), (4). Pub. L. 103-432, Sec. 123(b)(2)(A)(iii),

redesignated par. (4) as (3) and struck out former par. (3) which

read as follows:

"(3)(A) Payment under this part for services described in section

1395x(s)(2)(K)(iii) of this title may be made only on an

assignment-related basis, and any such assignment agreed to by a

nurse practitioner or clinical nurse specialist shall be binding

upon any other person presenting a claim or request for payment for

such services.

"(B) Except for deductible and coinsurance amounts applicable

under this section, any person who knowingly and willfully

presents, or causes to be presented, to an individual enrolled

under this part a bill or request for payment for services

described in section 1395x(s)(2)(K)(iii) of this title in violation

of subparagraph (A) is subject to a civil money penalty of not to

exceed $2,000 for each such bill or request. 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."

Subsec. (s). Pub. L. 103-432, Sec. 160(d)(1), redesignated

subsec. (r), relating to other prepaid organizations, as (s).

1993 - Subsec. (a)(1). Pub. L. 103-66, Sec. 13544(b)(2),

redesignated cl. (M) relating to nurse practitioner and clinical

nurse specialist services as (O), inserted comma before "(O)",

transferred and inserted such cl. to appear before semicolon at

end, struck out "and" before "(N)", and inserted ", and" and cl.

(P) following cl. (O) and before semicolon at end.

Subsec. (g). Pub. L. 103-66, Sec. 13555(a), substituted "$900"

for "$750" in two places.

Subsec. (h)(2)(A)(ii)(IV). Pub. L. 103-66, Sec. 13551(a), added

subcl. (IV).

Subsec. (h)(4)(B)(iv) to (vii). Pub. L. 103-66, Sec. 13551(b),

added cls. (iv) to (vii), and struck out former cl. (iv) which read

as follows: "after December 31, 1990, is equal to 88 percent of the

median of all the fee schedules established for that test for that

laboratory setting under paragraph (1)."

Subsec. (i)(3)(B)(ii). Pub. L. 103-66, Sec. 13532(a)(1), in

introductory provisions substituted "paragraph (4)" for "the last

sentence of this clause" and struck out concluding provisions which

read as follows: "In the case of a hospital that makes application

to the Secretary and demonstrates that it specializes in eye

services or eye and ear services (as determined by the Secretary),

receives more than 30 percent of its total revenues from outpatient

services and was an eye specialty hospital or an eye and ear

specialty hospital on October 1, 1987, the cost proportion and ASC

proportion in effect under subclauses (I) and (II) for cost

reporting periods beginning in fiscal year 1988 shall remain in

effect for cost reporting periods beginning on or after October 1,

1988, and before January 1, 1995."

Subsec. (i)(4). Pub. L. 103-66, Sec. 13532(a)(2), added par. (4).

Subsec. (l)(4)(B)(i). Pub. L. 103-66, Sec. 13516(b)(1), inserted

"and before January 1, 1994," after "1991,".

Subsec. (l)(4)(B)(ii). Pub. L. 103-66, Sec. 13516(b)(2), inserted

"and" at end of subcl. (II), substituted a period for the comma at

end of subcl. (III), and struck out subcls. (IV) to (VII) which

read as follows:

"(IV) for services furnished in 1994, $11.25,

"(V) for services furnished in 1995, $11.50,

"(VI) for services furnished in 1996, $11.70, and

"(VII) for services furnished in calendar years after 1997, the

previous year's conversion factor increased by the update

determined under section 1395w-4(d)(3) of this title for physician

anesthesia services for that year."

Subsec. (l)(4)(B)(iii). Pub. L. 103-66, Sec. 13516(b)(3), added

cl. (iii).

1990 - Subsec. (a)(1)(H). Pub. L. 101-508, Sec. 4118(f)(2)(D),

struck out ", as the case may be" after "section 1395w-4 of this

title".

Subsec. (a)(1)(J). Pub. L. 101-508, Sec. 4104(b)(1), struck out

"or physician pathology services" after "1395m(b)(6) of this

title)" and "or section 1395m(f) of this title, respectively" after

"1395m(b) of this title".

Subsec. (a)(1)(K). Pub. L. 101-508, Sec. 4155(b)(2)(A), which

directed amendment of cl. (K) by striking "and" at the end, could

not be executed because of prior amendment by Pub. L. 101-508, Sec.

4153(a)(2)(B)(i), see below.

Pub. L. 101-508, Sec. 4153(a)(2)(B)(i), struck out "and" after

"by a physician),".

Subsec. (a)(1)(L). Pub. L. 101-508, Sec. 4153(a)(2)(B)(ii),

substituted "subparagraph," for "subparagraph and" at end.

Subsec. (a)(1)(M). Pub. L. 101-508, Sec. 4155(b)(2)(B), added cl.

(M) relating to nurse practitioner and clinical nurse specialist

services.

Pub. L. 101-508, Sec. 4153(a)(2)(B)(ii), added cl. (M) relating

to prosthetic devices and orthotics.

Subsec. (a)(2). Pub. L. 101-508, Sec. 4153(a)(2)(C)(i),

substituted "(H), and (I)" for "and (H)" in introductory

provisions.

Subsec. (a)(2)(E)(i). Pub. L. 101-508, Sec. 4163(d)(1), inserted

", but excluding screening mammography" after "imaging services".

Subsec. (a)(7). Pub. L. 101-508, Sec. 4153(a)(2)(C)(ii)-(iv),

added par. (7).

Subsec. (b). Pub. L. 101-508, Sec. 4302, inserted "for calendar

years before 1991 and $100 for 1991 and subsequent years" after

"$75".

Subsec. (b)(5). Pub. L. 101-508, Sec. 4161(a)(3)(B), added cl.

(5) at end of first sentence.

Subsec. (h)(2)(A)(ii). Pub. L. 101-508, Sec. 4154(a)(1),

substituted "clause (i)" for "any other provision of this

subsection" in introductory provisions.

Subsec. (h)(2)(A)(ii)(III). Pub. L. 101-508, Sec. 4154(a)(2)-(4),

added subcl. (III).

Subsec. (h)(4)(B). Pub. L. 101-508, Sec. 4154(b)(1)(B), struck

out "and" at end of cl. (ii), inserted "and before January 1,

1991," after "1989," in cl. (iii), substituted ", and" for period

at end of cl. (iii), and added cl. (iv).

Subsec. (h)(5)(A)(ii)(II). Pub. L. 101-508, Sec. 4154(e)(1)(A),

substituted "wholly owned by" for "a wholly-owned subsidiary of".

Subsec. (h)(5)(A)(ii)(III). Pub. L. 101-508, Sec. 4154(e)(1)(C),

substituted "receives requests for testing during the year in which

the test is performed" for "submits bills or requests for payment

in any year".

Pub. L. 101-508, Sec. 4154(e)(1)(B), which directed substitution

of "laboratory (but not including a laboratory described in

subclause (II))," for "laboratory", was executed by making the

substitution for "laboratory" the second time appearing to reflect

the probable intent of Congress.

Subsec. (h)(5)(A)(iii). Pub. L. 101-508, Sec. 4008(m)(2)(C),

which directed technical correction to Pub. L. 101-239, Sec.

6003(g)(3)(C)(vii)(I), was executed by making technical correction

to Pub. L. 101-239, Sec. 6003(g)(3)(D)(vii)(I), resulting in no

change in text. See 1989 Amendment note below.

Subsec. (h)(5)(C). Pub. L. 101-508, Sec. 4154(c)(1)(A),

substituted "test, including a test performed in a physician's

office but excluding a test performed by a rural health clinic" for

"test performed by a laboratory other than a rural health clinic".

Subsec. (h)(5)(D). Pub. L. 101-508, Sec. 4154(c)(1)(B),

substituted "test, including a test performed in a physician's

office but excluding a test performed by a rural health clinic,"

for "test performed by a laboratory, other than a rural health

clinic".

Subsec. (i)(3)(B)(ii). Pub. L. 101-508, Sec. 4151(c)(1)(B),

substituted "on or after October 1, 1988, and before January 1,

1995" for "in fiscal year 1989 or fiscal year 1990" in last

sentence.

Subsec. (i)(3)(B)(ii)(I). Pub. L. 101-508, Sec. 4151(c)(1)(A)(i),

substituted "50 percent for reporting periods beginning on or after

October 1, 1988, and on or before December 31, 1990, and 42 percent

for portions of cost reporting periods beginning on or after

January 1, 1991" for "and 50 percent for other cost reporting

periods".

Subsec. (i)(3)(B)(ii)(II). Pub. L. 101-508, Sec.

4151(c)(1)(A)(ii), substituted "50 percent for reporting periods

beginning on or after October 1, 1988, and on or before December

31, 1990, and 58 percent for portions of cost reporting periods

beginning on or after January 1, 1991" for "and 50 percent for

other cost reporting periods".

Subsec. (l)(1). Pub. L. 101-508, Sec. 4160(1), designated

existing provisions as subpar. (A) and added subpars. (B) and (C).

Subsec. (l)(2). Pub. L. 101-508, Sec. 4160(2), struck out at end

"The fee schedule shall be adjusted annually (to become effective

on January 1 of each calendar year) by the percentage increase in

the MEI (as defined in section 1395u(i)(3) of this title) for that

year."

Subsec. (l)(4). Pub. L. 101-508, Sec. 4160(3), added par. (4) and

struck out former par. (4) which read as follows: "In establishing

the fee schedule under paragraph (1), the Secretary may utilize a

system of time units, a system of base and time units, or any

appropriate methodology. The Secretary may establish a nationwide

fee schedule or adjust the fee schedule for geographic areas (as

the Secretary may determine to be appropriate)."

Subsec. (m). Pub. L. 101-597 substituted "health professional

shortage area" for "health manpower shortage area".

Subsec. (n)(1)(B)(ii)(I). Pub. L. 101-508, Sec. 4151(c)(2),

inserted before period at end ", and such term means 42 percent in

the case of outpatient radiology services for portions of cost

reporting periods beginning on or after January 1, 1991".

Subsec. (r). Pub. L. 101-508, Sec. 4206(b)(2), added subsec. (r)

relating to other prepaid organizations.

Pub. L. 101-508, Sec. 4155(b)(3), added subsec. (r) relating to

cap on prevailing charge and billing on assignment-related basis.

1989 - Subsec. (a). Pub. L. 101-234, Sec. 202(a), repealed Pub.

L. 100-360, Sec. 212(c)(2), 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.

Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, Sec.

205(c)(3), 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)(F). Pub. L. 101-239, Sec. 6113(b)(3)(A), added cl.

(F).

Subsec. (a)(1)(H). Pub. L. 101-239, Sec. 6102(e)(5), inserted

"(or, for services furnished on or after January 1, 1992, the fee

schedule amount provided under section 1395w-4 of this title, as

the case may be)" after "prevailing charge that would be

recognized".

Subsec. (a)(1)(J). Pub. L. 101-239, Sec. 6102(f)(2), inserted "or

physician pathology services" after "1395m(b)(6) of this title)"

and "or section 1395m(f) of this title, respectively" after

"1395m(b) of this title".

Pub. L. 101-239, Sec. 6102(e)(6)(A), inserted "subject to section

1395w-4 of this title," before "the amounts".

Subsec. (a)(1)(K). Pub. L. 101-239, Sec. 6102(e)(7), inserted ",

or, for services furnished on or after January 1, 1992, 65 percent

of the fee schedule amount provided under section 1395w-4 of this

title for the same service performed by a physician" after "for the

same service performed by a physician".

Subsec. (a)(1)(M). Pub. L. 101-234, Sec. 201(a), repealed Pub. L.

100-360, Sec. 201(b)(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)(N). Pub. L. 101-239, Sec. 6102(e)(1)(B), added cl.

(N).

Subsec. (a)(2). Pub. L. 101-239, Sec. 6116(b)(1)(A), substituted

"(G), and (H)" for "and (G)" in introductory provisions.

Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, Secs.

202(b)(2), 203(c)(1)(A)-(D), 204(d)(1), and 205(c)(1), and provided

that the provisions of law amended or repealed by such sections are

restored or revived as if such sections had not been enacted, see

1988 Amendment notes below.

Subsec. (a)(3). Pub. L. 101-234, Sec. 201(a), repealed Pub. L.

100-360, Sec. 205(c)(2), 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)(6). Pub. L. 101-239, Sec. 6116(b)(1)(B)-(D), added

par. (6).

Subsec. (b). Pub. L. 101-234, Sec. 201(a), repealed Pub. L.

100-360, Secs. 202(b)(3), 203(c)(1)(E), and provided that the

provisions of law amended or repealed by such sections are restored

or revived as if such sections had not been enacted, see 1988

Amendment notes below.

Subsec. (c). Pub. L. 101-234, Sec. 201(a), repealed Pub. L.

100-360, Sec. 201(a)(1), (4), 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. (d). Pub. L. 101-234, Sec. 201(a), repealed Pub. L.

100-360, Sec. 201(a)(1)(D), (2), 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. (d)(1). Pub. L. 101-239, Sec. 6113(d), substituted "62

1/2 percent of such expenses." for "whichever of the following

amounts is the smaller:

"(A) $1375.00, or

"(B) 62 1/2 percent of such expenses."

Subsec. (g). Pub. L. 101-239, Sec. 6133(a), substituted "$750"

for "$500" in two places.

Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, Sec.

201(a)(3), 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. (h)(1)(B), (C). Pub. L. 101-239, Sec. 6111(a)(1),

substituted "on or after July 1, 1984" for "during the period

beginning on July 1, 1984, and ending on December 31, 1989. For

such tests furnished on or after January 1, 1990, the fee schedule

shall be established on a nationwide basis."

Subsec. (h)(1)(D). Pub. L. 101-239, Sec. 6003(e)(2)(A),

substituted "section 1395ww(d)(5)(D)(iii) of this title" for "the

last sentence of section 1395ww(d)(5)(C)(ii) of this title".

Subsec. (h)(4)(B)(ii). Pub. L. 101-239, Sec. 6111(a)(3)(A), (B),

substituted "after March 31, 1988, and before January 1, 1990," for

"after March 31, 1988, and so long as a fee schedule for the test

has not been established on a nationwide basis,".

Subsec. (h)(4)(B)(iii). Pub. L. 101-239, Sec. 6111(a)(2), (3)(C),

(4), added cl. (iii).

Subsec. (h)(5)(A)(ii). Pub. L. 101-239, Sec. 6111(b)(1),

substituted "referring laboratory but only if - " for "referring

laboratory, and" in introductory provisions, and added subcls. (I)

through (III).

Subsec. (h)(5)(A)(iii). Pub. L. 101-239, Sec.

6003(g)(3)(D)(vii)(I), as amended by Pub. L. 101-508, Sec.

4008(m)(2)(C), substituted "hospital or rural primary care

hospital," for "hospital,".

Subsec. (i)(1)(A). Pub. L. 101-239, Sec. 6003(g)(3)(D)(vii)(II),

inserted ", rural primary care hospital," after "section

1395k(a)(2)(F)(i) of this title)".

Subsec. (i)(3)(A). Pub. L. 101-239, Sec. 6003(g)(3)(D)(vii)(III),

inserted "or rural primary care hospital services" after "facility

services" in introductory provisions.

Subsec. (l)(5)(A). Pub. L. 101-239, Sec. 6003(g)(3)(D)(vii)(IV),

inserted "rural primary care hospital," after "hospital," in two

places.

Subsec. (l)(5)(C). Pub. L. 101-239, Sec. 6003(g)(3)(D)(vii)(V),

substituted "hospital or rural primary care hospital" for

"hospital" in two places.

Subsec. (m). Pub. L. 101-239, Sec. 6102(c)(1), struck out "class

1 or class 2" before "health manpower shortage area" and

substituted "10 percent" for "5 percent".

Subsec. (o)(1). Pub. L. 101-239, Sec. 6131(a)(1)(C), inserted

"(or inserts)" after "shoes" in two places in last sentence.

Subsec. (o)(1)(A). Pub. L. 101-239, Sec. 6131(a)(1)(A), amended

subpar. (A) generally. Prior to amendment, subpar. (A) read as

follows: "no payment may be made under this part for the furnishing

of more than one pair of shoes for any individual for any calendar

year, and".

Subsec. (o)(1)(B), (2)(A). Pub. L. 101-239, Sec. 6131(a)(1)(B),

substituted "limits" for "limit".

Subsec. (o)(2)(A)(i). Pub. L. 101-239, Sec. 6131(a)(1)(D),

amended cl. (i) generally. Prior to amendment, cl. (i) read as

follows: "for the furnishing of one pair of custom molded shoes is

$300".

Subsec. (o)(2)(A)(ii)(II). Pub. L. 101-239, Sec. 6131(a)(1)(E),

inserted "any pairs of" after "$50 for".

Subsec. (o)(2)(D). Pub. L. 101-239, Sec. 6131(b), added subpar.

(D).

Subsec. (p). Pub. L. 101-239, Sec. 6113(b)(3)(B), substituted

"1395x(s)(2)(L) of this title," for "1395x(s)(2)(L) of this title

and" and inserted "and in the case of clinical social worker

services for which payment may be made under this part only

pursuant to section 1395x(s)(2)(N) of this title," after "section

1395x(s)(2)(M) of this title,".

Subsec. (q). Pub. L. 101-239, Sec. 6204(b), added subsec. (q).

1988 - Subsec. (a). Pub. L. 100-360, Sec. 212(c)(2), inserted

"or, as provided in section 1395t-1(c) of this title, from the

Federal Catastrophic Drug Insurance Trust Fund" after "Fund" in

introductory provisions.

Pub. L. 100-360, Sec. 205(c)(3), inserted provision at end

relating to payment for in-home care for chronically dependent

individuals.

Subsec. (a)(1)(D)(i). Pub. L. 100-360, Sec. 411(i)(4)(C)(i),

amended Pub. L. 100-203, Sec. 4085(i)(1)(A), see 1987 Amendment

note below.

Subsec. (a)(1)(F). Pub. L. 100-360, Sec. 411(f)(12)(A), (14),

added and renumbered Pub. L. 100-203, Sec. 4055(a)(1), see 1987

Amendment note below.

Pub. L. 100-360, Sec. 411(i)(4)(C)(iv), made technical amendment

to directory language of Pub. L. 100-203, Sec. 4085(i)(21)(D)(i),

see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(i)(4)(C)(ii), repealed Pub. L. 100-203,

Sec. 4085(i)(1)(B), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(h)(4)(B)(i), (ii), redesignated and

amended directory language of Pub. L. 100-203, Sec. 4073(b)(1)(A),

see 1987 Amendment note below.

Subsec. (a)(1)(G). Pub. L. 100-360, Sec. 411(h)(7)(C)(ii),

repealed Pub. L. 100-203, Sec. 4077(b)(3)(A), see 1987 Amendment

note below.

Pub. L. 100-360, Sec. 411(h)(4)(B)(iii), repealed Pub. L.

100-203, Sec. 4073(b)(2)(B), see 1987 Amendment note below.

Subsec. (a)(1)(H). Pub. L. 100-360, Sec. 411(h)(7)(C)(ii),

repealed Pub. L. 100-203, Sec. 4077(b)(3)(B), see 1987 Amendment

note below.

Pub. L. 100-360, Sec. 411(g)(1)(E), which directed the amendment

of cl. (H) by striking "and" before "(I)" could not be executed

because of the prior amendment by section 4049(a)(1) of Pub. L.

100-203, see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(i)(3), added Pub. L. 100-203, Sec.

4084(c)(2), see 1987 Amendment note below.

Subsec. (a)(1)(J). Pub. L. 100-360, Sec. 411(f)(8)(B)(i), made

technical amendment to directory language of Pub. L. 100-203, Sec.

4049(a)(1), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(f)(8)(C), substituted "section

1395m(b)(6) of this title" for "section 1395m(b)(5) of this title".

Subsec. (a)(1)(K). Pub. L. 100-360, Sec. 411(h)(7)(C)(iii), (F),

redesignated and amended Pub. L. 100-203, Sec. 4077(b)(2)(A), see

1987 Amendment note below.

Pub. L. 100-360, Sec. 411(h)(4)(B)(i), (iv), (v), redesignated

and amended Pub. L. 100-203, Sec. 4073(b)(1)(B), see 1987 Amendment

note below.

Subsec. (a)(1)(L). Pub. L. 100-360, Sec. 411(h)(7)(C)(i), (iv),

(v), (F), redesignated and amended Pub. L. 100-203, Sec.

4077(b)(2)(B), see 1987 Amendment note below.

Subsec. (a)(1)(M). Pub. L. 100-360, Sec. 202(b)(1), added cl. (M)

relating to expenses incurred for covered outpatient drugs.

Subsec. (a)(2). Pub. L. 100-360, Sec. 205(c)(1), inserted

"(A)(ii)," after "subparagraphs" in introductory provisions.

Pub. L. 100-360, Sec. 202(b)(2), inserted "(other than covered

outpatient drugs)" after "in the case of services" in introductory

provisions.

Subsec. (a)(2)(B). Pub. L. 100-360, Sec. 203(c)(1)(A),

substituted "(E), or (F)" for "or (E)" in introductory provisions.

Subsec. (a)(2)(D)(i). Pub. L. 100-360, Sec. 411(i)(4)(C)(i),

amended Pub. L. 100-203, Sec. 4085(i)(1)(A), see 1987 Amendment

note below.

Subsec. (a)(2)(E)(i). Pub. L. 100-360, Sec. 204(d)(1), inserted

", but excluding screening mammography" after "imaging services".

Subsec. (a)(2)(F). Pub. L. 100-360, Sec. 203(c)(1)(B)-(D), added

cl. (F) relating to home intravenous drug therapy services.

Subsec. (a)(3). Pub. L. 100-360, Sec. 205(c)(2), substituted

"subparagraphs (A)(ii), (D)," for "subparagraphs (D)".

Subsec. (b). Pub. L. 100-360, Sec. 104(d)(7), as added by Pub. L.

100-485, Sec. 608(d)(3)(G), inserted at end "The deductible under

the previous sentence 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 1395e(a)(2) of this title

to blood or blood cells furnished the individual in the year."

Subsec. (b)(1). Pub. L. 100-360, Sec. 202(b)(3)(A), inserted "or

for covered outpatient drugs" after "section 1395x(s)(10)(A) of

this title".

Subsec. (b)(2). Pub. L. 100-360, Sec. 203(c)(1)(E), substituted

"services and home intravenous drug therapy services" for

"services".

Pub. L. 100-360, Sec. 202(b)(3)(B), inserted "or with respect to

covered outpatient drugs" after "home health services".

Subsec. (b)(3) to (5). Pub. L. 100-360, Sec. 411(f)(12)(A), (14),

added and renumbered Pub. L. 100-203, Sec. 4055(a)(2), see 1987

Amendment note below.

Subsec. (c). Pub. L. 100-360, Sec. 201(a)(4), added subsec. (c)

relating to limitation on out-of-pocket catastrophic cost-sharing,

adjustment, buy-out plans, and conditions for payments with respect

to plans other than buy-out plans. Former subsec. (c) redesignated

(d)(1).

Pub. L. 100-360, Sec. 411(h)(1)(A), substituted "monitoring or

changing drug prescriptions" for "prescribing or monitoring

prescription drugs" in last sentence.

Pub. L. 100-360, Sec. 201(a)(1)(A), as amended by Pub. L.

100-485, Sec. 608(d)(4), substituted "subsections (a) through (c)"

for "subsections (a) and (b)" in introductory provisions.

Pub. L. 100-360, Sec. 201(a)(1)(B), (C), redesignated former

pars. (1) and (2) as subpars. (A) and (B) and substituted "this

paragraph" for "this subsection" in last sentence.

Subsec. (d)(1). Pub. L. 100-360, Sec. 201(a)(1)(D), redesignated

former subsec. (c) as subsec. (d)(1). Former subsec. (d)

redesignated subsec. (d)(2).

Subsec. (d)(2). Pub. L. 100-360, Sec. 201(a)(2), redesignated

former subsec. (d) as subsec. (d)(2).

Subsec. (f). Pub. L. 100-360, Sec. 411(g)(5), substituted "MEI

(as defined in section 1395u(i)(3) of this title) applicable to

primary care services (as defined in section 1395u(i)(4) of this

title)" for "medicare economic index (referred to in the fourth

sentence of section 1395u(b)(3) of this title) applicable to

physicians' services".

Subsec. (g). Pub. L. 100-360, Sec. 201(a)(3), substituted

"subsections (a) through (c) of this section" for "subsections (a)

and (b) of this section" in two places.

Subsec. (h)(1)(D). Pub. L. 100-360, Sec. 411(g)(3)(E), (F),

amended and redesignated Pub. L. 100-203, Sec. 4064(c)(1), see 1987

Amendment note below.

Subsec. (h)(2)(A)(i). Pub. L. 100-360, Sec. 411(g)(3)(A), added

Pub. L. 100-203, Sec. 4064(a)(1), see 1987 Amendment note below.

Subsec. (h)(2)(A)(ii). Pub. L. 100-360, Sec. 411(g)(3)(A), added

Pub. L. 100-203, Sec. 4064(a)(3), see 1987 Amendment note below.

Subsec. (h)(2)(A)(iii). Pub. L. 100-360, Sec. 411(g)(3)(B), (C),

amended Pub. L. 100-203, Sec. 4064(b)(1), see 1987 Amendment note

below.

Subsec. (h)(2)(B). Pub. L. 100-360, Sec. 411(g)(3)(A), added Pub.

L. 100-203, Sec. 4064(a)(2), see 1987 Amendment note below.

Subsec. (h)(3). Pub. L. 100-647, Sec. 8421(a), inserted at end

"In establishing a fee to cover the transportation and personnel

expenses for trained personnel to travel to the location of an

individual to collect a sample, the Secretary shall provide a

method for computing the fee based on the number of miles traveled

and the personnel costs associated with the collection of each

individual sample, but the Secretary shall only be required to

apply such method in the case of tests furnished during the period

beginning on April 1, 1989, and ending on December 31, 1990, by a

laboratory that establishes to the satisfaction of the Secretary

(based on data for the 12-month period ending June 30, 1988) that

(i) the laboratory is dependent upon payments under this subchapter

for at least 80 percent of its collected revenues for clinical

diagnostic laboratory tests, (ii) at least 85 percent of its gross

revenues for such tests are attributable to tests performed with

respect to individuals who are homebound or who are residents in a

nursing facility, and (iii) the laboratory provided such tests for

residents in nursing facilities representing at least 20 percent of

the number of such facilities in the State in which the laboratory

is located."

Subsec. (h)(4)(B)(ii). Pub. L. 100-360, Sec. 411(g)(3)(D),

inserted "after" before "March 31, 1988".

Subsec. (h)(5)(A). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), added

Pub. L. 100-203, Sec. 4085(i)(22)(B), see 1987 Amendment note

below.

Subsec. (h)(5)(C). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), added

Pub. L. 100-203, Sec. 4085(i)(22)(B), see 1987 Amendment note

below.

Subsec. (h)(5)(D). Pub. L. 100-360, Sec. 411(i)(4)(B),

substituted "A person may not bill for a clinical diagnostic

laboratory test performed by a laboratory, other than a rural

health clinic, other than on an assignment-related basis. If a

person knowingly and willfully and on a repeated basis bills for a

clinical diagnostic laboratory test in violation of the previous

sentence" for "If a person knowingly and willfully and on a

repeated basis bills an individual enrolled under this part for

charges for a clinical diagnostic laboratory test for which payment

may only be made on an assignment-related basis under subparagraph

(C)" and "paragraphs (2) and (3) of section 1395u(j) of this title

in the same manner such paragraphs apply with respect to a

physician" for "section 1395u(j)(2) of this title".

Subsec. (i)(2)(A)(iii). Pub. L. 100-360, Sec. 411(g)(2)(D),

substituted "insertion" for "implantation" and inserted "or

subsequent to" after "during".

Subsec. (i)(4). Pub. L. 100-360, Sec. 411(f)(12)(A), (14), added

and renumbered Pub. L. 100-203, Sec. 4055(a)(3), see 1987 Amendment

note below.

Subsec. (i)(6). Pub. L. 100-485, Sec. 608(d)(22)(B), substituted

"Any person, including" for "Any person, other than".

Pub. L. 100-360, Sec. 411(g)(2)(E), added Pub. L. 100-203, Sec.

4063(e)(1), see 1987 Amendment note below.

Subsec. (l)(2). Pub. L. 100-360, Sec. 411(f)(2)(D), added Pub. L.

100-203, Sec. 4042(b)(2)(B), see 1987 Amendment note below.

Subsec. (l)(3)(B). Pub. L. 100-647, Sec. 8422(a), inserted "plus

applicable coinsurance" after "would have been paid".

Subsec. (l)(5)(B)(ii). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi),

added Pub. L. 100-203, Sec. 4085(i)(23), see 1987 Amendment note

below.

Subsec. (n)(1)(A). Pub. L. 100-360, Sec. 411(g)(4)(C)(i), as

amended by Pub. L. 100-485, Sec. 608(d)(22)(D), substituted "for

services described in subsection (a)(2)(E)(i) of this section

furnished under this part on or after October 1, 1988, and for

services described in subsection (a)(2)(E)(ii) of this section

furnished under this part on or after October 1, 1989," for

"beginning on or after October 1, 1988 under this part for services

described in subsection (a)(2)(E) of this section" in introductory

provisions.

Subsec. (n)(1)(B)(i)(II). Pub. L. 100-360, Sec. 411(g)(4)(C)(ii),

inserted "or (for services described in subsection (a)(2)(E)(i) of

this section furnished on or after January 1, 1989) the fee

schedule amount established" after "the prevailing charge".

Subsec. (n)(1)(B)(ii). Pub. L. 100-360, Sec. 411(g)(4)(C)(iii),

amended subcls. (I) and (II) generally. Prior to amendment, subcls.

(I) and (II) read as follows:

"(I) The term 'cost proportion' means 65 percent for all or any

part of cost reporting periods which occur in fiscal year 1989 and

50 percent for other cost reporting periods.

"(II) The term 'charge proportion' means 35 percent for all or

any parts of cost reporting periods which occur in fiscal year 1989

and 50 percent for other cost reporting periods."

Subsec. (o). Pub. L. 100-360, Sec. 411(h)(3)(B), as amended by

Pub. L. 100-485, Sec. 608(d)(23)(A), amended Pub. L. 100-203, Sec.

4072(b), see 1987 Amendment note below.

Subsec. (p). Pub. L. 100-360, Sec. 411(h)(7)(D), (F),

redesignated and amended Pub. L. 100-203, Sec. 4077(b)(3), see 1987

Amendment note below.

Pub. L. 100-360, Sec. 411(h)(4)(C), redesignated and amended Pub.

L. 100-203, Sec. 4073(b)(2), see 1987 Amendment note below.

1987 - Subsec. (a)(1)(D)(i). Pub. L. 100-203, Sec. 4085(i)(1)(A),

as amended by Pub. L. 100-360, Sec. 411(i)(4)(C)(i), substituted

"on an assignment-related basis," for "on the basis of an

assignment described in section 1395u(b)(3)(B)(ii) of this title,

under the procedure described in section 1395gg(f)(1) of this

title,".

Subsec. (a)(1)(F). Pub. L. 100-203, Sec. 4055(a)(1), formerly

Sec. 4054(a)(1), as added and renumbered by Pub. L. 100-360, Sec.

411(f)(12)(A), (14), struck out cl. (F) which read as follows:

"with respect to expenses incurred for services described in

subsection (i)(4) of this section under the conditions specified in

such subsection, the amounts paid shall be the reasonable charge

for such services,".

Pub. L. 100-203, Sec. 4085(i)(21)(D)(i), as amended by Pub. L.

100-360, Sec. 411(i)(4)(C)(iv), amended Pub. L. 99-509, Sec.

9343(e)(2)(A), see 1986 Amendment note below.

Pub. L. 100-203, Sec. 4085(i)(1)(B), which directed striking out

"and" at end, was repealed by Pub. L. 100-360, Sec.

411(i)(4)(C)(ii).

Pub. L. 100-203, Sec. 4073(b)(1)(A), formerly Sec. 4073(b)(2)(A),

as redesignated and amended by Pub. L. 100-360, Sec.

411(h)(4)(B)(i), (ii), struck out "and" at end.

Subsec. (a)(1)(G). Pub. L. 100-203, Sec. 4077(b)(3)(A), which

directed striking out "and" at end, was repealed by Pub. L.

100-360, Sec. 411(h)(7)(C)(ii).

Pub. L. 100-203, Sec. 4073(b)(2)(B), which directed substituting

"services," for "services; and", was repealed by Pub. L. 100-360,

Sec. 411(h)(4)(B)(iii).

Pub. L. 100-203, Sec. 4062(d)(3)(A)(i), substituted "services,"

for "services; and".

Subsec. (a)(1)(H). Pub. L. 100-203, Sec. 4077(b)(3)(B), which

directed substituting "services," for "services; and", was repealed

by Pub. L. 100-360, Sec. 411(h)(7)(C)(ii).

Pub. L. 100-203, Sec. 4084(c)(2), as added by Pub. L. 100-360,

Sec. 411(i)(3), substituted "least of the actual charge, the

prevailing charge that would be recognized if the services had been

performed by an anesthesiologist," for "lesser of the actual

charge".

Pub. L. 100-203, Sec. 4062(d)(3)(A)(ii), inserted "and" before

the cl. (I) added by section 4062(d)(3)(A)(ii) of Pub. L. 100-203,

see below.

Pub. L. 100-203, Sec. 4049(a)(1), struck out "and" before the cl.

(I) added by section 4062(d)(3)(A)(ii) of Pub. L. 100-203, see

below.

Subsec. (a)(1)(I). Pub. L. 100-203, Sec. 4062(d)(3)(A)(ii), added

cl. (I).

Subsec. (a)(1)(J). Pub. L. 100-203, Sec. 4049(a)(1), as amended

by Pub. L. 100-360, Sec. 411(f)(8)(B)(i), added cl. (J).

Subsec. (a)(1)(K). Pub. L. 100-203, Sec. 4077(b)(2)(A), formerly

Sec. 4077(b)(3)(C), as redesignated and amended by Pub. L. 100-360,

Sec. 411(h)(7)(C)(iii), (F), inserted "and" after "performed by a

physician),".

Pub. L. 100-203, Sec. 4073(b)(1)(B), formerly Sec. 4073(b)(2)(C),

as redesignated and amended by Pub. L. 100-360, Sec.

411(h)(4)(B)(i), (iv), (v), added cl. (K), formerly (I), relating

to amounts paid with respect to certified nurse-midwife services

under section 1395x(s)(2)(L) of this title.

Subsec. (a)(1)(L). Pub. L. 100-203, Sec. 4077(b)(2)(B), formerly

Sec. 4077(b)(3)(D), as redesignated and amended by Pub. L. 100-360,

Sec. 411(h)(7)(C)(i), (iv), (v), (F), added cl. (L), formerly (J),

relating to amounts paid with respect to qualified psychologist

services under section 1395x(s)(2)(M) of this title.

Subsec. (a)(2). Pub. L. 100-203, Sec. 4062(d)(3)(B)(i), inserted

reference to subpar. (G).

Subsec. (a)(2)(A). Pub. L. 100-203, Sec. 4062(d)(3)(B)(ii),

struck out "(other than durable medical equipment)" after "home

health services".

Subsec. (a)(2)(B). Pub. L. 100-203, Sec. 4066(b), inserted

reference to subpar. (E).

Subsec. (a)(2)(D)(i). Pub. L. 100-203, Sec. 4085(i)(1)(A), as

amended by Pub. L. 100-360, Sec. 411(i)(4)(C)(i), substituted "on

an assignment-related basis," for "on the basis of an assignment

described in section 1395u(b)(3)(B)(ii) of this title, under the

procedure described in section 1395gg(f)(1) of this title,".

Subsec. (a)(2)(E). Pub. L. 100-203, Sec. 4066(a)(1), added

subpar. (E).

Subsec. (a)(5). Pub. L. 100-203, Sec. 4062(d)(3)(C)-(E), added

par. (5).

Subsec. (b)(3). Pub. L. 100-203, Sec. 4055(a)(2), formerly Sec.

4054(a)(2), as added and renumbered by Pub. L. 100-360, Sec.

411(f)(12)(A), (14), redesignated par. (4) as (3) and struck out

former par. (3) which read as follows: "such total amount shall not

include expenses incurred for services the amount of payment for

which is determined under subsection (a)(1)(F) of this section,".

Pub. L. 100-203, Sec. 4085(i)(21)(D)(i), amended Pub. L. 99-509,

Sec. 9343(e)(2)(A), see 1986 Amendment note below.

Subsec. (b)(4). Pub. L. 100-203, Sec. 4055(a)(2), formerly Sec.

4054(a)(2), as added and renumbered by Pub. L. 100-360, Sec.

411(f)(12)(A), (14), redesignated cl. (5) as (4). Former cl. (4)

redesignated (3).

Subsec. (b)(4)(A). Pub. L. 100-203, Sec. 4085(i)(1)(C),

substituted "on an assignment-related basis" for "on the basis of

an assignment described in section 1395u(b)(3)(B)(ii) of this

title, under the procedure described in section 1395gg(f)(1) of

this title".

Subsec. (b)(5). Pub. L. 100-203, Sec. 4055(a)(2), formerly Sec.

4054(a)(2), as added and renumbered by Pub. L. 100-360, Sec.

411(f)(12)(A), (14), redesignated cl. (5) as (4).

Subsec. (c). Pub. L. 100-203, Sec. 4070(b)(4), inserted "or

partial hospitalization services that are not directly provided by

a physician" before period at end of last sentence.

Pub. L. 100-203, Sec. 4070(a)(2), inserted sentence at end

defining "treatment".

Subsec. (c)(1). Pub. L. 100-203, Sec. 4070(a)(1), substituted

"$1375.00" for "$312.50".

Subsec. (f). Pub. L. 100-203, Sec. 4067(a), added subsec. (f).

Subsec. (h)(1)(C). Pub. L. 100-203, Sec. 4085(i)(2), inserted

before period at end ", and ending on December 31, 1989. For such

tests furnished on or after January 1, 1990, the fee schedule shall

be established on a nationwide basis".

Subsec. (h)(1)(D). Pub. L. 100-203, Sec. 4064(c)(1), formerly

Sec. 4064(c), as amended and redesignated by Pub. L. 100-360, Sec.

411(g)(3)(E), (F), inserted ", in a sole community hospital (as

defined in the last sentence of section 1395ww(d)(5)(C)(ii) of this

title),".

Subsec. (h)(2). Pub. L. 100-203, Sec. 4064(c), which had directed

that "laboratory in a sole community hospital" be substituted for

"hospital laboratory" in subsec. (h)(2), was redesignated Sec.

4064(c)(1) by section 411(g)(3)(F) of Pub. L. 100-360 and amended

by section 411(g)(3)(E) of Pub. L. 100-360 to provide for amendment

of subsec. (h)(1)(D) instead of subsec. (h)(2).

Subsec. (h)(2)(A)(i). Pub. L. 100-203, Sec. 4064(a)(1), as added

by Pub. L. 100-360, Sec. 411(g)(3)(A), inserted "(A)(i)" after

"(2)".

Subsec. (h)(2)(A)(ii). Pub. L. 100-203, Sec. 4064(a)(3), as added

by Pub. L. 100-360, Sec. 411(g)(3)(A), added cl. (ii).

Subsec. (h)(2)(A)(iii). Pub. L. 100-203, Sec. 4064(b)(1), as

amended by Pub. L. 100-360, Sec. 411(g)(3)(B), (C), set out as cl.

(iii) provisions formerly set out in an otherwise undesignated

sentence in par. (2) relating to the rebasing of fee schedules for

certain automated and similar tests for 1988 and for the

continuation of such reduced fee schedules as the base for 1989 and

subsequent years.

Subsec. (h)(2)(B). Pub. L. 100-203, Sec. 4064(a)(2), as added by

Pub. L. 100-360, Sec. 411(g)(3)(A), inserted subpar. (B)

designation preceding second sentence and redesignated former

subpars. (A) and (B) of par. (2) as cls. (i) and (ii).

Subsec. (h)(4)(B)(i). Pub. L. 100-203, Sec. 4064(b)(2)(A),

substituted "April" for "January".

Subsec. (h)(4)(B)(ii). Pub. L. 100-203, Sec. 4064(b)(2)(B),

amended cl. (ii) generally. Prior to amendment, cl. (ii) read as

follows: "after December 31, 1987, and so long as a fee schedule

for the test has not been established on a nationwide basis, is

equal to 110 percent of the median of all the fee schedules

established for that test for that laboratory setting under

paragraph (1)."

Subsec. (h)(5)(A). Pub. L. 100-203, Sec. 4085(i)(22)(B), as added

by Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), substituted "on an

assignment-related basis" for "on the basis of an assignment

described in section 1395u(b)(3)(B)(ii) of this title, under the

procedure described in section 1395gg(f)(1) of this title," in

introductory provisions.

Subsec. (h)(5)(A)(iii). Pub. L. 100-203, Sec. 4085(i)(3), added

cl. (iii).

Subsec. (h)(5)(C). Pub. L. 100-203, Sec. 4085(i)(22)(B), as added

by Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), substituted "on an

assignment-related basis" for "on the basis of an assignment

described in section 1395u(b)(3)(B)(ii) of this title, in

accordance with section 1395u(b)(6)(B) of this title, under the

procedure described in section 1395gg(f)(1) of this title,".

Subsec. (h)(5)(D). Pub. L. 100-203, Sec. 4085(b)(1), added

subpar. (D).

Subsec. (i)(2)(A)(iii). Pub. L. 100-203, Sec. 4063(b), added cl.

(iii).

Subsec. (i)(3)(B)(ii). Pub. L. 100-203, Sec. 4068(a)(1),

substituted "Subject to the last sentence of this clause, in" for

"In".

Pub. L. 100-203, Sec. 4068(a)(2), inserted sentence at end

relating to cost and ASC proportions in the case of an eye or eye

and ear specialty hospital.

Subsec. (i)(4). Pub. L. 100-203, Sec. 4055(a)(3), formerly Sec.

4054(a)(3), as added and renumbered by Pub. L. 100-360, Sec.

411(f)(12)(A), (14), struck out par. (4) which read as follows: "In

the case of services (including all pre- and post-operative

services) described in paragraphs (1) and (2)(A) of section

1395x(s) of this title and furnished in connection with surgical

procedures (specified pursuant to paragraph (1) of this subsection)

in a physician's office, an ambulatory surgical center described in

such paragraph, or a hospital outpatient department, payment for

such services shall be determined in accordance with subsection

(a)(1)(F) of this section if the physician accepts an assignment

described in section 1395u(b)(3)(B)(ii) of this title with respect

to payment for such services."

Subsec. (i)(6). Pub. L. 100-203, Sec. 4063(e)(1), as added by

Pub. L. 100-360, Sec. 411(g)(2)(E), added par. (6).

Subsec. (l)(2). Pub. L. 100-203, Sec. 4084(a)(1), substituted

"1985 and such other data as the Secretary determines necessary"

for "1985".

Pub. L. 100-203, Sec. 4042(b)(2)(B), as added by Pub. L. 100-360,

Sec. 411(f)(2)(D), substituted "1395u(i)(3)" for

"1395u(b)(4)(E)(ii)".

Subsec. (l)(5)(A). Pub. L. 100-203, Sec. 4084(a)(2), substituted

"group practice, or ambulatory surgical center" for "or group

practice" in two places.

Subsec. (l)(5)(B)(ii). Pub. L. 100-203, Sec. 4085(i)(23), as

added by Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), substituted "money

penalty" for "monetary penalty" and amended second sentence

generally. Prior to amendment, second sentence read as follows:

"Such a penalty shall be imposed in the same manner as civil

monetary penalties are imposed under section 1320a-7a of this title

with respect to actions described in subsection (a) of that

section."

Subsec. (l)(6). Pub. L. 100-203, Sec. 4045(c)(2)(A)(i), (ii),

struck out subpar. (A) designation and substituted "after the

effective date of the reduction, the physician's actual charge is

subject to a limit under section 1395u(j)(1)(D) of this title." for

"(subject to subparagraph (D)), the physician may not charge the

individual more than the limiting charge (as defined in

subparagraph (B)) plus (for services furnished during the 12-month

period beginning on the effective date of the reduction) 1/2 of

the amount by which the physician's actual charges for the service

for the previous 12-month period exceeds the limiting charge."

Pub. L. 100-203, Sec. 4045(c)(2)(A)(iii), struck out subpars. (B)

to (D) which read as follows:

"(B) In subparagraph (A), the term 'limiting charge' means, with

respect to a service, 125 percent of the prevailing charge for the

service after the reduction referred to in subparagraph (A).

"(C) If a physician knowingly and willfully imposes charges in

violation of subparagraph (A), the Secretary may apply sanctions

against such physician in accordance with subsection (j)(2) of this

section.

"(D) This paragraph shall not apply to services furnished after

the earlier of (i) December 31, 1990, or (ii) one-year after the

date the Secretary reports to Congress, under section 1395w-1(e)(3)

of this title, on the development of the relative value scale under

section 1395w-1 of this title."

Subsec. (m). Pub. L. 100-203, Sec. 4043(a), added subsec. (m).

Subsec. (n). Pub. L. 100-203, Sec. 4066(a)(2), added subsec. (n).

Subsec. (o). Pub. L. 100-203, Sec. 4072(b), as amended by Pub. L.

100-360, Sec. 411(h)(3)(B), as amended by Pub. L. 100-485, Sec.

608(d)(23)(A), added subsec. (o) [originally added as subsec. (f)].

Subsec. (p). Pub. L. 100-203, Sec. 4077(b)(3), formerly Sec.

4077(b)(4), as redesignated and amended by Pub. L. 100-360, Sec.

411(h)(7)(D), (F), inserted "and in the case of qualified

psychologists services for which payment may be made under this

part only pursuant to section 1395x(s)(2)(M) of this title".

Pub. L. 100-203, Sec. 4073(b)(2), formerly Sec. 4073(b)(3), as

redesignated and amended by Pub. L. 100-360, Sec. 411(h)(4)(C),

added subsec. (p) [originally added as subsec. (m)] and inserted

provision relating to monetary penalty for whoever knowingly and

willfully presents, or causes to be presented, to an enrolled

individual a bill or request for payment for described services.

1986 - Subsec. (a)(1)(D). Pub. L. 99-272, Sec. 9401(b)(2)(B),

substituted ", under the procedure described in section

1395gg(f)(1) of this title, or for tests furnished in connection

with obtaining a second opinion required under section

1320c-13(c)(2) of this title (or a third opinion, if the second

opinion was in disagreement with the first opinion)" for "or under

the procedure described in section 1395gg(f)(1) of this title".

Subsec. (a)(1)(D)(i). Pub. L. 99-272, Sec. 9303(b)(1), inserted

", the limitation amount for that test determined under subsection

(h)(4)(B) of this section," after "lesser of the amount determined

under such fee schedule".

Subsec. (a)(1)(F). Pub. L. 99-509, Sec. 9343(e)(2)(A), as amended

by Pub. L. 100-203, Sec. 4085(i)(21)(D)(i), substituted "(i)(4)"

for "(i)(3)".

Subsec. (a)(1)(G). Pub. L. 99-272, Sec. 9401(b)(2)(A), added cl.

(G).

Subsec. (a)(1)(H). Pub. L. 99-509, Sec. 9320(e)(1), added cl.

(H).

Subsec. (a)(2)(A). Pub. L. 99-272, Sec. 9401(b)(2)(C), inserted

", to items and services (other than clinical diagnostic laboratory

tests) furnished in connection with obtaining a second opinion

required under section 1320c-13(c)(2) of this title (or a third

opinion, if the second opinion was in disagreement with the first

opinion)," after "(other than durable medical equipment)".

Subsec. (a)(2)(D). Pub. L. 99-272, Sec. 9401(b)(2)(D),

substituted "to a provider having an agreement under section 1395cc

of this title, or for tests furnished in connection with obtaining

a second opinion required under section 1320c-13(c)(2) of this

title (or a third opinion, if the second opinion was in

disagreement with the first opinion)" for "or to a provider having

an agreement under section 1395cc of this title".

Subsec. (a)(2)(D)(i). Pub. L. 99-272, Sec. 9303(b)(1), inserted

", the limitation amount for that test determined under subsection

(h)(4)(B) of this section," after "lesser of the amount determined

under such fee schedule".

Subsec. (a)(3). Pub. L. 99-272, Sec. 9401(b)(2)(E), inserted "and

for items and services furnished in connection with obtaining a

second opinion required under section 1320c-13(c)(2) of this title,

or a third opinion, if the second opinion was in disagreement with

the first opinion" after "1395x(s)(10)(A) of this title".

Subsec. (a)(4). Pub. L. 99-509, Sec. 9343(a)(1)(A), amended par.

(4) generally. Prior to amendment, par. (4) read as follows: "in

the case of facility services described in subparagraph (F) of

section 1395k(a)(2) of this title, the applicable amount described

in paragraph (2) of subsection (i) of this section."

Subsec. (b)(3). Pub. L. 99-509, Sec. 9343(e)(2)(A), as amended by

Pub. L. 100-203, Sec. 4085(i)(21)(D)(i), which directed that cl.

(3) be amended by striking "or under subsection (i)(2) or (i)(4) of

this section", was executed by striking "or under subsection (i)(2)

or (i)(5) of this section", to reflect the probable intent of

Congress and an earlier amendment by Pub. L. 99-509, Sec.

9343(a)(2), see below.

Pub. L. 99-509, Sec. 9343(a)(2), substituted "(i)(5)" for

"(i)(4)".

Subsec. (b)(5). Pub. L. 99-272, Sec. 9401(b)(1), added cl. (5).

Subsec. (g). Pub. L. 99-509, Sec. 9337(b), substituted "second

sentence" for "next to last sentence", and inserted at end "In the

case of outpatient occupational therapy services which are

described in the second sentence of section 1395x(p) of this title

through the operation of section 1395x(g) of this title, with

respect to expenses incurred in any calendar year, no more than

$500 shall be considered as incurred expenses for purposes of

subsections (a) and (b) of this section."

Subsec. (h)(1)(B). Pub. L. 99-509, Sec. 9339(b)(1), substituted

"December 31, 1989" and "January 1, 1990" for "December 31, 1987"

and "January 1, 1988", respectively.

Pub. L. 99-509, Sec. 9339(a)(1)(A), substituted "qualified

hospital laboratory (as defined in subparagraph (D))" for "hospital

laboratory".

Pub. L. 99-272, Sec. 9303(a)(1)(A), substituted "December 31,

1987" for "June 30, 1987" and "January 1, 1988" for "July 1, 1987".

Subsec. (h)(1)(C). Pub. L. 99-509, Sec. 9339(a)(1)(B),

substituted "qualified hospital laboratory (as defined in

subparagraph (D))" for "hospital laboratory", struck out ", and

ending on December 31, 1987" after "July 1, 1984", and struck out

"For such tests furnished on or after January 1, 1988, the fee

schedule under subparagraph (A) shall not apply with respect to

clinical diagnostic laboratory tests performed by a hospital

laboratory for outpatients of such hospital." which constituted

second sentence.

Pub. L. 99-272, Sec. 9303(a)(1)(A), substituted "December 31,

1987" for "June 30, 1987" and "January 1, 1988" for "July 1, 1987".

Subsec. (h)(1)(D). Pub. L. 99-509, Sec. 9339(a)(1)(C), added

subpar. (D).

Subsec. (h)(2). Pub. L. 99-509, Sec. 9339(b)(2), struck out "(or,

effective January 1, 1988, for the United States)" after

"applicable region, State, or area".

Pub. L. 99-509, Sec. 9339(a)(1)(D), substituted "qualified

hospital laboratory (as defined in paragraph (1)(D))" for "hospital

laboratory".

Pub. L. 99-272, Sec. 9303(a)(1), substituted "January 1, 1988"

for "July 1, 1987", and inserted "(to become effective on January 1

of each year)" after "adjusted annually".

Subsec. (h)(3). Pub. L. 99-509, Sec. 9339(c)(1), inserted cl. (A)

designation after "provide for and establish", and added cl. (B).

Subsec. (h)(4). Pub. L. 99-272, Sec. 9303(b)(2), designated

existing provisions as subpar. (A) and added subpar. (B).

Subsec. (h)(5)(C). Pub. L. 99-272, Sec. 9303(b)(3), substituted

"laboratory other than" for "laboratory which is independent of a

physician's office or".

Subsec. (i)(1). Pub. L. 99-509, Sec. 9343(b)(2), inserted at end

"The lists of procedures established under subparagraphs (A) and

(B) shall be reviewed and updated not less often than every 2

years."

Subsec. (i)(2). Pub. L. 99-509, Sec. 9343(e)(2)(B), inserted "80

percent of" before "a standard overhead amount" in introductory

provisions of subpars. (A) and (B).

Pub. L. 99-509, Sec. 9343(b)(1), substituted "shall be reviewed

and updated not later than July 1, 1987, and annually thereafter"

for "shall be reviewed periodically" in concluding provisions of

subpars. (A) and (B).

Subsec. (i)(3) to (5). Pub. L. 99-509, Sec. 9343(a)(1)(B), added

par. (3) and redesignated former pars. (3) and (4) as (4) and (5),

respectively.

Subsec. (l). Pub. L. 99-509, Sec. 9320(e)(2), added subsec. (l).

1984 - Subsec. (a)(1). Pub. L. 98-369, Sec. 2354(b)(7), struck

out "and" at the end.

Subsec. (a)(1)(B). Pub. L. 98-369, Sec. 2323(b)(1), substituted

"section 1395x(s)(10)(A) of this title" for "section 1395x(s)(10)

of this title".

Subsec. (a)(1)(D). Pub. L. 98-369, Sec. 2303(a), amended cl. (D)

generally. Prior to amendment, cl. (D) read as follows: "with

respect to diagnostic tests performed in a laboratory for which

payment is made under this part to the laboratory, the amounts paid

shall be equal to 100 percent of the negotiated rate for such tests

(as determined pursuant to subsection (h) of this section),".

Subsec. (a)(1)(F), (G). Pub. L. 98-369, Sec. 2305(a),

redesignated cl. (G) as (F), and struck out former cl. (F) which

related to payment of reasonable charges for preadmission

diagnostic services furnished by a physician to individuals

enrolled under this part which are furnished in the outpatient

department of a hospital within seven days of such individual's

admission to the same hospital or another hospital or furnished in

the physician's office within seven days of such individual's

admission to a hospital as an inpatient.

Subsec. (a)(2). Pub. L. 98-369, Sec. 2305(c), struck out "and in

paragraph (5) of this subsection" after "of such section".

Subsec. (a)(2)(A). Pub. L. 98-617, Sec. 3(b)(2), 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 provision),".

Pub. L. 98-369, Sec. 2354(b)(5), realigned margin of subpar. (A).

Pub. L. 98-369, Sec. 2321(b)(1), inserted in provision preceding

cl. (i) "(other than durable medical equipment)".

Pub. L. 98-369, Sec. 2323(b)(1), substituted "section

1395x(s)(10)(A) of this title" for "section 1395x(s)(10) of this

title".

Subsec. (a)(2)(B). Pub. L. 98-369, Sec. 2354(b)(5), realigned

margin of subpar. (B).

Pub. L. 98-369, Sec. 2321(b)(2), inserted in provision preceding

cl. (i) "items and" after "to other".

Pub. L. 98-369, Sec. 2303(b)(1), inserted "or (D)" after

"subparagraph (C)".

Subsec. (a)(2)(B)(ii). Pub. L. 98-369, Sec. 2308(b)(2)(B),

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 clause),".

Subsec. (a)(2)(D). Pub. L. 98-369, Sec. 2303(b)(2)-(4), added

subpar. (D).

Subsec. (a)(3). Pub. L. 98-369, Sec. 2323(b)(1), substituted

"section 1395x(s)(10)(A) of this title" for "section 1395x(s)(10)

of this title".

Subsec. (a)(5). Pub. L. 98-369, Sec. 2305(b), struck out par. (5)

which related to payment of reasonable costs for preadmission

diagnostic services described in section 1395x(s)(2)(C) of this

title furnished to an individual by the outpatient department of a

hospital within seven days of such individual's admission to the

same hospital as an inpatient or to another hospital.

Subsec. (b)(1). Pub. L. 98-369, Sec. 2323(b)(2), substituted

"section 1395x(s)(10)(A) of this title" for "section 1395x(s)(10)

of this title".

Subsec. (b)(3). Pub. L. 98-369, Sec. 2305(d), substituted

"subsection (a)(1)(F)" for "subsection (a)(1)(G)".

Subsec. (b)(4). Pub. L. 98-369, Sec. 2303(c), added cl. (4).

Subsec. (f). Pub. L. 98-369, Sec. 2321(d)(4)(A), transferred

subsec. (f) to part C of this subchapter and redesignated its

provisions as section 1889 of the Social Security Act, which is

classified to section 1395zz of this title.

Subsec. (h). Pub. L. 98-369, Sec. 2303(d), amended subsec. (h)

generally, substituting provisions directing the Secretary to

establish fee schedules for clinical diagnostic laboratory tests at

a percentage of the prevailing charge level and nominal fees to

cover costs in collecting samples and authorizing the Secretary to

make adjustments in the fee schedule, setting forth the recipients

of payments, and authorizing the Secretary to establish a

negotiated payment rate for provision authorizing the Secretary to

establish a negotiated rate of payment with the laboratory which

would be considered the full charge for such tests.

Subsec. (h)(5)(C). Pub. L. 98-617, Sec. 3(b)(3), inserted a comma

before "under the procedure described in section".

Subsec. (i)(3). Pub. L. 98-369, Sec. 2305(d), substituted

"subsection (a)(1)(F)" for "subsection (a)(1)(G)".

Subsec. (k). Pub. L. 98-369, Sec. 2323(b)(4), added subsec. (k).

1982 - Subsec. (a)(1)(B). Pub. L. 97-248, Sec. 112(a)(1),

substituted provisions that with respect to items and services

described in section 1395x(s)(10) of this title, amounts paid shall

be 100 percent of reasonable charges for such items and services

for provision that with respect to expenses incurred for

radiological or pathological services for which payment could be

made under this part, furnished to any inpatient of a hospital by a

physician in field of radiology or pathology who had in effect an

agreement with Secretary by which the physician agreed to accept an

assignment (as provided for in section 1395u(b)(3)(B)(ii) of this

title) for all physicians' services furnished by him to hospital

inpatients enrolled under this part, the amounts paid would be

equal to 100 percent of the reasonable charges for such services.

Subsec. (a)(1)(H). Pub. L. 97-248, Sec. 112(a)(2), (3), struck

out cl. (H) which provided that, with respect to items and services

described in section 1395x(s)(10) of this title, the amount of

benefits paid would be 100 percent of reasonable charges for such

items and services.

Subsec. (a)(2)(B). Pub. L. 97-248, Sec. 101(c)(2), inserted "and

except as may be provided in section 1395ww of this title".

Subsec. (b)(1). Pub. L. 97-248, Sec. 112(b), struck out subcl.

(A) provision that total amount of expenses shall not include

expenses incurred for radiological or pathological services

furnished an individual as an inpatient of a hospital by a

physician in field of radiology or pathology who has an agreement

with Secretary by which physician agrees to accept an assignment

(as provided for in section 1395u(b)(3)(B)(ii) of this title) for

all physicians' services furnished by him to hospital inpatients

under this part, and redesignated subcl. (B) provisions as cl. (1).

Subsec. (i)(1). Pub. L. 97-248, Sec. 148(d), struck out

requirement of consultation with National Professional Standards

Review Council.

Subsec. (j). Pub. L. 97-248, Sec. 117(a)(2), added subsec. (j).

1981 - Subsec. (a)(2)(A). Pub. L. 97-35, Sec. 2106(a),

substituted provisions that with respect to home health services

and to items and services described in section 1395x(s)(10) of this

title, the lesser of reasonable cost of such services as determined

under section 1395x(v) of this title or customary charges with

respect to such services, or if such services are furnished by a

public provider of services free of charge or at nominal charges to

the public, the amount determined in accordance with section

1395f(b)(2) of this title for provisions that with respect to home

health services and to items and services described in section

1395x(s)(10) of this title, the reasonable cost of such services,

as determined under section 1395x(v) of this title.

Subsec. (a)(2)(B). Pub. L. 97-35, Sec. 2106(a), substituted new

formula in cls. (i) to (iii) with respect to other services for

provisions providing for reasonable costs of such services less the

amount a provider may charge as described in section

1395cc(a)(2)(A) of this title and that in no case may payment for

such other services exceed 80 percent of such costs.

Subsec. (b). Pub. L. 97-35, Secs. 2133(a), 2134(a), redesignated

cls. (2) to (4) as (1) to (3), and struck out former cl. (1), which

provided that amount of deductible for such calendar year as so

determined shall first be reduced by amount of any expenses

incurred by such individual in last three months of preceding

calendar year and applied toward such individual's deductible under

this section for such preceding year.

Pub. L. 97-35, Sec. 2134(a), substituted "by a deductible of $75"

for "by a deductible of $60".

1980 - Subsec. (a)(1)(B). Pub. L. 96-499, Sec. 943(a), inserted

"who has in effect an agreement with the Secretary by which the

physician agrees to accept an assignment (as provided for in

section 1395u(b)(3)(B)(ii) of this title) for all physicians'

services furnished by him to hospital inpatients enrolled under

this part" after "radiology or pathology".

Subsec. (a)(1)(D). Pub. L. 96-499, Sec. 918(a)(4), substituted

"subsection (h)" for "subsection (g)".

Subsec. (a)(1)(F). Pub. L. 96-499, Sec. 932(a)(1)(B), added cl.

(F).

Subsec. (a)(1)(G). Pub. L. 96-499, Sec. 934(d)(1), added cl. (G).

Subsec. (a)(1)(H). Pub. L. 96-611, Sec. 1(b)(1)(A), (B), added

cl. (H).

Subsec. (a)(2). Pub. L. 96-611, Sec. 1(b)(1)(C), inserted in

subpar. (A) "and to items and services described in section

1395x(s)(10) of this title".

Pub. L. 96-499, Sec. 942, authorized payment of reasonable cost

of home health services and prescribed formulae for determining

payment amounts for services other than home health services.

Subsec. (a)(3). Pub. L. 96-611, Sec. 1(b)(1)(D), inserted "(other

than for items and services described in section 1395x(s)(10) of

this title)".

Pub. L. 96-499, Sec. 942, prescribed a formula for determining

payment amounts for services described in subpars. (D) and (E) of

section 1395k(a)(2) of this title.

Subsec. (a)(4), (5). Pub. L. 96-499, Sec. 942, added pars. (4)

and (5).

Subsec. (b)(2). Pub. L. 96-611, Sec. 1(b)(2), inserted "(A)"

after "expenses incurred" and added cl. (B).

Pub. L. 96-499, Sec. 943(a), inserted "who has in effect an

agreement with the Secretary by which the physician agrees to

accept an assignment (as provided for in section 1395u(b)(3)(B)(ii)

of this title) for all physicians' services furnished by him to

hospital inpatients enrolled under this part".

Subsec. (b)(3). Pub. L. 96-499, Sec. 930(h)(2), added cl. (3).

Subsec. (b)(4). Pub. L. 96-499, Sec. 934(d)(3), added cl. (4).

Subsec. (g). Pub. L. 96-499, Sec. 935(a), substituted "$500" for

"$100".

Subsec. (h). Pub. L. 96-473 redesignated subsec. (g) as added by

section 279(b) of Pub. L. 92-603 as (h), which for purposes of

codification had been editorially set out as subsec. (h), thereby

requiring no change in text. See 1972 Amendment note below.

Subsec. (i). Pub. L. 96-499, Sec. 934(b), added subsec. (i).

1978 - Subsec. (a)(1)(E). Pub. L. 95-292, Sec. 4(b)(2), added cl.

(E).

Subsec. (a)(2). Pub. L. 95-292, Sec. 4(c), inserted "(unless

otherwise specified in section 1395rr of this title)" after "and

with respect to other services" in provisions preceding subpar.

(A).

1977 - Subsec. (a)(2). Pub. L. 95-210, Sec. 1(b)(2), inserted

parenthetical provisions preceding subpar. (A) excepting those

services described in subparagraph (D) of section 1395k(a)(2) of

this title.

Subsec. (a)(3). Pub. L. 95-210, Sec. 1(b)(1), (3), (4), added

par. (3).

Subsec. (f)(1). Pub. L. 95-142 substituted provisions relating to

determinations by Secretary with respect to presumptions regarding

purchase price or practicality of buying or renting durable medical

equipment, for provisions relating to purchase price of durable

medical equipment authorized to be paid by Secretary.

Subsec. (f)(2). Pub. L. 95-142 substituted provisions relating to

waiver of coinsurance amount in purchase of used durable medical

equipment, for provisions relating to reimbursement procedures

established by Secretary in cases of rental of durable medical

equipment.

Subsec. (f)(3), (4). Pub. L. 95-142 added pars. (3) and (4).

1972 - Subsec. (a). Pub. L. 92-603, Sec. 226(c)(2), inserted

reference to section 1395mm of this title in provisions preceding

par. (1).

Subsec. (a)(1). Pub. L. 92-603, Secs. 211(c)(4), 279(a), added

cls. (C) and (D).

Subsec. (a)(2). Pub. L. 92-603, Secs. 233(b), 251(a)(3), 299K(a),

substituted subpars. (A) and (B) for provisions relating to the

amount payable by reference to section 1395x(v) of this title,

added subpar. (C), and in provisions preceding subpar. (A),

inserted "with respect to home health services, 100 percent, and

with respect to other services," before "80 percent".

Subsec. (b). Pub. L. 92-603, Sec. 204(a), substituted "$60" for

"$50".

Subsec. (f). Pub. L. 92-603, Sec. 245(d), designated existing

provisions as par. (1)(A) and added par. (1)(B) and (2).

Subsec. (g). Pub. L. 92-603, Sec. 251(a)(2), added subsec. (g).

Subsec. (h). Pub. L. 92-603, Sec. 279(b), added subsec. (h).

Subsec. was in the original (g) and was changed to accommodate

subsec. (g) as added by section 251(a)(2) of Pub. L. 92-603.

1968 - Subsec. (a)(1). Pub. L. 90-248, Sec. 131(a)(1), (2),

designated existing provisions as subpar. (A) and added subpar.

(B).

Subsec. (b). Pub. L. 90-248, Secs. 129(c)(7), 131(b), struck out

reference in cl. (1) to expenses regarded under former cl. (2) as

incurred for services furnished in last three months of preceding

year, struck out former cl. (2) which provided that amount of any

deduction imposed by section 1395e(a)(2)(A) of this title for

outpatient hospital diagnostic services furnished in any calendar

year is to be regarded as an incurred expense for such year; and

added cl. (2).

Pub. L. 90-248, Sec. 135(c), inserted last sentence providing

that there shall be a deductible equal to expenses incurred for

first three pints of whole blood (or equivalent quantities of

packed red blood cells as defined under regulations) furnished to

an individual during a calendar year which deductible is to be

appropriately reduced to extent that such blood has been replaced,

and such blood will be deemed to have been replaced when

institution or person furnishing such blood is given one pint of

blood for each pint of blood (or equivalent quantities of packed

red blood cells) furnished individual to which three pint

deductible applies.

Subsec. (d). Pub. L. 90-248, Sec. 129(c)(8), struck out reference

to subsection (a)(2)(A) of section 1395e of this title.

Subsec. (f). Pub. L. 90-248, Sec. 132(b), added subsec. (f).

EFFECTIVE DATE OF 2000 AMENDMENT

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 105(e)], Dec. 21,

2000, 114 Stat. 2763, 2763A-472, provided that: "The amendments

made by this section [amending this section and sections 1395u and

1395x of this title] shall apply to services furnished on or after

January 1, 2002."

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 111(a)(2)], Dec. 21,

2000, 114 Stat. 2763, 2763A-473, provided that: "The amendment made

by paragraph (1) [amending this section] shall apply with respect

to services furnished on or after April 1, 2001."

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 201(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-481, provided that: "The amendment made

-

"(1) by subsection (a) [amending section 1395m of this title]

shall apply to services furnished on or after the date of the

enactment of BBRA [Pub. L. 106-113, Sec. 1000(a)(6), approved

Nov. 29, 1999];

"(2) by subsection (b)(1) [amending this section] shall apply

as if included in the enactment of section 403(e)(1) of BBRA (113

Stat. 1501A-371) [Pub. L. 106-113, Sec. 1000(a)(6) [title IV,

Sec. 403(e)(1)]]; and

"(3) by subsection (b)(2) [amending provisions set out as a

note under section 1395m of this title] shall apply as if

included in the enactment of section 403(d)(2) of BBRA (113 Stat.

1501A-371) [Pub. L. 106-113, Sec. 1000(a)(6) [title IV, Sec.

403(d)(2)], set out as a note under section 1395m of this

title]."

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 205(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-483, provided that: "The amendments

made by this section [amending this section and section 1395m of

this title] shall apply to services furnished on or after the date

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

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 223(e)], Dec. 21,

2000, 114 Stat. 2763, 2763A-490, provided that: "The amendments

made by subsections (b) and (c) [amending this section and section

1395m of this title] shall be effective for services furnished on

or after October 1, 2001."

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 224(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-490, provided that: "The amendment made

by subsection (a) [amending this section] shall apply to services

furnished on or after July 1, 2001."

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 401(b)(2)], Dec.

21, 2000, 114 Stat. 2763, 2763A-503, provided that: "The amendments

made by paragraph (1) [amending this section] shall take effect as

if included in the enactment of BBA [Pub. L. 105-33]."

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 402(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-505, provided that: "The amendments

made by this section [amending this section] take effect on the

date of the enactment of this Act [Dec. 21, 2000]."

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 403(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-506, provided that: "The amendment made

by subsection (a) [amending this section] shall take effect as if

included in the enactment of BBRA [Pub. L. 106-113, Sec.

1000(a)(6)]."

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 405(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-507, provided that: "The amendments

made by subsection (a) [amending this section] shall apply as if

included in the enactment of section 202 of BBRA [Pub. L. 106-113,

Sec. 1000(a)(6) [title II, Sec. 202]] (113 Stat. 1501A-342)."

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 406(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-508, provided that: "The amendment made

by subsection (a) [amending this section] shall apply to devices

furnished on or after April 1, 2001."

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 430(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-525, provided that: "The amendments

made by this section [amending this section and section 1395x of

this title] apply to items and services furnished on or after July

1, 2001."

EFFECTIVE DATE OF 1999 AMENDMENT

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec.

201(h)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-340, provided

that: "The Secretary of Health and Human Services shall first

conduct the annual review under the amendment made by paragraph

(1)(A) [amending this section] in 2001 for application in 2002 and

the amendment made by paragraph (1)(B) [amending this section]

takes effect on the date of the enactment of this Act [Nov. 29,

1999]."

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 201(m)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-341, provided that: "Except as

provided in this section, the amendments made by this section

[amending this section and sections 1395m and 1395x of this title]

shall be effective as if included in the enactment of BBA [the

Balanced Budget Act of 1997, Pub. L. 105-33]."

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 202(b)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-344, provided that: "The

amendments made by this section [amending this section] shall be

effective as if included in the enactment of BBA [the Balanced

Budget Act of 1997, Pub. L. 105-33]."

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 204(c)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-345, provided that: "The

amendments made by this section [amending this section] apply as if

included in the enactment of BBA [the Balanced Budget Act of 1997,

Pub. L. 105-33] and shall only apply to procedures performed for

which payment is made on the basis of the prospective payment

system under section 1833(t) of the Social Security Act [subsec.

(t) of this section]."

Amendment by section 1000(a)(6) [title III, Sec. 321(g)(2),

(k)(2)] of Pub. L. 106-113 effective as if included in the

enactment of the Balanced Budget Act of 1997, Pub. L. 105-33,

except as otherwise provided, see section 1000(a)(6) [title III,

Sec. 321(m)] of Pub. L. 106-113, set out as a note under section

1395d of this title.

Amendment by section 1000(a)(6) [title IV, Sec. 401(b)(1)] of

Pub. L. 106-113 effective Jan. 1, 2000, see section 1000(a)(6)

[title IV, Sec. 401(c)] of Pub. L. 106-113, set out as a note under

section 1395i-4 of this title.

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

403(e)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-371, provided

that: "The amendments made by paragraph (1) [amending this section]

shall apply to services furnished on or after the date of the

enactment of this Act [Nov. 29, 1999]."

EFFECTIVE DATE OF 1997 AMENDMENT

Section 4002(j)(1)(B) of Pub. L. 105-33 provided that: "The

amendment made by subparagraph (A) [amending this section] applies

to new contracts entered into after the date of enactment of this

Act [Aug. 5, 1997] and, with respect to contracts in effect as of

such date, shall apply to payment for services furnished after

December 31, 1998."

Section 4101(d) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and section 1395m of

this title] shall apply to items and services furnished on or after

January 1, 1998."

Section 4102(e) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and sections 1395w-4,

1395x, and 1395y of this title] shall apply to items and services

furnished on or after January 1, 1998."

Section 4103(e) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and sections 1395w-4,

1395x, and 1395y of this title] shall apply to items and services

furnished on or after January 1, 2000."

Section 4104(e) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and sections 1395m,

1395w-4, 1395x, and 1395y of this title] shall apply to items and

services furnished on or after January 1, 1998."

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 4205(a)(1)(B) of Pub. L. 105-33 provided that: "The

amendment made by subparagraph (A) [amending this section] applies

to services furnished on or after January 1, 1998."

Section 4315(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and section 1395u of

this title] to the extent such amendments substitute fee schedules

for reasonable charges, shall apply to particular services as of

the date specified by the Secretary of Health and Human Services."

Amendment by section 4432(b)(5)(C) of Pub. L. 105-33 applicable

to items and services furnished on or after July 1, 1998, see

section 4432(d) of Pub. L. 105-33, set out as a note under section

1395i-3 of this title.

Amendment by section 4511(b) of Pub. L. 105-33 applicable with

respect to services furnished and supplies provided on and after

Jan. 1, 1998, see section 4511(e) of Pub. L. 105-33, set out as a

note under section 1395k of this title.

Section 4512(d) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and sections 1395u and

1395x of this title] shall apply with respect to services furnished

and supplies provided on and after January 1, 1998."

Section 4521(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section] shall apply to

services furnished during portions of cost reporting periods

occurring on or after October 1, 1997."

Section 4523(d)(1)(A)(ii) of Pub. L. 105-33 provided that: "The

amendment made by clause (i) [amending this section] shall apply to

services furnished on or after January 1, 1999."

Section 4531(b)(3) of Pub. L. 105-33 provided that: "The

amendments made by this subsection [amending this section and

section 1395m of this title] shall apply to services furnished on

or after January 1, 2000."

Section 4541(e) of Pub. L. 105-33 provided that:

"(1) The amendments made by subsections (a)(1), (a)(2), and (b)

[amending this section and sections 1395m and 1395y of this title]

apply to services furnished on or after January 1, 1998, including

portions of cost reporting periods occurring on or after such date,

except that section 1834(k) of the Social Security Act [section

1395m(k) of this title] (as added by subsection (a)(2)) shall not

apply to services described in section 1833(a)(8)(B) of such Act

[subsec. (a)(8)(B) of this section] (as added by subsection (a)(1))

that are furnished during 1998.

"(2) The amendments made by subsections (a)(3) and (c) [amending

this section and section 1395cc of this title] apply to services

furnished on or after January 1, 1999.

"(3) The amendments made by subsection (d)(1) [amending this

section] apply to expenses incurred on or after January 1, 1999."

Section 4556(d) of Pub. L. 105-33 provided that: "The amendments

made by subsections (a) and (b) [amending this section and section

1395u of this title] shall apply to drugs and biologicals furnished

on or after January 1, 1998."

Amendment by section 4603(c)(2)(A) 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.

EFFECTIVE DATE OF 1994 AMENDMENT

Section 123(f)(1), (2) of Pub. L. 103-432 provided that:

"(1) Enforcement; miscellaneous and technical amendments. - The

amendments made by subsections (a) and (e) [amending this section

and section 1395w-4 of this title] shall apply to services

furnished on or after the date of the enactment of this Act [Oct.

31, 1994]; except that the amendments made by subsection (a)

[amending section 1395w-4 of this title] shall not apply to

services of a nonparticipating supplier or other person furnished

before January 1, 1995.

"(2) Practitioners. - The amendments made by subsection (b)

[amending this section and section 1395u of this title] shall apply

to services furnished on or after January 1, 1995."

Section 141(c)(2) of Pub. L. 103-432 provided that: "The

amendments made by paragraph (1) [amending this section] shall take

effect as if included in the enactment of OBRA-1990 [Pub. L.

101-508]."

Amendment by section 147(a), (e)(2), (3), (f)(6)(C), (D) of Pub.

L. 103-432 effective as if included in the enactment of Pub. L.

101-508, see section 147(g) of Pub. L. 103-432, set out as a note

under section 1320a-3a of this title.

Section 147(d)(1), (2) of Pub. L. 103-432 provided that the

amendment made by that section is effective as if included in the

enactment of Pub. L. 101-239.

Amendment by section 156(a)(2)(B) of Pub. L. 103-432 applicable

to services provided on or after Oct. 31, 1994, see section

156(a)(3) of Pub. L. 103-432, set out as a note under section

1320c-3 of this title.

EFFECTIVE DATE OF 1993 AMENDMENT

Section 13532(b) of Pub. L. 103-66 provided that: "The amendments

made by subsection (a) [amending this section] shall apply to

portions of cost reporting periods beginning on or after January 1,

1994."

Section 13544(b)(3) of Pub. L. 103-66 provided that: "The

amendments made by this subsection [amending this section and

section 1395m of this title] shall apply to items furnished on or

after January 1, 1994."

Section 13555(b) of Pub. L. 103-66 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

services furnished on or after January 1, 1994."

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4104(d) of Pub. L. 101-508 provided that: "The amendments

made by this section [amending this section and sections 1395m and

1395w-4 of this title] shall apply to services furnished on or

after January 1, 1991."

Amendment by section 4153(a)(2)(B), (C) of Pub. L. 101-508

applicable to items furnished on or after Jan. 1, 1991, see section

4153(a)(3) of Pub. L. 101-508, set out as a note under section

1395k of this title.

Section 4154(b)(2) of Pub. L. 101-508 provided that: "The

amendments made by paragraph (1) [amending this section] shall

apply to tests furnished on or after January 1, 1991."

Section 4154(c)(2) of Pub. L. 101-508 provided that: "The

amendment made by paragraph (1)(A) [amending this section] shall

take effect as if included in the enactment of the Consolidated

Omnibus Budget Reconciliation Act of 1985 [Pub. L. 99-272], and the

amendment made by paragraph (1)(B) [amending this section] shall

take effect as if included in the enactment of the Omnibus Budget

Reconciliation Act of 1987 [Pub. L. 100-203]."

Section 4154(e)(5) of Pub. L. 101-508, as amended by Pub. L.

103-432, title I, Sec. 147(f)(2), Oct. 31, 1994, 108 Stat. 4431,

provided that: "The amendments made by paragraphs (1)(A), (1)(B),

(2), and (4) [amending this section, section 1395w-2 of this title,

and provisions set out as a note below] shall take effect as if

included in the enactment of the Omnibus Budget Reconciliation Act

of 1989 [Pub. L. 101-239], and the amendment made by paragraph

(1)(C) [amending this section] shall take effect January 1, 1991."

Amendment by section 4155(b)(2), (3) of Pub. L. 101-508

applicable to services furnished on or after Jan. 1, 1991, see

section 4155(e) of Pub. L. 101-508, set out as a note under section

1395k of this title.

Amendment by section 4161(a)(3)(B) of Pub. L. 101-508 applicable

to services furnished on or after Oct. 1, 1991, see section

4161(a)(8) of Pub. L. 101-508, set out as a note under section

1395k of this title.

Section 4163(e) of Pub. L. 101-508, as amended by Pub. L.

103-432, title I, Sec. 147(f)(5)(B), Oct. 31, 1994, 108 Stat. 4431,

provided that: "Except as provided in subsection (d)(3) [enacting

provisions set out as a note under section 1395y of this title],

the amendments made by this section [amending this section and

sections 1395m, 1395x, 1395y, 1395z, 1395aa, and 1395bb of this

title] shall apply to screening mammography performed on or after

January 1, 1991."

Section 4206(e)(2) of Pub. L. 101-508 provided that: "The

amendments made by subsection (b) [amending this section and

section 1395mm of this title] shall apply to contracts under

section 1876 of the Social Security Act [section 1395mm of this

title] and payments under section 1833(a)(1)(A) of such Act

[subsec. (a)(1)(A) of this section] as of 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 AMENDMENTS

Section 6102(c)(2) of Pub. L. 101-239 provided that: "The

amendments made by paragraph (1) [amending this section] shall

apply to services furnished on or after January 1, 1991."

Section 6102(f)(3) of Pub. L. 101-239 provided that: "The

amendments made by this subsection [amending this section and

section 1395m of this title] shall apply to services furnished on

or after January 1, 1991."

Section 6102(g) of Pub. L. 101-239 provided that: "Except as

otherwise provided in this section, this section, and the

amendments made by this section [enacting section 1395w-4 of this

title, amending this section and sections 1395m, 1395u, and 1395rr

of this title, and enacting provisions set out as notes under this

section and sections 1395m, 1395u, and 1395w-4 of this title],

shall take effect on the date of the enactment of this Act [Dec.

19, 1989]."

Section 6111(b)(2) of Pub. L. 101-239, as amended by Pub. L.

101-508, title IV, Sec. 4154(e)(4), Nov. 5, 1990, 104 Stat.

1388-86, provided that: "The amendment made by paragraph (1)

[amending this section] shall apply with respect to clinical

diagnostic laboratory tests performed on or after May 1, 1990."

Section 6113(e) of Pub. L. 101-239 provided that: "The amendments

made by this section [amending this section and section 1395x of

this title], and the provisions of subsection (c) [set out below],

shall apply to services furnished on or after July 1, 1990, and the

amendments made by subsection (d) [amending this section] shall

apply to expenses incurred in a year beginning with 1990."

Section 6131(c) of Pub. L. 101-239 provided that:

"(1) The amendments made by this section [amending this section

and section 1395x of this title] shall apply with respect to

therapeutic shoes and inserts furnished on or after July 1, 1989.

"(2) In applying the amendments made by this section, the

increase under subparagraph (C) of section 1833(o)(2) of the Social

Security Act [subsec. (o)(2)(C) of this section] shall apply to the

dollar amounts specified under subparagraph (A) of such section (as

amended by this section) in the same manner as the increase would

have applied to the dollar amounts specified under subparagraph (A)

of such section (as in effect before the date of the enactment of

this Act [Dec. 19, 1989])."

Section 6133(b) of Pub. L. 101-239 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

services furnished on or after January 1, 1990."

Amendment by section 6204(b) of Pub. L. 101-239 effective with

respect to referrals made on or after Jan. 1, 1992, see section

6204(c) of Pub. L. 101-239, set out as a note under section 1395nn

of this title.

Amendment by section 201(a) of 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.

Amendment by section 202(a) of Pub. L. 101-234 effective Jan. 1,

1990, see section 202(b) of Pub. L. 101-234, set out as a note

under section 401 of this title.

EFFECTIVE DATE OF 1988 AMENDMENTS

Section 8422(b) of Pub. L. 100-647 provided that: "The amendment

made by subsection (a) [amending this section] shall become

effective as if included in the amendment made by section

9320(e)(2) of the Omnibus Budget Reconciliation Act of 1986 [Pub.

L. 99-509]."

Amendment by Pub. L. 100-485 effective as if included in the

enactment of the Medicare Catastrophic Coverage Act of 1988, Pub.

L. 100-360, see section 608(g) of Pub. L. 100-485, set out as a

note under section 704 of this title.

Amendment by section 202(b)(1)-(3) of Pub. L. 100-360 applicable

to items dispensed on or after Jan. 1, 1990, see section 202(m)(1)

of Pub. L. 100-360, set out as a note under section 1395u of this

title.

Amendment by section 203(c)(1)(A)-(E) 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.

Amendment by section 204(d)(1) of Pub. L. 100-360 applicable to

screening mammography performed on or after Jan. 1, 1990, see

section 204(e) of Pub. L. 100-360, set out as a note under section

1395m of this title.

Amendment by section 205(c) of Pub. L. 100-360 applicable to

items and services furnished on or after Jan. 1, 1990, see section

205(f) of Pub. L. 100-360, set out as a note under section 1395k of

this title.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by section 411(f)(2)(D), (8)(B)(i), (C),

(12)(A), (14), (g)(1)(E), (2)(D), (E), (3)(A)-(F), (4)(C), (5),

(h)(1)(A), (3)(B), (4)(B), (C), (7)(C), (D), (F), (i)(3),

(4)(B)-(C)(ii), (iv), and (vi) 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 4043(c) of Pub. L. 100-203 provided that: "The amendments

made by this [sic] subsection (a) [amending this section] shall

apply with respect to services furnished in a rural area (as

defined in section 1886(d)(2)(D) of the Social Security Act

[section 1395ww(d)(2)(D) of this title]) on or after January 1,

1989, and to other services furnished on or after January 1, 1991."

Amendment by section 4045(c)(2)(A) of Pub. L. 100-203 applicable

to items and services furnished on or after Apr. 1, 1988, see

section 4045(d) of Pub. L. 100-203, set out as a note under section

1395u of this title.

Amendment by section 4049(a)(1) of Pub. L. 100-203 applicable to

services performed on or after Apr. 1, 1989, see section 4049(b)(2)

of Pub. L. 100-203, as amended, set out as a note under section

1395m of this title.

Section 4055(b), formerly Sec. 4054(b), of Pub. L. 100-203, as

added and renumbered by Pub. L. 100-360, title IV, Sec.

411(f)(12)(A), (14), July 1, 1988, 102 Stat. 781, provided that:

"The amendments made by subsection (a) [amending this section]

shall apply to services furnished on or after April 1, 1988."

Amendment by section 4062(d)(3) of Pub. L. 100-203 applicable to

covered items (other than oxygen and oxygen equipment) furnished on

or after Jan. 1, 1989, and to oxygen and oxygen equipment furnished

on or after June 1, 1989, see section 4062(e) of Pub. L. 100-203,

as amended, set out as a note under section 1395f of this title.

Section 4063(c) of Pub. L. 100-203 provided that: "The amendments

made by this section [amending this section and section 1395u of

this title] shall apply to items furnished on or after July 1,

1988."

Section 4064(b)(3) of Pub. L. 100-203 provided that: "The

amendments made by paragraphs (1) and (2) [amending this section]

shall apply with respect to services furnished on or after April 1,

1988."

Section 4064(c)(2) of Pub. L. 100-203, as added by Pub. L.

100-360, title IV, Sec. 411(g)(3)(F), July 1, 1988, 102 Stat. 784,

provided that: "The amendment made by paragraph (1) [amending this

section] shall apply with respect to diagnostic laboratory tests

furnished on or after April 1, 1988."

Section 4066(c) of Pub. L. 100-203 provided that: "The amendments

made by subsection (a) [amending this section] shall apply with

respect to outpatient hospital radiology services furnished on or

after October 1, 1988, and other diagnostic procedures performed on

or after October 1, 1989."

Section 4067(c) of Pub. L. 100-203 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

services furnished on or after April 1, 1988."

Section 4068(c) of Pub. L. 100-203 provided that: "The amendments

made by subsection (a) [amending this section] shall be effective

as if included in the amendment made by section 9343(a)(1)(B) of

the Omnibus Budget Reconciliation Act of 1986 [Pub. L. 99-509]."

Section 4070(c)(1) of Pub. L. 100-203 provided that: "The

amendment made by subsection (a)(1) [amending this section] shall

apply with respect to calendar years beginning with 1988; except

that with respect to 1988, any reference in section 1833(c) of the

Social Security Act [subsec. (c) of this section], as amended by

subsection (a), to '$1375.00' is deemed a reference to '$562.50'.

The amendment made by subsection (a)(2) [amending this section]

shall apply to services furnished on or after January 1, 1989."

For effective date of amendment by section 4072(b) of Pub. L.

100-203, see section 4072(e) of Pub. L. 100-203, set out as a note

under section 1395x of this title.

Amendment by section 4073(b) of Pub. L. 100-203 effective with

respect to services performed on or after July 1, 1988, see section

4073(e) of Pub. L. 100-203, set out as a note under section 1395k

of this title.

Amendment by section 4077(b)(2), (3) of Pub. L. 100-203 effective

with respect to services performed on or after July 1, 1988, see

section 4077(b)(5) of Pub. L. 100-203, set out as a note under

section 1395k of this title.

Section 4084(b) of Pub. L. 100-203 provided that: "The amendments

made by subsection (a) [amending this section] shall apply as if

included in the amendment made by section 9320(e)(2) of the Omnibus

Budget Reconciliation Act of 1986 [Pub. L. 99-509]."

Section 4084(c)(3) of Pub. L. 100-203, as added by Pub. L.

100-360, title IV, Sec. 411(i)(3), July 1, 1988, 102 Stat. 788,

provided that: "The amendments made by this subsection [amending

this section and section 1395x of this title] shall apply to

services furnished after December 31, 1988."

Section 4085(b)(2) of Pub. L. 100-203 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to procedures performed on or after January 1, 1988."

Section 4085(i)(21) of Pub. L. 100-203 provided that the

amendment to section 9343 of Pub. L. 99-509 by section

4085(i)(21)(D) of Pub. L. 100-203, amending this section and

provisions set out as an Effective Date of 1986 Amendments note

below, is effective as if included in the enactment of Pub. L.

99-509.

EFFECTIVE DATE OF 1986 AMENDMENTS

Amendment by section 9320(e)(1), (2) of Pub. L. 99-509 applicable

to services furnished on or after Jan. 1, 1989, with exceptions for

hospitals located in rural areas which meet certain requirements

related to certified registered nurse anesthetists, see section

9320(i), (k) of Pub. L. 99-509, as amended, set out as notes under

section 1395k of this title.

Amendment by section 9337(b) of Pub. L. 99-509 applicable to

expenses incurred for outpatient occupational therapy services

furnished on or after July 1, 1987, see section 9337(e) of Pub. L.

99-509, set out as a note under section 1395k of this title.

Section 9339(a)(2) of Pub. L. 99-509 provided that: "The

amendments made by this subsection [amending this section] apply to

clinical diagnostic laboratory tests performed on or after January

1, 1987."

Section 9339(c)(2) of Pub. L. 99-509 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to samples collected on or after January 1, 1987."

Section 9343(h) of Pub. L. 99-509, as amended by Pub. L. 100-203,

title IV, Sec. 4085(i)(21)(D)(ii), (iii), Dec. 22, 1987, 101 Stat.

1330-134; Pub. L. 100-360, title IV, Sec. 411(i)(4)(C)(v), July 1,

1988, 102 Stat. 789, provided that:

"(1) The amendments made by subsection (a)(1) [amending this

section] shall apply to cost reporting periods beginning on or

after October 1, 1987.

"(2) The amendments made by subsections (b)(1) and (c) [amending

this section and sections 1395y and 1395cc of this title] shall

apply to services furnished after June 30, 1987.

"(3) The Secretary of Health and Human Services shall first

provide, under the amendment made by subsection (b)(2) [amending

this section], for the review and update of procedure lists within

6 months after the date of the enactment of this Act [Oct. 21,

1986].

"(4) The amendments made by subsection (d) [amending section

1320c-3 of this title] shall apply to contracts entered into or

renewed after January 1, 1987."

Section 9303(a)(2) of Pub. L. 99-272 provided that: "The

amendments made by paragraph (1) [amending this section] shall

apply to clinical laboratory diagnostic tests performed on or after

July 1, 1986."

Section 9303(b)(5)(A), (B) of Pub. L. 99-272 provided that:

"(A) The amendments made by paragraphs (1) and (2) [amending this

section] shall apply to clinical diagnostic laboratory tests

performed on or after July 1, 1986.

"(B) The amendment made by paragraph (3) [amending this section]

shall apply to clinical diagnostic laboratory tests performed on or

after January 1, 1987."

EFFECTIVE DATE OF 1984 AMENDMENTS

Amendment by Pub. L. 98-617 effective as if originally included

in the Deficit Reduction Act of 1984, Pub. L. 98-369, see section

3(c) of Pub. L. 98-617, set out as a note under section 1395f of

this title.

Section 2303(j) of Pub. L. 98-369 provided that:

"(1) Except as provided in paragraphs (2) and (3), the amendments

made by this section [amending this section and sections 1395u,

1395cc, 1396a, and 1396b of this title and enacting provisions set

out as notes under this section and section 1395u of this title]

shall apply to clinical diagnostic laboratory tests furnished on or

after July 1, 1984.

"(2) The amendments made by subsection (g)(2) [amending section

1396b of this title] shall apply to payments for calendar quarters

beginning on or after October 1, 1984.

"(3) The amendments made by this section shall not apply to

clinical diagnostic laboratory tests furnished to inpatients of a

provider operating under a waiver granted pursuant to section

602(k) of the Social Security Amendments of 1983 [section 602(k) of

Pub. L. 98-21, set out as a note under section 1395y of this

title]. Payment for such services shall be made under part B of

title XVIII of the Social Security Act [this part] at 80 percent

(or 100 percent in the case of such tests for which payment is made

on the basis of an assignment described in section

1842(b)(3)(B)(ii) of the Social Security Act [section

1395u(b)(3)(B)(ii) of this title] or under the procedure described

in section 1870(f)(1) of such Act [section 1395gg(f)(1) of this

title]) of the reasonable charge for such service. The deductible

under section 1833(b) of such Act [subsec. (b) of this section]

shall not apply to such tests if payment is made on the basis of

such an assignment or procedure."

Section 2305(e) of Pub. L. 98-369 provided that: "The amendments

made by this section [amending this section and enacting provisions

set out below] shall apply to services performed after the date of

the enactment of this Act [July 18, 1984]."

Amendment by section 2321(b), (d)(4)(A) of Pub. L. 98-369

applicable to items and services furnished on or after July 18,

1984, see section 2321(g) of Pub. L. 98-369, set out as a note

under section 1395f of this title.

Section 2323(d) of Pub. L. 98-369 provided that: "The amendments

made by this section [amending this section and sections 1395x,

1395cc, and 1395rr of this title and enacting provisions set out

below] apply to services furnished on or after September 1, 1984."

Amendment by section 2354(b)(5), (7) 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 1982 AMENDMENT

Section 112(c) of Pub. L. 97-248 provided that: "The amendments

made by this section [amending this section] shall apply with

respect to items and services furnished on or after October 1,

1982."

Amendment by section 117(a)(2) of Pub. L. 97-248 applicable to

final determinations made on or after Sept. 3, 1982, see section

117(b) of Pub. L. 97-248, set out as a note under section 1395g of

this title.

Amendment by section 148(d) 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 1981 AMENDMENT

Section 2106(c) of Pub. L. 97-35 provided that: "The amendment

made by subsection (a) [amending this section] is effective as of

December 5, 1980, and the amendment made by subsection (b)(2)

[amending section 1395q(b) of this title], is effective as of April

1, 1981."

Section 2133(b) of Pub. L. 97-35 provided that: "The amendments

made by subsection (a) [amending this section] first apply to the

deductible for calendar year 1982 with respect to expenses incurred

on or after October 1, 1981."

Section 2134(b) of Pub. L. 97-35 provided that: "The amendment

made by subsection (a) [amending this section] shall take effect on

January 1, 1982, and shall apply to the deductible for calendar

years beginning with 1982."

EFFECTIVE DATE OF 1980 AMENDMENTS

Section 2 of Pub. L. 96-611 provided that: "The amendments made

by this Act [probably should be the amendments made by section 1 of

this Act, which amended this section and sections 1395x, 1395y,

1395aa, and 1395cc of this title] shall take effect on, and apply

to services furnished on or after, July 1, 1981."

Amendment by section 930(h) 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 935(b) of Pub. L. 96-499 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

expenses incurred in calendar years beginning with calendar year

1982."

Section 943(b) of Pub. L. 96-499 provided that: "The amendments

made by subsection (a) [amending this section] shall apply to

services furnished after the sixth calendar month beginning after

the date of the enactment of this Act [Dec. 5, 1980]."

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 AMENDMENTS

Amendment by Pub. L. 95-210 applicable to services rendered on or

after first day of third calendar month which begins after Dec. 31,

1977, see section 1(j) of Pub. L. 95-210, set out as a note under

section 1395k of this title.

Section 16(b) of Pub. L. 95-142 provided that: "The amendment

made by subsection (a) [amending this section] shall apply with

respect to durable medical equipment purchased or rented on or

after October 1, 1977."

EFFECTIVE DATE OF 1972 AMENDMENT

Section 204(c) of Pub. L. 92-603 provided that: "The amendments

made by this section [amending this section and section 1395n of

this title] shall be effective with respect to calendar years after

1972 (except that, for purposes of applying clause (1) of the first

sentence of section 1833(b) of the Social Security Act [subsec. (b)

of this section], such amendments shall be deemed to have taken

effect on January 1, 1972)."

Amendment by section 211(c)(4) of Pub. L. 92-603 applicable to

services furnished with respect to admissions occurring after Dec.

31, 1972, see section 211(d) of Pub. L. 92-603, set out as a note

under section 1395f of this title.

Amendment by section 226(c)(2) 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 233(b) of Pub. L. 92-603 applicable to

services furnished by hospitals, extended care facilities, and home

health agencies in accounting periods beginning after Dec. 31,

1972, see section 233(f) of Pub. L. 92-603, set out as a note under

section 1395f of this title. See, also, Pub. L. 93-233, Sec. 16,

Dec. 31, 1973, 87 Stat. 967, set out as a note under section 1395f

of this title.

Amendment by section 251(a)(2), (3) of Pub. L. 92-603 applicable

with respect to services furnished on or after July 1, 1973, see

section 251(d)(1) of Pub. L. 92-603, set out as a note under

section 1395x of this title.

Section 299K(b) of Pub. L. 92-603 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

services furnished by home health agencies in accounting periods

beginning after December 31, 1972."

EFFECTIVE DATE OF 1968 AMENDMENT

Amendment by section 129(c)(7), (8) 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 131(c) of Pub. L. 90-248 provided that: "The amendments

made by this section [amending this section] shall apply with

respect to services furnished after March 31, 1968."

Section 132(c) of Pub. L. 90-248 provided that: "The amendments

made by this section [amending this section and section 1395x of

this title] shall apply only with respect to items purchased after

December 31, 1967."

Amendment by section 135(c) of Pub. L. 90-248 applicable with

respect to payment for blood (or packed red blood cells) furnished

an individual after Dec. 31, 1967, see section 135(d) of Pub. L.

90-248, set out as a note under section 1395e of this title.

CONSTRUCTION REGARDING LIMITING INCREASES IN COST-SHARING

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 111(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-473, provided that: "Nothing in this

Act [H.R. 5661, as enacted by section 1(a)(6) of Pub. L. 106-554,

see Tables for classification] or the Social Security Act [this

chapter] shall be construed as preventing a hospital from waiving

the amount of any coinsurance for outpatient hospital services

under the medicare program under title XVIII of the Social Security

Act [this subchapter] that may have been increased as a result of

the implementation of the prospective payment system under section

1833(t) of the Social Security Act (42 U.S.C. 1395l(t))."

GAO STUDY OF REDUCTION IN MEDIGAP PREMIUM LEVELS RESULTING FROM

REDUCTIONS IN COINSURANCE

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 111(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-473, provided that: "The Comptroller

General of the United States shall work, in concert with the

National Association of Insurance Commissioners, to evaluate the

extent to which the premium levels for medicare supplemental

policies reflect the reductions in coinsurance resulting from the

amendment made by subsection (a) [amending this section]. Not later

than April 1, 2004, the Comptroller General shall submit to

Congress a report on such evaluation and the extent to which the

reductions in beneficiary coinsurance effected by such amendment

have resulted in actual savings to medicare beneficiaries."

MEDPAC STUDY ON LOW-VOLUME, ISOLATED RURAL HEALTH CARE PROVIDERS

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 225], Dec. 21,

2000, 114 Stat. 2763, 2763A-490, provided that:

"(a) Study. - The Medicare Payment Advisory Commission shall

conduct a study on the effect of low patient and procedure volume

on the financial status of low-volume, isolated rural health care

providers participating in the medicare program under title XVIII

of the Social Security Act [this subchapter].

"(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)

indicating -

"(1) whether low-volume, isolated rural health care providers

are having, or may have, significantly decreased medicare margins

or other financial difficulties resulting from any of the payment

methodologies described in subsection (c);

"(2) whether the status as a low-volume, isolated rural health

care provider should be designated under the medicare program and

any criteria that should be used to qualify for such a status;

and

"(3) any changes in the payment methodologies described in

subsection (c) that are necessary to provide appropriate

reimbursement under the medicare program to low-volume, isolated

rural health care providers (as designated pursuant to paragraph

(2)).

"(c) Payment Methodologies Described. - The payment methodologies

described in this subsection are the following:

"(1) The prospective payment system for hospital outpatient

department services under section 1833(t) of the Social Security

Act (42 U.S.C. 1395l(t)).

"(2) The fee schedule for ambulance services under section

1834(l) of such Act (42 U.S.C. 1395m(l)).

"(3) The prospective payment system for inpatient hospital

services under section 1886 of such Act (42 U.S.C. 1395ww).

"(4) The prospective payment system for routine service costs

of skilled nursing facilities under section 1888(e) of such Act

(42 U.S.C. 1395yy(e)).

"(5) The prospective payment system for home health services

under section 1895 of such Act (42 U.S.C. 1395fff)."

SPECIAL RULE FOR PAYMENT FOR 2001

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 401(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-503, provided that: "Notwithstanding

the amendment made by subsection (a) [amending this section], for

purposes of making payments under section 1833(t) of the Social

Security Act (42 U.S.C. 1395l(t)) for covered OPD services

furnished during 2001, the medicare OPD fee schedule amount under

such section -

"(1) for services furnished on or after January 1, 2001, and

before April 1, 2001, shall be the medicare OPD fee schedule

amount for 2001 as determined under the provisions of law in

effect on the day before the date of the enactment of this Act

[Dec. 21, 2000]; and

"(2) for services furnished on or after April 1, 2001, and

before January 1, 2002, shall be the fee schedule amount (as

determined taking into account the amendment made by subsection

(a)), increased by a transitional percentage allowance equal to

0.32 percent (to account for the timing of implementation of the

full market basket update)."

TRANSITION PROVISIONS APPLICABLE TO SUBSECTION (T)(6)(B)

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 402(d)], Dec. 21,

2000, 114 Stat. 2763, 2763A-506, provided that:

"(1) In general. - In the case of a medical device provided as

part of a service (or group of services) furnished during the

period before initial categories are implemented under subparagraph

(B)(i) of section 1833(t)(6) of the Social Security Act [subsec.

(t)(6)(B)(i) of this section] (as amended by subsection (a)),

payment shall be made for such device under such section in

accordance with the provisions in effect before the date of the

enactment of this Act [Dec. 21, 2000]. In addition, beginning on

the date that is 30 days after the date of the enactment of this

Act, payment shall be made for such a device that is not included

in a program memorandum described in such subparagraph if the

Secretary of Health and Human Services determines that the device

(including a device that would have been included in such program

memoranda but for the requirement of subparagraph (A)(iv)(I) of

that section) is likely to be described by such an initial

category.

"(2) Application of current process. - Notwithstanding any other

provision of law, the Secretary shall continue to accept

applications with respect to medical devices under the process

established pursuant to paragraph (6) of section 1833(t) of the

Social Security Act [subsec. (t)(6) of this section] (as in effect

on the day before the date of the enactment of this Act [Dec. 21,

2000]) through December 1, 2000, and any device -

"(A) with respect to which an application was submitted

(pursuant to such process) on or before such date; and

"(B) that meets the requirements of clause (ii) or (iv) of

subparagraph (A) of such paragraph (as determined pursuant to

such process),

shall be treated as a device with respect to which an initial

category is required to be established under subparagraph (B)(i) of

such paragraph (as amended by subsection (a)(2))."

STUDY ON STANDARDS FOR SUPERVISION OF PHYSICAL THERAPIST ASSISTANTS

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 421(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-516, provided that:

"(1) Study. - The Secretary of Health and Human Services shall

conduct a study of the implications -

"(A) of eliminating the 'in the room' supervision requirement

for medicare payment for services of physical therapy assistants

who are supervised by physical therapists; and

"(B) of such requirement on the cap imposed under section

1833(g) of the Social Security Act (42 U.S.C. 1395l(g)) on

physical therapy services.

"(2) Report. - Not later than 18 months after the date of the

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

to Congress a report on the study conducted under paragraph (1)."

DELAY IN IMPLEMENTATION OF PROSPECTIVE PAYMENT SYSTEM FOR

AMBULATORY SURGICAL CENTERS

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 424(a)], Dec. 21,

2000, 114 Stat. 2763, 2763A-518, provided that: "The Secretary of

Health and Human Services may not implement a revised prospective

payment system for services of ambulatory surgical facilities under

section 1833(i) of the Social Security Act (42 U.S.C. 1395l(i))

before January 1, 2002."

MEDPAC STUDY AND REPORT ON MEDICARE REIMBURSEMENT FOR SERVICES

PROVIDED BY CERTAIN PROVIDERS

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 434], Dec. 21,

2000, 114 Stat. 2763, 2763A-526, provided that:

"(a) Study. - The Medicare Payment Advisory Commission shall

conduct a study on the appropriateness of the current payment rates

under the medicare program under title XVIII of the Social Security

Act [this subchapter] for services provided by a -

"(1) certified nurse-midwife (as defined in subsection (gg)(2)

of section 1861 of such Act (42 U.S.C. 1395x));

"(2) physician assistant (as defined in subsection (aa)(5)(A)

of such section);

"(3) nurse practitioner (as defined in such subsection); and

"(4) clinical nurse specialist (as defined in subsection

(aa)(5)(B) of such section).

The study shall separately examine the appropriateness of such

payment rates for orthopedic physician assistants, taking into

consideration the requirements for accreditation, training, and

education.

"(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 determines to be appropriate as a result of such study."

MEDPAC STUDY ON ACCESS TO OUTPATIENT PAIN MANAGEMENT SERVICES

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 438], Dec. 21,

2000, 114 Stat. 2763, 2763A-528, provided that:

"(a) Study. - The Medicare Payment Advisory Commission shall

conduct a study on the barriers to coverage and payment for

outpatient interventional pain medicine procedures under the

medicare program under title XVIII of the Social Security Act [this

subchapter]. Such study shall examine -

"(1) the specific barriers imposed under the medicare program

on the provision of pain management procedures in hospital

outpatient departments, ambulatory surgery centers, and

physicians' offices; and

"(2) the consistency of medicare payment policies for pain

management procedures in those different settings.

"(b) Report. - Not later than 1 year after the date of the

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

to Congress a report on the study."

ESTABLISHMENT OF CODING AND PAYMENT PROCEDURES FOR NEW CLINICAL

DIAGNOSTIC LABORATORY TESTS AND OTHER ITEMS ON A FEE SCHEDULE

Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 531(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-547, provided that: "Not later than 1

year after the date of the enactment of this Act [Dec. 21, 2000],

the Secretary of Health and Human Services shall establish

procedures for coding and payment determinations for the categories

of new clinical diagnostic laboratory tests and new durable medical

equipment under part B of title XVIII of the Social Security Act

[this part] that permit public consultation in a manner consistent

with the procedures established for implementing coding

modifications for ICD-9-CM."

REPORT ON PROCEDURES USED FOR ADVANCED, IMPROVED TECHNOLOGIES

Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 531(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-547, provided that: "Not later than 1

year 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 that identifies the specific procedures used by the

Secretary under part B of title XVIII of the Social Security Act

[this part] to adjust payments for clinical diagnostic laboratory

tests and durable medical equipment which are classified to

existing codes where, because of an advance in technology with

respect to the test or equipment, there has been a significant

increase or decrease in the resources used in the test or in the

manufacture of the equipment, and there has been a significant

improvement in the performance of the test or equipment. The report

shall include such recommendations for changes in law as may be

necessary to assure fair and appropriate payment levels under such

part for such improved tests and equipment as reflects increased

costs necessary to produce improved results."

CONGRESSIONAL INTENTION REGARDING BASE AMOUNTS IN APPLYING HOPD PPS

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 201(l)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-341, provided that: "With

respect to determining the amount of copayments described in

paragraph (3)(A)(ii) of section 1833(t) of the Social Security Act

[subsec. (t) of this section], as added by section 4523(a) of BBA

[the Balanced Budget Act of 1997, Pub. L. 105-33], Congress finds

that such amount should be determined without regard to such

section, in a budget neutral manner with respect to aggregate

payments to hospitals, and that the Secretary of Health and Human

Services has the authority to determine such amount without regard

to such section."

STUDY AND REPORT TO CONGRESS REGARDING SPECIAL TREATMENT OF RURAL

AND CANCER HOSPITALS IN PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL

OUTPATIENT DEPARTMENT SERVICES

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 203],

Nov. 29, 1999, 113 Stat. 1536, 1501A-344, provided that:

"(a) Study. -

"(1) In general. - The Medicare Payment Advisory Commission

(referred to in this section as 'MedPAC') shall conduct a study

to determine the appropriateness (and the appropriate method) of

providing payments to hospitals described in paragraph (2) for

covered OPD services (as defined in paragraph (1)(B) of section

1833(t) of the Social Security Act (42 U.S.C. 1395l(t))) based on

the prospective payment system established by the Secretary in

accordance with such section.

"(2) Hospitals described. - The hospitals described in this

paragraph are the following:

"(A) A medicare-dependent, small rural hospital (as defined

in section 1886(d)(5)(G)(iv) of the Social Security Act (42

U.S.C. 1395ww(d)(5)(G)(iv))).

"(B) A sole community hospital (as defined in section

1886(d)(5)(D)(iii) of such Act (42 U.S.C.

1395ww(d)(5)(D)(iii))).

"(C) Rural health clinics (as defined in section 1861(aa)(2)

of such Act (42 U.S.C. 1395x(aa)(2)).

"(D) Rural referral centers (as so classified under section

1886(d)(5)(C) of such Act (42 U.S.C. 1395ww(d)(5)(C)).

"(E) Any other rural hospital with not more than 100 beds.

"(F) Any other rural hospital that the Secretary determines

appropriate.

"(G) A hospital described in section 1886(d)(1)(B)(v) of such

Act (42 U.S.C. 1395ww(d)(1)(B)(v)).

"(b) Report. - Not later than 2 years after the date of the

enactment of this Act [Nov. 29, 1999], MedPAC shall submit a report

to the Secretary of Health and Human Services and Congress on the

study conducted under subsection (a), together with any

recommendations for legislation that MedPAC determines to be

appropriate as a result of such study.

"(c) Comments. - Not later than 60 days after the date on which

MedPAC submits the report under subsection (b) to the Secretary of

Health and Human Services, the Secretary shall submit comments on

such report to Congress."

GAO STUDY ON RESOURCES REQUIRED TO PROVIDE SAFE AND EFFECTIVE

OUTPATIENT CANCER THERAPY

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 213],

Nov. 29, 1999, 113 Stat. 1536, 1501A-350, provided that:

"(a) Study. - The Comptroller General of the United States shall

conduct a nationwide study to determine the physician and

non-physician clinical resources necessary to provide safe

outpatient cancer therapy services and the appropriate payment

rates for such services under the medicare program. In making such

determination, the Comptroller General shall -

"(1) determine the adequacy of practice expense relative value

units associated with the utilization of those clinical

resources;

"(2) determine the adequacy of work units in the practice

expense formula; and

"(3) assess various standards to assure the provision of safe

outpatient cancer therapy services.

"(b) Report to Congress. - The Comptroller General shall submit

to Congress a report on the study conducted under subsection (a).

The report shall include recommendations regarding practice expense

adjustments to the payment methodology under part B of title XVIII

of the Social Security Act [this part], including the development

and inclusion of adequate work units to assure the adequacy of

payment amounts for safe outpatient cancer therapy services. The

study shall also include an estimate of the cost of implementing

such recommendations."

FOCUSED MEDICAL REVIEWS OF CLAIMS DURING MORATORIUM PERIOD

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec.

221(a)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-351, as amended by

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 421(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-516, provided that: "During years in

which paragraph (4) of section 1833(g) of the Social Security Act

(42 U.S.C. 1395l(g)) applies, the Secretary of Health and Human

Services shall conduct focused medical reviews of claims for

reimbursement for services described in paragraph (1) or (3) of

such section, with an emphasis on such claims for services that are

provided to residents of skilled nursing facilities."

STUDY AND REPORT ON UTILIZATION

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 221(d)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-352, provided that:

"(1) Study. -

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

shall conduct a study which compares -

"(i) utilization patterns (including nationwide patterns, and

patterns by region, types of settings, and diagnosis or

condition) of outpatient physical therapy services, outpatient

occupational therapy services, and speech-language pathology

services that are covered under the medicare program under

title XVIII of the Social Security Act (42 U.S.C. 1395) [this

subchapter] and provided on or after January 1, 2000; with

"(ii) such patterns for such services that were provided in

1998 and 1999.

"(B) Review of claims. - In conducting the study under this

subsection the Secretary of Health and Human Services shall

review a statistically significant number of claims for

reimbursement for the services described in subparagraph (A).

"(2) Report. - Not later than June 30, 2001, the Secretary of

Health and Human Services shall submit a report to Congress on the

study conducted under paragraph (1), together with any

recommendations for legislation that the Secretary determines to be

appropriate as a result of such study."

PHASE-IN OF PPS FOR AMBULATORY SURGICAL CENTERS

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 226],

Nov. 29, 1999, 113 Stat. 1536, 1501A-354, as amended by Pub. L.

106-554, Sec. 1(a)(6) [title IV, Sec. 424(b), (c)], Dec. 21, 2000,

114 Stat. 2763, 2763A-518, 2763A-519, provided that: "If the

Secretary of Health and Human Services implements a revised

prospective payment system for services of ambulatory surgical

facilities under section 1833(i) of the Social Security Act (42

U.S.C. 1395l(i)), prior to incorporating data from the 1999

Medicare cost survey or a subsequent cost survey, such system shall

be implemented in a manner so that -

"(1) in the first year of its implementation, only a proportion

(specified by the Secretary and not to exceed one-fourth) of the

payment for such services shall be made in accordance with such

system and the remainder shall be made in accordance with current

regulations; and

"(2) in each of the following 2 years a proportion (specified

by the Secretary and not to exceed one-half and three-fourths,

respectively) of the payment for such services shall be made

under such system and the remainder shall be made in accordance

with current regulations.

By not later than January 1, 2003, the Secretary shall incorporate

data from a 1999 medicare cost survey or a subsequent cost survey

for purposes of implementing or revising such system."

MEDPAC STUDY ON POSTSURGICAL RECOVERY CARE CENTER SERVICES

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 229(a)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-356, provided that:

"(1) In general. - The Medicare Payment Advisory Commission shall

conduct a study on the cost-effectiveness and efficacy of covering

under the medicare program under title XVIII of the Social Security

Act [this subchapter] services of a post-surgical recovery care

center (that provides an intermediate level of recovery care

following surgery). In conducting such study, the Commission shall

consider data on these centers gathered in demonstration projects.

"(2) Report. - Not later than 1 year after the date of the

enactment of this Act [Nov. 29,1999], the Commission shall submit

to Congress a report on such study and shall include in the report

recommendations on the feasibility, costs, and savings of covering

such services under the medicare program."

MEDICARE REIMBURSEMENT FOR TELEHEALTH SERVICES

Section 4206 of Pub. L. 105-33, as amended by Pub. L. 106-554,

Sec. 1(a)(6) [title II, Sec. 223(a)], Dec. 21, 2000, 114 Stat.

2763, 2763A-487, provided that:

"(a) In General. - For services furnished on and after January 1,

1999, and before October 1, 2001, the Secretary of Health and Human

Services shall make payments from the Federal Supplementary Medical

Insurance Trust Fund under part B of title XVIII of the Social

Security Act (42 U.S.C. 1395j et seq.) in accordance with the

methodology described in subsection (b) for professional

consultation via telecommunications systems with a physician (as

defined in section 1861(r) of such Act (42 U.S.C. 1395x(r)) or a

practitioner (described in section 1842(b)(18)(C) of such Act (42

U.S.C. 1395u(b)(18)(C)) furnishing a service for which payment may

be made under such part to a beneficiary under the medicare program

residing in a county in a rural area (as defined in section

1886(d)(2)(D) of such Act (42 U.S.C. 1395ww(d)(2)(D))) that is

designated as a health professional shortage area under section

332(a)(1)(A) of the Public Health Service Act (42 U.S.C.

254e(a)(1)(A)), notwithstanding that the individual physician or

practitioner providing the professional consultation is not at the

same location as the physician or practitioner furnishing the

service to that beneficiary.

"(b) Methodology for Determining Amount of Payments. - Taking

into account the findings of the report required under section 192

of the Health Insurance Portability and Accountability Act of 1996

(Public Law 104-191; 110 Stat. 1988), the findings of the report

required under paragraph (c), and any other findings related to the

clinical efficacy and cost-effectiveness of telehealth

applications, the Secretary shall establish a methodology for

determining the amount of payments made under subsection (a) within

the following parameters:

"(1) The payment shall [be] shared between the referring

physician or practitioner and the consulting physician or

practitioner. The amount of such payment shall not be greater

than the current fee schedule of the consulting physician or

practitioner for the health care services provided.

"(2) The payment shall not include any reimbursement for any

telephone line charges or any facility fees, and a beneficiary

may not be billed for any such charges or fees.

"(3) The payment shall be made subject to the coinsurance and

deductible requirements under subsections (a)(1) and (b) of

section 1833 of the Social Security Act (42 U.S.C. 1395l).

"(4) The payment differential of section 1848(a)(3) of such Act

(42 U.S.C. 1395w-4(a)(3)) shall apply to services furnished by

non-participating physicians. The provisions of section 1848(g)

of such Act (42 U.S.C. 1395w-4(g)) and section 1842(b)(18) of

such Act (42 U.S.C. 1395u(b)(18)) shall apply. Payment for such

service shall be increased annually by the update factor for

physicians' services determined under section 1848(d) of such Act

(42 U.S.C. 1395w-4(d)).

"(c) Supplemental Report. - Not later than January 1, 1999, the

Secretary shall submit a report to Congress which shall contain a

detailed analysis of -

"(1) how telemedicine and telehealth systems are expanding

access to health care services;

"(2) the clinical efficacy and cost-effectiveness of

telemedicine and telehealth applications;

"(3) the quality of telemedicine and telehealth services

delivered; and

"(4) the reasonable cost of telecommunications charges incurred

in practicing telemedicine and telehealth in rural, frontier, and

underserved areas.

"(d) Expansion of Telehealth Services for Certain Medicare

Beneficiaries. -

"(1) In general. - Not later than January 1, 1999, the

Secretary shall submit a report to Congress that examines the

possibility of making payments from the Federal Supplementary

Medical Insurance Trust Fund under part B of title XVIII of the

Social Security Act (42 U.S.C. 1395j et seq.) for professional

consultation via telecommunications systems with such a physician

or practitioner furnishing a service for which payment may be

made under such part to a beneficiary described in paragraph (2),

notwithstanding that the individual physician or practitioner

providing the professional consultation is not at the same

location as the physician or practitioner furnishing the service

to that beneficiary.

"(2) Beneficiary described. - A beneficiary described in this

paragraph is a beneficiary under the medicare program under title

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

does not reside in a rural area (as so defined) that is

designated as a health professional shortage area under section

332(a)(1)(A) of the Public Health Service Act (42 U.S.C.

254e(a)(1)(A)), who is homebound or nursing homebound, and for

whom being transferred for health care services imposes a serious

hardship.

"(3) Report. - The report described in paragraph (1) shall

contain a detailed statement of the potential costs and savings

to the medicare program of making the payments described in that

paragraph using various reimbursement schemes."

REPORT ON COVERAGE OF OUTPATIENT OCCUPATIONAL THERAPY SERVICES

Pub. L. 105-33, title IV, Sec. 4541(d)(2), Aug. 5, 1997, 111

Stat. 457, as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6)

[title II, Sec. 221(c)(1)], Nov. 29, 1999, 113 Stat. 1536,

1501A-351, provided that: "Not later than January 1, 2001, the

Secretary of Health and Human Services shall submit to Congress a

report that includes recommendations on -

"(A) the establishment of a mechanism for assuring appropriate

utilization of outpatient physical therapy services, outpatient

occupational therapy services, and speech-language pathology

services that are covered under the medicare program under title

XVIII of the Social Security Act (42 U.S.C. 1395) [this

subchapter]; and

"(B) the establishment of an alternative payment policy for

such services based on classification of individuals by

diagnostic category, functional status, prior use of services (in

both inpatient and outpatient settings), and such other criteria

as the Secretary determines appropriate, in place of the uniform

dollar limitations specified in section 1833(g) of such Act

[subsec. (g) of this section], as amended by paragraph (1).

The recommendations shall include how such a mechanism or policy

might be implemented in a budget-neutral manner."

[Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec.

221(c)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-352, provided

that: "The amendment made by paragraph (1) [amending section

4541(d)(2) of Pub. L. 105-33, set out above] shall take effect as

if included in the enactment of section 4541 of BBA [the Balanced

Budget Act of 1997, Pub. L. 105-33]."]

STUDY AND REPORT ON CLINICAL LABORATORY TESTS

Section 4553(c) of Pub. L. 105-33 provided that:

"(1) In general. - The Secretary shall request the Institute of

Medicine of the National Academy of Sciences to conduct a study of

payments under part B of title XVIII of the Social Security Act

[this part] for clinical laboratory tests. The study shall include

a review of the adequacy of the current methodology and

recommendations regarding alternative payment systems. The study

shall also analyze and discuss the relationship between such

payment systems and access to high quality laboratory tests for

medicare beneficiaries, including availability and access to new

testing methodologies.

"(2) Report to congress. - The Secretary shall, not later than 2

years after the date of enactment of this section [Aug. 5, 1997],

report to the Committees on Ways and Means and Commerce of the

House of Representatives and the Committee on Finance of the Senate

the results of the study described in paragraph (1), including any

recommendations for legislation."

ADJUSTMENTS TO PAYMENT AMOUNTS FOR NEW TECHNOLOGY INTRAOCULAR

LENSES

Section 141(b) of Pub. L. 103-432 provided that:

"(1) Establishment of process for review of amounts. - Not later

than 1 year after the date of the enactment of this Act [Oct. 31,

1994], the Secretary of Health and Human Services (in this

subsection referred to as the 'Secretary') shall develop and

implement a process under which interested parties may request

review by the Secretary of the appropriateness of the reimbursement

amount provided under section 1833(i)(2)(A)(iii) of the Social

Security Act [subsec. (i)(2)(A)(iii) of this section] with respect

to a class of new technology intraocular lenses. For purposes of

the preceding sentence, an intraocular lens may not be treated as a

new technology lens unless it has been approved by the Food and

Drug Administration.

"(2) Factors considered. - In determining whether to provide an

adjustment of payment with respect to a particular lens under

paragraph (1), the Secretary shall take into account whether use of

the lens is likely to result in reduced risk of intraoperative or

postoperative complication or trauma, accelerated postoperative

recovery, reduced induced astigmatism, improved postoperative

visual acuity, more stable postoperative vision, or other

comparable clinical advantages.

"(3) Notice and comment. - The Secretary shall publish notice in

the Federal Register from time to time (but no less often than once

each year) of a list of the requests that the Secretary has

received for review under this subsection, and shall provide for a

30-day comment period on the lenses that are the subjects of the

requests contained in such notice. The Secretary shall publish a

notice of the Secretary's determinations with respect to

intraocular lenses listed in the notice within 90 days after the

close of the comment period.

"(4) Effective date of adjustment. - Any adjustment of a payment

amount (or payment limit) made under this subsection shall become

effective not later than 30 days after the date on which the notice

with respect to the adjustment is published under paragraph (3)."

STUDY OF MEDICARE COVERAGE OF PATIENT CARE COSTS ASSOCIATED WITH

CLINICAL TRIALS OF NEW CANCER THERAPIES

Section 142 of Pub. L. 103-432 directed Secretary of Health and

Human Services to conduct a study, and to submit a report to

Congress not later than 2 years after Oct. 31, 1994, of effects of

expressly covering under medicare program patient care costs for

beneficiaries enrolled in clinical trials of new cancer therapies,

where protocol for the trial has been approved by the National

Cancer Institute or met similar scientific and ethical standards,

including approval by an institutional review board.

STUDY OF ANNUAL CAP ON AMOUNT OF MEDICARE PAYMENT FOR OUTPATIENT

PHYSICAL THERAPY AND OCCUPATIONAL THERAPY SERVICES

Section 143 of Pub. L. 103-432 directed Secretary of Health and

Human Services to submit to Congress, not later than Jan. 1, 1996,

study and report on appropriateness of continuing annual limitation

on amount of payment for outpatient services of independently

practicing physical and occupational therapists under medicare

program, which was to include such recommendations for changes in

such annual limitation as Secretary found appropriate.

AMBULATORY SURGICAL CENTER SERVICES; INFLATION UPDATE

Section 13531 of Pub. L. 103-66 provided that: "The Secretary of

Health and Human Services shall not provide for any inflation

update in the payment amounts under subparagraphs (A) and (B) of

section 1833(i)(2) of the Social Security Act [subsec. (i)(2)(A)

and (B) of this section] for fiscal year 1994 or for fiscal year

1995."

FREEZE IN ALLOWANCE FOR INTRAOCULAR LENSES

Section 13533 of Pub. L. 103-66 provided that: "Notwithstanding

section 1833(i)(2)(A)(iii) of the Social Security Act [subsec.

(i)(2)(A)(iii) of this section], the amount of payment determined

under such section for an intraocular lens inserted subsequent to

or during cataract surgery in an ambulatory surgical center on or

after January 1, 1994, and before January 1, 1999, shall be equal

to $150."

Section 4151(c)(3) of Pub. L. 101-508, as amended by Pub. L.

103-432, title I, Sec. 141(d), Oct. 31, 1994, 108 Stat. 4426,

provided that: "Notwithstanding section 1833(i)(2)(A)(iii) of the

Social Security Act [subsec. (i)(2)(A)(iii) of this section], the

amount of payment determined under such section for an intraocular

lens inserted during or subsequent to cataract surgery furnished to

an individual in an ambulatory surgical center on or after the date

of the enactment of this Act [Nov. 5, 1990] and on or before

December 31, 1992, shall be equal to $200."

[Section 141(d) of Pub. L. 103-432 provided that the amendment

made by that section to section 4151(c)(3) of Pub. L. 101-508, set

out above, is effective as if included in the enactment of Pub. L.

101-508.]

REDUCTION IN PAYMENTS UNDER PART B DURING FINAL TWO MONTHS OF 1990

Section 4158 of Pub. L. 101-508 provided that:

"(a) In General. - Notwithstanding any other provision of law

(including any other provision of this Act, other than subsection

(b)(4)), payments under part B of title XVIII of the Social

Security Act [this part] for items and services furnished during

the period beginning on November 1, 1990, and ending on December

31, 1990, shall be reduced by 2 percent, in accordance with

subsection (b).

"(b) Special Rules for Application of Reduction. -

"(1) Payment on the basis of cost reporting periods. - In the

case in which payment for services of a provider of services is

made under part B of such title on a basis relating to the

reasonable cost incurred for the services during a cost reporting

period of the provider, the reduction made under subsection (a)

shall be applied to payment for costs for such services incurred

at any time during each cost reporting period of the provider any

part of which occurs during the period described in such

subsection, but only in the same proportion as the fraction of

the cost reporting period that occurs during such period.

"(2) No increase in beneficiary charges in assignment-related

cases. - If a reduction in payment amounts is made under

subsection (a) for items or services for which payment under part

B of such title is made on an assignment-related basis (as

defined in section 1842(i)(1) of the Social Security Act [section

1395u(i)(1) of this title]), the person furnishing the items or

services shall be considered to have accepted payment of the

reasonable charge for the items or services, less any reduction

in payment amount made under subsection (a), as payment in full.

"(3) Treatment of payments to health maintenance organizations.

- Subsection (a) shall not apply to payments under risk-sharing

contracts under section 1876 of the Social Security Act [section

1395mm of this title] or under similar contracts under section

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

enacting section 1395b-1 of this title and amending section

1395ll of this title] or section 222 of the Social Security

Amendments of 1972 [Pub. L. 92-603, amending sections 1395b-1 and

1395ll of this title and enacting provisions set out as a note

under section 1395b-1 of this title]."

EFFECT ON STATE LAW

Conscientious objections of health care provider under State law

unaffected by enactment of subsecs. (a)(1)(Q) and (f) of this

section, see section 4206(c) of Pub. L. 101-508, set out as a note

under section 1395cc of this title.

DEVELOPMENT OF CRITERIA REGARDING CONSULTATION WITH A PHYSICIAN

Section 6113(c) of Pub. L. 101-239, as amended by Pub. L.

103-432, title I, Sec. 147(b), Oct. 31, 1994, 108 Stat. 4429,

provided that: "The Secretary of Health and Human Services shall,

taking into consideration concerns for patient confidentiality,

develop criteria with respect to payment for qualified psychologist

services and clinical social worker services for which payment may

be made directly to the psychologist or clinical social worker

under part B of title XVIII of the Social Security Act [this part]

under which such a psychologist or clinical social worker must

agree to consult with a patient's attending physician in accordance

with such criteria."

[Section 147(b) of Pub. L. 103-432 provided that the amendment

made by that section to section 6113(c) of Pub. L. 101-239, set out

above, is effective with respect to services furnished on or after

Jan. 1, 1991.]

STUDY OF REIMBURSEMENT FOR AMBULANCE SERVICES

Section 6136 of Pub. L. 101-239 directed Secretary of Health and

Human Services to conduct a study to determine adequacy and

appropriateness of payment amounts under this subchapter for

ambulance services and, not later than one year after Dec. 19,

1989, submit a report to Congress on results of the study, with

report to include such recommendations for changes in medicare

payment policy with respect to ambulance services as may be needed

to ensure access by medicare beneficiaries to quality ambulance

services in metropolitan and rural areas.

PROPAC STUDY OF PAYMENTS FOR SERVICES IN HOSPITAL OUTPATIENT

DEPARTMENTS

Section 6137 of Pub. L. 101-239, directed Prospective Payment

Assessment Commission to conduct a study on payment under this

subchapter for hospital outpatient services and, not later than

July 1, 1990, and not later than Mar. 1, 1991, to submit reports to

Congress on specified portions of the study, with the reports to

include such recommendations as the Commission deemed appropriate,

prior to repeal by Pub. L. 103-432, title I, Sec. 147(c)(1), Oct.

31, 1994, 108 Stat. 4429.

BUDGET NEUTRALITY

Section 8421(b) of Pub. L. 100-647 provided that: "The Secretary

of Health and Human Services shall adjust the fees for

transportation and personnel established under section

1833(h)(3)(B) of the Social Security Act [subsec. (h)(3)(B) of this

section] for tests not covered under the amendment made by

subsection (a) [amending this section] in such manner that the

total cost of fees under such section is the same as would have

been the case without such amendment."

ADJUSTMENT OF CONTRACTS WITH PREPAID HEALTH PLANS

For requirement that Secretary of Health and Human Services

modify contracts under subsection (a)(1)(A) of this section to take

into account amendments made by Pub. L. 100-360 and that such

organizations make appropriate adjustments in their agreements with

medicare beneficiaries to take into account such amendments, see

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

1395mm of this title.

STUDY AND REPORT TO CONGRESS RESPECTING INCENTIVE PAYMENTS FOR

PHYSICIANS' SERVICES FURNISHED IN UNDERSERVED AREAS

Section 4043(b) of Pub. L. 100-203 directed Secretary of Health

and Human Services to study and report to Congress, by not later

than Jan. 1, 1990, on feasibility of making additional payments

described in section 1395l(m) of this title with respect to

physician services performed in health manpower shortage areas

located in urban areas, prior to repeal by Pub. L. 101-508, title

IV, Sec. 4118(g)(1), Nov. 5, 1990, 104 Stat. 1388-70.

FEE SCHEDULES FOR PHYSICIAN PATHOLOGY SERVICES

Section 4050 of Pub. L. 100-203 directed Secretary of Health and

Human Services to develop a relative value scale and fee schedules

with updating index for payment of physician pathology services

under this part, and to report to committees of Congress not later

than Apr. 1, 1989, on the scale, schedules, and index, prior to

repeal by Pub. L. 101-508, title IV, Sec. 4104(b)(3), Nov. 5, 1990,

104 Stat. 1388-59.

APPLYING COPAYMENT AND DEDUCTIBLE TO CERTAIN OUTPATIENT PHYSICIANS'

SERVICES

Section 4054 of Pub. L. 100-203, relating to payment under part B

of title XVIII of the Social Security Act (this part) for

physicians' services specified in subsec. (i) of this section and

furnished on or after Apr. 1, 1988, in an ambulatory surgical

center or hospital outpatient department on an assignment-related

basis, was negated in the amendment of section 4054 by Pub. L.

100-360, title IV, Sec. 411(f)(12)(A), July 1, 1988, 102 Stat. 781.

OTHER PHYSICIAN PAYMENT STUDIES

Section 4056(c), formerly Sec. 4055(c), of Pub. L. 100-203, as

renumbered by Pub. L. 100-360, title IV, Sec. 411(f)(14), July 1,

1988, 102 Stat. 781, provided directed Secretary to (1) conduct a

study of changes in the payment system for physicians' services,

under part B, that would be required for the implementation of a

national fee schedule for such services furnished on or after Jan.

1, 1990, and report to Congress on such study by not later than

July 1, 1989, (2) conduct a study of issues relating to the volume

and intensity of physicians' services under part B and submit to

Congress an interim report on such study not later than May 1,

1988, and a final report on such study not later than May 1, 1989,

and (3) conduct a survey to determine distribution of (A) the

liabilities and expenditures for health care services of

individuals entitled to benefits under this subchapter, including

liabilities for charges (not paid on an assignment-related basis)

in excess of the reasonable charge recognized, and (B) the

collection rates among different classes of physicians for such

liabilities, including collection rates for required coinsurance

and for charges (not paid on an assignment-related basis) in excess

of the reasonable charge recognized, report to Congress on such

study by not later than July 1, 1990.

STUDY OF PAYMENT FOR CHEMOTHERAPY IN PHYSICIANS' OFFICES

Section 4056(d), formerly Sec. 4055(d), of Pub. L. 100-203, as

renumbered by Pub. L. 100-360, title IV, Sec. 411(f)(14), July 1,

1988, 102 Stat. 781, directed Secretary to study ways of modifying

part B to permit adequate payment under such part for costs

associated with providing chemotherapy to cancer patients in

physicians' offices, with the Secretary to report to Congress on

results of study by not later than Apr. 1, 1989, prior to repeal by

Pub. L. 105-362, title VI, Sec. 601(b)(7), Nov. 10, 1998, 112 Stat.

3286.

CLINICAL DIAGNOSTIC LABORATORY TESTS; LIMITATION ON CHANGES IN FEE

SCHEDULES

Section 4064(a) of Pub. L. 100-203 which provided 3-month freeze

in fee schedules for clinical laboratory diagnostic laboratory

tests under part B of title XVIII of the Social Security Act (this

part) and directed the Secretary of Health and Human Services to

not adjust the fee schedules established under subsec. (h) of this

section to take into account any increase in the consumer price

index, was negated in the amendment of section 4064(a) by Pub. L.

100-360, title IV, Sec. 411(g)(3)(A), July 1, 1988, 102 Stat. 783.

GAO STUDY OF FEE SCHEDULES

Section 4064(b)(4) of Pub. L. 100-203 directed Comptroller

General to conduct a study of level of fee schedules established

for clinical diagnostic laboratory services under subsec. (h)(2) of

this section to determine, based on costs of, and revenues received

for, such tests the appropriateness of such schedules, with

Comptroller General to report to Congress on results of such study

by not later than Jan. 1, 1990, and with provision that suppliers

of such tests which fail to provide Comptroller General with

reasonable access to necessary records to carry out study being

subject to exclusion from the medicare program under section

1320a-7(a) of this title.

AMOUNTS PAID FOR INDEPENDENT RURAL HEALTH CLINIC SERVICES

Section 4067(b) of Pub. L. 100-203 provided that: "The Secretary

of Health and Human Services shall report to Congress, by not later

than March 1, 1989, on the adequacy of the amounts paid under title

XVIII of the Social Security Act [this subchapter] for rural health

clinic services provided by independent rural health clinics."

REPORT ON ESTABLISHMENT OF NATIONAL FEE SCHEDULES FOR PAYMENT OF

CLINICAL DIAGNOSTIC LABORATORY TESTS

Section 9339(b)(3) of Pub. L. 99-509 directed Secretary of Health

and Human Services to report to Congress, by not later than Apr. 1,

1988, on advisability and feasibility of, and methodology for,

establishing national fee schedules for payment for clinical

diagnostic laboratory tests under section 1395l(h) of this title,

prior to repeal by Pub. L. 101-508, title IV, Sec. 4154(e)(3), Nov.

5, 1990, 104 Stat. 1388-86, effective as if included in enactment

of Pub. L. 99-509.

STATE STANDARDS FOR DIRECTORS OF CLINICAL LABORATORIES

Section 9339(d) of Pub. L. 99-509 provided that:

"(1) In general. - If a State (as defined for purposes of title

XVIII of the Social Security Act [this subchapter]) provides for

the licensing or other standards with respect to the operation of

clinical laboratories (including such laboratories in hospitals) in

the State under which such a laboratory may be directed by an

individual with certain qualifications, nothing in such title shall

be construed as authorizing the Secretary of Health and Human

Services to require such a laboratory, as a condition of payment or

participation under such title, to be directed by an individual

with other qualifications.

"(2) Effective date. - Paragraph (1) shall take effect on January

1, 1987."

TRANSITIONAL PROVISIONS FOR PAYMENT OF FEES FOR CLINICAL DIAGNOSTIC

LABORATORY TESTS

Section 9303(a)(3) of Pub. L. 99-272 provided that: "The

Secretary of Health and Human Services shall provide that the

annual adjustment under section 1833(h) of the Social Security Act

[subsec. (h) of this section] for 1986 -

"(A) shall take effect on January 1, 1987,

"(B) shall apply for the 12-month period beginning on that

date, and

"(C) shall take into account the percentage increase or

decrease in the Consumer Price Index for all urban consumers

(United States city average) occurring over an 18-month period,

rather than over a 12-month period."

EXTENSION OF MEDICARE PHYSICIAN PAYMENT PROVISIONS

Amount of payment under this part for physicians' services

furnished between Oct. 1, 1985, and Mar. 14, 1986, to be determined

on the same basis as the amount of such services furnished on Sept.

30, 1985, see section 5(b) of Pub. L. 99-107, as amended, set out

as a note under section 1395ww of this title.

FEE SCHEDULES FOR DIAGNOSTIC LABORATORY TESTS AND FEASIBILITY OF

DIRECT PAYMENTS TO PHYSICIANS; REPORT TO CONGRESS

Section 2303(i) of Pub. L. 98-369 provided that:

"(1) The Comptroller General shall report to the Congress on -

"(A) the appropriateness of the fee schedules under section

1833(h) of the Social Security Act [subsec. (h) of this section]

and their impact on the volume and quality of clinical diagnostic

laboratory tests;

"(B) the potential impact of the adoption of a national fee

schedule; and

"(C) the potential impact of applying a national fee schedule

to clinical diagnostic laboratory tests provided by hospitals to

their outpatients.

"(2) The Secretary of Health and Human Services shall report to

the Congress with respect to the advisability and feasibility of a

system of direct payment to any physician for all clinical

diagnostic laboratory tests ordered by such physician.

"(3) The reports required by paragraphs (1) and (2) shall be

submitted not later than January 1, 1987."

PACEMAKER REIMBURSEMENT REVIEW AND REFORM

Section 2304(a) of Pub. L. 98-369 provided that:

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

revisions to the current guidelines for the payment under part B of

title XVIII of the Social Security Act [this part] for the

transtelephonic monitoring of cardiac pacemakers. Such revised

guidelines shall include provisions regarding the specifications

for and frequency of transtelephonic monitoring procedures which

will be found to be reasonable and necessary.

"(2)(A) Except as provided in subparagraph (B), if the guidelines

required by paragraph (1) have not been issued and put into effect

by October 1, 1984, and until such guidelines have been issued and

put into effect, payment may not be made under part B of title

XVIII of the Social Security Act for transtelephonic monitoring

procedures, with respect to a single-chamber cardiac pacemaker

powered by lithium batteries, conducted more frequently than -

"(i) weekly during the first month after implantation,

"(ii) once every two months during the period representing 80

percent of the estimated life of the implanted device, and

"(iii) monthly thereafter.

"(B) Subparagraph (A) shall not apply in cases where the

Secretary determines that special medical factors (including

possible evidence of pacemaker or lead malfunction) justify more

frequent transtelephonic monitoring procedures."

PAYMENT FOR PREADMISSION DIAGNOSTIC TESTING PERFORMED IN

PHYSICIAN'S OFFICE

Section 2305(f) of Pub. L. 98-369 provided that: "The amendments

made by this section [amending this section and enacting provisions

set out above] shall not be construed as prohibiting payment,

subject to the applicable copayments, under part B of title XVIII

of the Social Security Act [this part] for preadmission diagnostic

testing performed in a physician's office to the extent such

testing is otherwise reimbursable under regulations of the

Secretary."

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

For provision directing the Secretary to issue regulations

requiring providers of services to calculate and report the

lesser-of-cost-or-charges determinations separately with respect to

payments for services under parts A and B of this subchapter other

than diagnostic tests under subsec. (h) of this section, see

section 2308(a) of Pub. L. 98-369, set out as a note under section

1395f of this title.

DETERMINATION OF NOMINAL CHARGES FOR APPLYING NOMINALITY TEST

For provision directing the Secretary to provide, in addition to

other rules deemed appropriate, that charges representing 60

percent or less of costs be considered nominal for purposes of

applying the nominality test under subsec. (a)(2)(B)(ii) of this

section, see section 2308(b)(1) of Pub. L. 98-369, set out as a

note under section 1395f of this title.

STUDY OF MEDICARE PART B PAYMENTS; COMPILATION OF CENTRALIZED

CHARGE DATA BASE; REPORT TO CONGRESS

Section 2309 of Pub. L. 98-369 directed Director of Office of

Technology Assessment to conduct a study of physician reimbursement

under the Medicare program and make a report not later than Dec.

31, 1985, covering findings and recommendations on methods by which

payment amounts and other program policies under the program might

be modified, and directed that Secretary of Health and Human

Services compile a centralized Medicare part B charge data base to

aid in the study.

MONITORING PROVISION OF HEPATITIS B VACCINE; REVIEW OF CHANGES IN

MEDICAL TECHNOLOGY

Section 2323(e) of Pub. L. 98-369 provided that: "The Secretary

shall monitor the provision of hepatitis B vaccine under part B of

title XVIII of the Social Security Act [this part], and shall

review any changes in medical technology which may have an effect

on the amounts which should be paid for such service."

REPORT ON PREADMISSION DIAGNOSTIC TESTING EXPENSES

Section 932(b) of Pub. L. 96-499 required a report to Congress,

no later than one year after Dec. 5, 1980, on the policy respecting

expenses incurred for preadmission diagnostic testing furnished to

an individual at a hospital within seven days of an individual's

admission to another hospital.

STUDY OF FEASIBILITY AND DESIRABILITY OF IMPOSING COPAYMENT

REQUIREMENT ON RURAL HEALTH CLINIC VISITS; REPORT NOT LATER THAN

DECEMBER 13, 1978

Section 1(c) of Pub. L. 95-210 directed Secretary of Health,

Education, and Welfare to conduct a study of the feasibility and

desirability of imposing a copayment for each visit to a rural

health clinic for rural health clinic services under this part and

that Secretary report to appropriate committee of Congress, not

later than one year after Dec. 13, 1977, on such study.

PROHIBITION AGAINST PAYMENTS IN CASES OF NONENTITLEMENT TO MONTHLY

BENEFITS UNDER SUBCHAPTER II OR SUSPENSION OF BENEFITS OF ALIENS

OUTSIDE THE UNITED STATES

Section 104(b)(1) of Pub. L. 89-97 provided that: "No payments

shall be made under part B of title XVIII of the Social Security

Act [this part] with respect to expenses incurred by an individual

during any month for which such individual may not be paid monthly

benefits under title II of such Act [subchapter II of this chapter]

(or for which such monthly benefits would be suspended if he were

otherwise entitled thereto) by reason of section 202(t) of such Act

[section 402(t) of this title] (relating to suspension of benefits

of aliens who are outside the United States)."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1320a-7a, 1320c-3, 1395e,

1395f, 1395k, 1395m, 1395n, 1395u, 1395x, 1395cc, 1395cc-2, 1395mm,

1395nn, 1395rr, 1395ss, 1395uu, 1395yy, 1395ccc, 1395eee, 1396a,

1396b, 1396d of this title.

-FOOTNOTE-

(!1) So in original. The word "and" probably should not appear.

(!2) So in original. The comma after "subclause (II))" probably

should follow "is performed".

(!3) So in original.

(!4) So in original. Probably should be "such paragraph

applies".

(!5) So in original. The word "this" probably should not appear.

(!6) So in original. Probably should be "are - ".

(!7) So in original. Probably should be "subparagraph".

(!8) So in original. No par. (2) has been enacted.

(!9) So in original. Probably should be "pair".

(!10) See References in Text note below.

(!11) So in original. No subpar. (B) has been enacted.

-End-

-CITE-

42 USC Sec. 1395m 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part B - Supplementary Medical Insurance Benefits for Aged and

Disabled

-HEAD-

Sec. 1395m. Special payment rules for particular items and services

-STATUTE-

(a) Payment for durable medical equipment

(1) General rule for payment

(A) In general

With respect to a covered item (as defined in paragraph (13))

for which payment is determined under this subsection, payment

shall be made in the frequency specified in paragraphs (2)

through (7) and in an amount equal to 80 percent of the payment

basis described in subparagraph (B).

(B) Payment basis

The payment basis described in this subparagraph is the

lesser of -

(i) the actual charge for the item, or

(ii) the payment amount recognized under paragraphs (2)

through (7) of this subsection for the item;

except that clause (i) shall not apply if the covered item 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) free of charge or at nominal charges to the public.

(C) Exclusive payment rule

This subsection shall constitute the exclusive provision of

this subchapter for payment for covered items under this part

or under part A of this subchapter to a home health agency.

(D) Reduction in fee schedules for certain items

With respect to a seat-lift chair or transcutaneous

electrical nerve stimulator furnished on or after April 1,

1990, the Secretary shall reduce the payment amount applied

under subparagraph (B)(ii) for such an item by 15 percent, and,

in the case of a transcutaneous electrical nerve stimulator

furnished on or after January 1, 1991, the Secretary shall

further reduce such payment amount (as previously reduced) by

45 percent.

(2) Payment for inexpensive and other routinely purchased durable

medical equipment

(A) In general

Payment for an item of durable medical equipment (as defined

in paragraph (13)) -

(i) the purchase price of which does not exceed $150,

(ii) which the Secretary determines is acquired at least 75

percent of the time by purchase, or

(iii) which is an accessory used in conjunction with a

nebulizer, aspirator, or a ventilator excluded under

paragraph (3)(A),

shall be made on a rental basis or in a lump-sum amount for the

purchase of the item. The payment amount recognized for

purchase or rental of such equipment is the amount specified in

subparagraph (B) for purchase or rental, except that the total

amount of payments with respect to an item may not exceed the

payment amount specified in subparagraph (B) with respect to

the purchase of the item.

(B) Payment amount

For purposes of subparagraph (A), the amount specified in

this subparagraph, with respect to the purchase or rental of an

item furnished in a carrier service area -

(i) in 1989 and in 1990 is the average reasonable charge in

the area for the purchase or rental, respectively, of the

item for the 12-month period ending on June 30, 1987,

increased by the percentage increase in the consumer price

index for all urban consumers (U.S. city average) for the

6-month period ending with December 1987;

(ii) in 1991 is the sum of (I) 67 percent of the local

payment amount for the item or device computed under

subparagraph (C)(i)(I) for 1991, and (II) 33 percent of the

national limited payment amount for the item or device

computed under subparagraph (C)(ii) for 1991;

(iii) in 1992 is the sum of (I) 33 percent of the local

payment amount for the item or device computed under

subparagraph (C)(i)(II) for 1992, and (II) 67 percent of the

national limited payment amount for the item or device

computed under subparagraph (C)(ii) for 1992; and

(iv) in 1993 and each subsequent year is the national

limited payment amount for the item or device computed under

subparagraph (C)(ii) for that year (reduced by 10 percent, in

the case of a blood glucose testing strip furnished after

1997 for an individual with diabetes).

(C) Computation of local payment amount and national limited

payment amount

For purposes of subparagraph (B) -

(i) the local payment amount for an item or device for a

year is equal to -

(I) for 1991, the amount specified in subparagraph (B)(i)

for 1990 increased by the covered item update for 1991, and

(II) for 1992, 1993, and 1994, the amount determined

under this clause for the preceding year increased by the

covered item update for the year; and

(ii) the national limited payment amount for an item or

device for a year is equal to -

(I) for 1991, the local payment amount determined under

clause (i) for such item or device for that year, except

that the national limited payment amount may not exceed 100

percent of the weighted average of all local payment

amounts determined under such clause for such item for that

year and may not be less than 85 percent of the weighted

average of all local payment amounts determined under such

clause for such item,

(II) for 1992 and 1993, the amount determined under this

clause for the preceding year increased by the covered item

update for such subsequent year,

(III) for 1994, the local payment amount determined under

clause (i) for such item or device for that year, except

that the national limited payment amount may not exceed 100

percent of the median of all local payment amounts

determined under such clause for such item for that year

and may not be less than 85 percent of the median of all

local payment amounts determined under such clause for such

item or device for that year, and

(IV) for each subsequent year, the amount determined

under this clause for the preceding year increased by the

covered item update for such subsequent year.

(3) Payment for items requiring frequent and substantial

servicing

(A) In general

Payment for a covered item (such as IPPB machines and

ventilators, excluding ventilators that are either continuous

airway pressure devices or intermittent assist devices with

continuous airway pressure devices) for which there must be

frequent and substantial servicing in order to avoid risk to

the patient's health shall be made on a monthly basis for the

rental of the item and the amount recognized is the amount

specified in subparagraph (B).

(B) Payment amount

For purposes of subparagraph (A), the amount specified in

this subparagraph, with respect to an item or device furnished

in a carrier service area -

(i) in 1989 and in 1990 is the average reasonable charge in

the area for the rental of the item or device for the

12-month period ending with June 1987, increased by the

percentage increase in the consumer price index for all urban

consumers (U.S. city average) for the 6-month period ending

with December 1987;

(ii) in 1991 is the sum of (I) 67 percent of the local

payment amount for the item or device computed under

subparagraph (C)(i)(I) for 1991, and (II) 33 percent of the

national limited payment amount for the item or device

computed under subparagraph (C)(ii) for 1991;

(iii) in 1992 is the sum of (I) 33 percent of the local

payment amount for the item or device computed under

subparagraph (C)(i)(II) for 1992, and (II) 67 percent of the

national limited payment amount for the item or device

computed under subparagraph (C)(ii) for 1992; and

(iv) in 1993 and each subsequent year is the national

limited payment amount for the item or device computed under

subparagraph (C)(ii) for that year.

(C) Computation of local payment amount and national limited

payment amount

For purposes of subparagraph (B) -

(i) the local payment amount for an item or device for a

year is equal to -

(I) for 1991, the amount specified in subparagraph (B)(i)

for 1990 increased by the covered item update for 1991, and

(II) for 1992, 1993, and 1994, the amount determined

under this clause for the preceding year increased by the

covered item update for the year; and

(ii) the national limited payment amount for an item or

device for a year is equal to -

(I) for 1991, the local payment amount determined under

clause (i) for such item or device for that year, except

that the national limited payment amount may not exceed 100

percent of the weighted average of all local payment

amounts determined under such clause for such item for that

year and may not be less than 85 percent of the weighted

average of all local payment amounts determined under such

clause for such item,

(II) for 1992 and 1993, the amount determined under this

clause for the preceding year increased by the covered item

update for such subsequent year,

(III) for 1994, the local payment amount determined under

clause (i) for such item or device for that year, except

that the national limited payment amount may not exceed 100

percent of the median of all local payment amounts

determined under such clause for such item for that year

and may not be less than 85 percent of the median of all

local payment amounts determined under such clause for such

item or device for that year, and

(IV) for each subsequent year, the amount determined

under this clause for the preceding year increased by the

covered item update for such subsequent year.

(4) Payment for certain customized items

Payment with respect to a covered item that is uniquely

constructed or substantially modified to meet the specific needs

of an individual patient, and for that reason cannot be grouped

with similar items for purposes of payment under this subchapter,

shall be made in a lump-sum amount (A) for the purchase of the

item in a payment amount based upon the carrier's individual

consideration for that item, and (B) for the reasonable and

necessary maintenance and servicing for parts and labor not

covered by the supplier's or manufacturer's warranty, when

necessary during the period of medical need, and the amount

recognized for such maintenance and servicing shall be paid on a

lump-sum, as needed basis based upon the carrier's individual

consideration for that item.

(5) Payment for oxygen and oxygen equipment

(A) In general

Payment for oxygen and oxygen equipment shall be made on a

monthly basis in the monthly payment amount recognized under

paragraph (9) for oxygen and oxygen equipment (other than

portable oxygen equipment), subject to subparagraphs (B), (C),

and (E).

(B) Add-on for portable oxygen equipment

When portable oxygen equipment is used, but subject to

subparagraph (D), the payment amount recognized under

subparagraph (A) shall be increased by the monthly payment

amount recognized under paragraph (9) for portable oxygen

equipment.

(C) Volume adjustment

When the attending physician prescribes an oxygen flow rate -

(i) exceeding 4 liters per minute, the payment amount

recognized under subparagraph (A), subject to subparagraph

(D), shall be increased by 50 percent, or

(ii) of less than 1 liter per minute, the payment amount

recognized under subparagraph (A) shall be decreased by 50

percent.

(D) Limit on adjustment

When portable oxygen equipment is used and the attending

physician prescribes an oxygen flow rate exceeding 4 liters per

minute, there shall only be an increase under either

subparagraph (B) or (C), whichever increase is larger, and not

under both such subparagraphs.

(E) Recertification for patients receiving home oxygen therapy

In the case of a patient receiving home oxygen therapy

services who, at the time such services are initiated, has an

initial arterial blood gas value at or above a partial pressure

of 56 or an arterial oxygen saturation at or above 89 percent

(or such other values, pressures, or criteria as the Secretary

may specify) no payment may be made under this part for such

services after the expiration of the 90-day period that begins

on the date the patient first receives such services unless the

patient's attending physician certifies that, on the basis of a

follow-up test of the patient's arterial blood gas value or

arterial oxygen saturation conducted during the final 30 days

of such 90-day period, there is a medical need for the patient

to continue to receive such services.

(6) Payment for other covered items (other than durable medical

equipment)

Payment for other covered items (other than durable medical

equipment and other covered items described in paragraph (3),

(4), or (5)) shall be made in a lump-sum amount for the purchase

of the item in the amount of the purchase price recognized under

paragraph (8).

(7) Payment for other items of durable medical equipment

(A) In general

In the case of an item of durable medical equipment not

described in paragraphs (2) through (6) -

(i) payment shall be made on a monthly basis for the rental

of such item during the period of medical need (but payments

under this clause may not extend over a period of continuous

use of longer than 15 months, or, in the case of an item for

which a purchase agreement has been entered into under clause

(iii), a period of continuous use of longer than 13 months),

and, subject to subparagraph (B), the amount recognized for

each of the first 3 months of such period is 10 percent of

the purchase price recognized under paragraph (8) with

respect to the item, and for each of the remaining months of

such period is 7.5 percent of such purchase price;

(ii) in the case of a power-driven wheelchair, at the time

the supplier furnishes the item, the supplier shall offer the

individual patient the option to purchase the item, and

payment for such item shall be made on a lump-sum basis if

the patient exercises such option;

(iii) during the 10th continuous month during which payment

is made for the rental of an item under clause (i), the

supplier of such item shall offer the individual patient the

option to enter into a purchase agreement under which, if the

patient notifies the supplier not later than 1 month after

the supplier makes such offer that the patient agrees to

accept such offer and exercise such option -

(I) the supplier shall transfer title to the item to the

individual patient on the first day that begins after the

13th continuous month during which payment is made for the

rental of the item under clause (i),

(II) after the supplier transfers title to the item under

subclause (I), maintenance and servicing payments shall be

made in accordance with clause (vi);

(iv) in the case of an item for which a purchase agreement

has not been entered into under clause (ii) or clause (iii),

during the first 6-month period of medical need that follows

the period of medical need during which payment is made under

clause (i), no payment shall be made for rental or

maintenance and servicing of the item;

(v) in the case of an item for which a purchase agreement

has not been entered into under clause (ii) or clause (iii),

during the first month of each succeeding 6-month period of

medical need, a maintenance and servicing payment may be made

(for parts and labor not covered by the supplier's or

manufacturer's warranty, as determined by the Secretary to be

appropriate for the particular type of durable medical

equipment) and the amount recognized for each such 6-month

period is the lower of (I) a reasonable and necessary

maintenance and servicing fee or fees established by the

Secretary, or (II) 10 percent of the total of the purchase

price recognized under paragraph (8) with respect to the

item; and

(vi) in the case of an item for which a purchase agreement

has been entered into under clause (ii) or clause (iii),

maintenance and servicing payments may be made (for parts and

labor not covered by the supplier's or manufacturer's

warranty, as determined by the Secretary to be appropriate

for the particular type of durable medical equipment), and

such payments shall be in an amount established by the

Secretary on the basis of reasonable charges in the locality

for maintenance and servicing.

The Secretary shall determine the meaning of the term

"continuous" in subparagraph (A).

(B) Range for rental amounts

(i) For 1989

For items furnished during 1989, the payment amount

recognized under subparagraph (A)(i) shall not be more than

115 percent, and shall not be less than 85 percent, of the

prevailing charge established for rental of the item in

January 1987, increased by the percentage increase in the

consumer price index for all urban consumers (U.S. city

average) for the 6-month period ending with December 1987.

(ii) For 1990

For items furnished during 1990, clause (i) shall apply in

the same manner as it applies to items furnished during 1989.

(C) Replacement of items

(i) Establishment of reasonable useful lifetime

In accordance with clause (iii), the Secretary shall

determine and establish a reasonable useful lifetime for

items of durable medical equipment for which payment may be

made under this paragraph.

(ii) Payment for replacement items

If the reasonable lifetime of such an item, as so

established, has been reached during a continuous period of

medical need, or the carrier determines that the item is lost

or irreparably damaged, the patient may elect to have payment

for an item serving as a replacement for such item made -

(I) on a monthly basis for the rental of the replacement

item in accordance with subparagraph (A); or

(II) in the case of an item for which a purchase

agreement has been entered into under subparagraph (A)(ii)

or (A)(iii), in a lump-sum amount for the purchase of the

item.

(iii) Length of reasonable useful lifetime

The reasonable useful lifetime of an item of durable

medical equipment under this subparagraph shall be equal to 5

years, except that, if the Secretary determines that, on the

basis of prior experience in making payments for such an item

under this subchapter, a reasonable useful lifetime of 5

years is not appropriate with respect to a particular item,

the Secretary shall establish an alternative reasonable

lifetime for such item.

(8) Purchase price recognized for miscellaneous devices and items

For purposes of paragraphs (6) and (7), the amount that is

recognized under this paragraph as the purchase price for a

covered item is the amount described in subparagraph (C) of this

paragraph, determined as follows:

(A) Computation of local purchase price

Each carrier under section 1395u of this title shall compute

a base local purchase price for the item as follows:

(i) The carrier shall compute a base local purchase price,

for each item described -

(I) in paragraph (6) equal to the average reasonable

charge in the locality for the purchase of the item for the

12-month period ending with June 1987, or

(II) in paragraph (7) equal to the average of the

purchase prices on the claims submitted on an

assignment-related basis for the unused item supplied

during the 6-month period ending with December 1986.

(ii) The carrier shall compute a local purchase price, with

respect to the furnishing of each particular item -

(I) in 1989 and 1990, equal to the base local purchase

price computed under clause (i) increased by the percentage

increase in the consumer price index for all urban

consumers (U.S. city average) for the 6-month period ending

with December 1987,

(II) in 1991, equal to the local purchase price computed

under this clause for the previous year, increased by the

covered item update for 1991, and decreased by the

percentage by which the average of the reasonable charges

for claims paid for all items described in paragraph (7) is

lower than the average of the purchase prices submitted for

such items during the final 9 months of 1988; (!1) or

(III) in 1992, 1993, and 1994, equal to the local

purchase price computed under this clause for the previous

year increased by the covered item update for the year.

(B) Computation of national limited purchase price

With respect to the furnishing of a particular item in a

year, the Secretary shall compute a national limited purchase

price -

(i) for 1991, equal to the local purchase price computed

under subparagraph (A)(ii) for the item for the year, except

that such national limited purchase price may not exceed 100

percent of the weighted average of all local purchase prices

for the item computed under such subparagraph for the year,

and may not be less than 85 percent of the weighted average

of all local purchase prices for the item computed under such

subparagraph for the year;

(ii) for 1992 and 1993, the amount determined under this

subparagraph for the preceding year increased by the covered

item update for such subsequent year;

(iii) for 1994, the local purchase price computed under

subparagraph (A)(ii) for the item for the year, except that

such national limited purchase price may not exceed 100

percent of the median of all local purchase prices computed

for the item under such subparagraph for the year and may not

be less than 85 percent of the median of all local purchase

prices computed under such subparagraph for the item for the

year; and

(iv) for each subsequent year, equal to the amount

determined under this subparagraph for the preceding year

increased by the covered item update for such subsequent

year.

(C) Purchase price recognized

For purposes of paragraphs (6) and (7), the amount that is

recognized under this paragraph as the purchase price for each

item furnished -

(i) in 1989 or 1990, is 100 percent of the local purchase

price computed under subparagraph (A)(ii)(I);

(ii) in 1991, is the sum of (I) 67 percent of the local

purchase price computed under subparagraph (A)(ii)(II) for

1991, and (II) 33 percent of the national limited purchase

price computed under subparagraph (B) for 1991;

(iii) in 1992, is the sum of (I) 33 percent of the local

purchase price computed under subparagraph (A)(ii)(III) for

1992, and (II) 67 percent of the national limited purchase

price computed under subparagraph (B) for 1992; and

(iv) in 1993 or a subsequent year, is the national limited

purchase price computed under subparagraph (B) for that year.

(9) Monthly payment amount recognized with respect to oxygen and

oxygen equipment

For purposes of paragraph (5), the amount that is recognized

under this paragraph for payment for oxygen and oxygen equipment

is the monthly payment amount described in subparagraph (C) of

this paragraph. Such amount shall be computed separately (i) for

all items of oxygen and oxygen equipment (other than portable

oxygen equipment) and (ii) for portable oxygen equipment (each

such group referred to in this paragraph as an "item").

(A) Computation of local monthly payment rate

Each carrier under this section shall compute a base local

payment rate for each item as follows:

(i) The carrier shall compute a base local average monthly

payment rate per beneficiary as an amount equal to (I) the

total reasonable charges for the item during the 12-month

period ending with December 1986, divided by (II) the total

number of months for all beneficiaries receiving the item in

the area during the 12-month period for which the carrier

made payment for the item under this subchapter.

(ii) The carrier shall compute a local average monthly

payment rate for the item applicable -

(I) to 1989 and 1990, equal to 95 percent of the base

local average monthly payment rate computed under clause

(i) for the item increased by the percentage increase in

the consumer price index for all urban consumers (U.S. city

average) for the 6-month period ending with December 1987,

or

(II) to 1991, 1992, 1993, and 1994, equal to the local

average monthly payment rate computed under this clause for

the item for the previous year increased by the covered

item increase for the year.

(B) Computation of national limited monthly payment rate

With respect to the furnishing of an item in a year, the

Secretary shall compute a national limited monthly payment rate

equal to -

(i) for 1991, the local monthly payment rate computed under

subparagraph (A)(ii)(II) for the item for the year, except

that such national limited monthly payment rate may not

exceed 100 percent of the weighted average of all local

monthly payment rates computed for the item under such

subparagraph for the year, and may not be less than 85

percent of the weighted average of all local monthly payment

rates computed for the item under such subparagraph for the

year;

(ii) for 1992 and 1993, the amount determined under this

subparagraph for the preceding year increased by the covered

item update for such subsequent year;

(iii) for 1994, the local monthly payment rate computed

under subparagraph (A)(ii) for the item for the year, except

that such national limited monthly payment rate may not

exceed 100 percent of the median of all local monthly payment

rates computed for the item under such subparagraph for the

year and may not be less than 85 percent of the median of all

local monthly payment rates computed for the item under such

subparagraph for the year;

(iv) for 1995, 1996, and 1997, equal to the amount

determined under this subparagraph for the preceding year

increased by the covered item update for such subsequent

year;

(v) for 1998, 75 percent of the amount determined under

this subparagraph for 1997; and

(vi) for 1999 and each subsequent year, 70 percent of the

amount determined under this subparagraph for 1997.

(C) Monthly payment amount recognized

For purposes of paragraph (5), the amount that is recognized

under this paragraph as the base monthly payment amount for

each item furnished -

(i) in 1989 and in 1990, is 100 percent of the local

average monthly payment rate computed under subparagraph

(A)(ii) for the item;

(ii) in 1991, is the sum of (I) 67 percent of the local

average monthly payment rate computed under subparagraph

(A)(ii)(II) for the item for 1991, and (II) 33 percent of the

national limited monthly payment rate computed under

subparagraph (B)(i) for the item for 1991;

(iii) in 1992, is the sum of (I) 33 percent of the local

average monthly payment rate computed under subparagraph

(A)(ii)(II) for the item for 1992, and (II) 67 percent of the

national limited monthly payment rate computed under

subparagraph (B)(ii) for the item for 1992; and

(iv) in a subsequent year, is the national limited monthly

payment rate computed under subparagraph (B) for the item for

that year.

(D) Authority to create classes

(i) In general

Subject to clause (ii), the Secretary may establish

separate classes for any item of oxygen and oxygen equipment

and separate national limited monthly payment rates for each

of such classes.

(ii) Budget neutrality

The Secretary may take actions under clause (i) only to the

extent such actions do not result in expenditures for any

year to be more or less than the expenditures which would

have been made if such actions had not been taken.

(10) Exceptions and adjustments

(A) Areas outside continental United States

Exceptions to the amounts recognized under the previous

provisions of this subsection shall be made to take into

account the unique circumstances of covered items furnished in

Alaska, Hawaii, or Puerto Rico.

(B) Adjustment for inherent reasonableness

The Secretary is authorized to apply the provisions of

paragraphs (8) and (9) of section 1395u(b) of this title to

covered items and suppliers of such items and payments under

this subsection.

(C) Transcutaneous electrical nerve stimulator (TENS)

In order to permit an attending physician time to determine

whether the purchase of a transcutaneous electrical nerve

stimulator is medically appropriate for a particular patient,

the Secretary may determine an appropriate payment amount for

the initial rental of such item for a period of not more than 2

months. If such item is subsequently purchased, the payment

amount with respect to such purchase is the payment amount

determined under paragraph (2).

(11) Improper billing and requirement of physician order

(A) Improper billing for certain rental items

Notwithstanding any other provision of this subchapter, a

supplier of a covered item for which payment is made under this

subsection and which is furnished on a rental basis shall

continue to supply the item without charge (other than a charge

provided under this subsection for the maintenance and

servicing of the item) after rental payments may no longer be

made under this subsection. If a supplier knowingly and

willfully violates the previous sentence, the Secretary may

apply sanctions against the supplier under section 1395u(j)(2)

of this title in the same manner such sanctions may apply with

respect to a physician.

(B) Requirement of physician order

The Secretary is authorized to require, for specified covered

items, that payment may be made under this subsection with

respect to the item only if a physician has communicated to the

supplier, before delivery of the item, a written order for the

item.

(12) Regional carriers

The Secretary may designate, by regulation under section 1395u

of this title, one carrier for one or more entire regions to

process all claims within the region for covered items under this

section.

(13) "Covered item" defined

In this subsection, the term "covered item" means durable

medical equipment (as defined in section 1395x(n) of this title),

including such equipment described in section 1395x(m)(5) of this

title, but not including implantable items for which payment may

be made under section 1395l(t) of this title.

(14) Covered item update

In this subsection, the term "covered item update" means, with

respect to a year -

(A) for 1991 and 1992, the percentage increase in the

consumer price index for all urban consumers (U.S. city

average) for the 12-month period ending with June of the

previous year reduced by 1 percentage point;

(B) for 1993, 1994, 1995, 1996, and 1997, the percentage

increase in the consumer price index for all urban consumers

(U.S. city average) for the 12-month period ending with June of

the previous year;

(C) for each of the years 1998 through 2000, 0 percentage

points;

(D) for 2001, the percentage increase in the consumer price

index for all urban consumers (U.S. city average) for the

12-month period ending with June 2000;

(E) for 2002, 0 percentage points; and

(F) for a subsequent year, the percentage increase in the

consumer price index for all urban consumers (U.S. urban

average) for the 12-month period ending with June of the

previous year.

(15) Advance determinations of coverage for certain items

(A) Development of lists of items by Secretary

The Secretary may develop and periodically update a list of

items for which payment may be made under this subsection that

the Secretary determines, on the basis of prior payment

experience, are frequently subject to unnecessary utilization

throughout a carrier's entire service area or a portion of such

area.

(B) Development of lists of suppliers by Secretary

The Secretary may develop and periodically update a list of

suppliers of items for which payment may be made under this

subsection with respect to whom -

(i) the Secretary has found that a substantial number of

claims for payment under this part for items furnished by the

supplier have been denied on the basis of the application of

section 1395y(a)(1) of this title; or

(ii) the Secretary has identified a pattern of

overutilization resulting from the business practice of the

supplier.

(C) Determinations of coverage in advance

A carrier shall determine in advance of delivery of an item

whether payment for the item may not be made because the item

is not covered or because of the application of section

1395y(a)(1) of this title if -

(i) the item is included on the list developed by the

Secretary under subparagraph (A);

(ii) the item is furnished by a supplier included on the

list developed by the Secretary under subparagraph (B); or

(iii) the item is a customized item (other than inexpensive

items specified by the Secretary) and the patient to whom the

item is to be furnished or the supplier requests that such

advance determination be made.

(16) Disclosure of information and surety bond

The Secretary shall not provide for the issuance (or renewal)

of a provider number for a supplier of durable medical equipment,

for purposes of payment under this part for durable medical

equipment furnished by the supplier, unless the supplier provides

the Secretary on a continuing basis -

(A) with -

(i) full and complete information as to the identity of

each person with an ownership or control interest (as defined

in section 1320a-3(a)(3) of this title) in the supplier or in

any subcontractor (as defined by the Secretary in

regulations) in which the supplier directly or indirectly has

a 5 percent or more ownership interest; and

(ii) to the extent determined to be feasible under

regulations of the Secretary, the name of any disclosing

entity (as defined in section 1320a-3(a)(2) of this title)

with respect to which a person with such an ownership or

control interest in the supplier is a person with such an

ownership or control interest in the disclosing entity; and

(B) with a surety bond in a form specified by the Secretary

and in an amount that is not less than $50,000.

The Secretary may waive the requirement of a bond under

subparagraph (B) in the case of a supplier that provides a

comparable surety bond under State law. The Secretary, at the

Secretary's discretion, may impose the requirements of the first

sentence with respect to some or all providers of items or

services under part A of this subchapter or some or all suppliers

or other persons (other than physicians or other practitioners,

as defined in section 1395u(b)(18)(C) of this title) who furnish

items or services under this part.

(17) (!2) Certain upgraded items

(A) Individual's right to choose upgraded item

Notwithstanding any other provision of this subchapter, the

Secretary may issue regulations under which an individual may

purchase or rent from a supplier an item of upgraded durable

medical equipment for which payment would be made under this

subsection if the item were a standard item.

(B) Payments to supplier

In the case of the purchase or rental of an upgraded item

under subparagraph (A) -

(i) the supplier shall receive payment under this

subsection with respect to such item as if such item were a

standard item; and

(ii) the individual purchasing or renting the item shall

pay the supplier an amount equal to the difference between

the supplier's charge and the amount under clause (i).

In no event may the supplier's charge for an upgraded item

exceed the applicable fee schedule amount (if any) for such

item.

(C) Consumer protection safeguards

Any regulations under subparagraph (A) shall provide for

consumer protection standards with respect to the furnishing of

upgraded equipment under subparagraph (A). Such regulations

shall provide for -

(i) determination of fair market prices with respect to an

upgraded item;

(ii) full disclosure of the availability and price of

standard items and proof of receipt of such disclosure

information by the beneficiary before the furnishing of the

upgraded item;

(iii) conditions of participation for suppliers in the

billing arrangement;

(iv) sanctions of suppliers who are determined to engage in

coercive or abusive practices, including exclusion; and

(v) such other safeguards as the Secretary determines are

necessary.

(17) (!2) Prohibition against unsolicited telephone contacts by

suppliers

(A) In general

A supplier of a covered item under this subsection may not

contact an individual enrolled under this part by telephone

regarding the furnishing of a covered item to the individual

unless 1 of the following applies:

(i) The individual has given written permission to the

supplier to make contact by telephone regarding the

furnishing of a covered item.

(ii) The supplier has furnished a covered item to the

individual and the supplier is contacting the individual only

regarding the furnishing of such covered item.

(iii) If the contact is regarding the furnishing of a

covered item other than a covered item already furnished to

the individual, the supplier has furnished at least 1 covered

item to the individual during the 15-month period preceding

the date on which the supplier makes such contact.

(B) Prohibiting payment for items furnished subsequent to

unsolicited contacts

If a supplier knowingly contacts an individual in violation

of subparagraph (A), no payment may be made under this part for

any item subsequently furnished to the individual by the

supplier.

(C) Exclusion from program for suppliers engaging in pattern of

unsolicited contacts

If a supplier knowingly contacts individuals in violation of

subparagraph (A) to such an extent that the supplier's conduct

establishes a pattern of contacts in violation of such

subparagraph, the Secretary shall exclude the supplier from

participation in the programs under this chapter, in accordance

with the procedures set forth in subsections (c), (f), and (g)

of section 1320a-7 of this title.

(18) Refund of amounts collected for certain disallowed items

(A) In general

If a nonparticipating supplier furnishes to an individual

enrolled under this part a covered item for which no payment

may be made under this part by reason of paragraph (17)(B), the

supplier shall refund on a timely basis to the patient (and

shall be liable to the patient for) any amounts collected from

the patient for the item, unless -

(i) the supplier establishes that the supplier did not know

and could not reasonably have been expected to know that

payment may not be made for the item by reason of paragraph

(17)(B), or

(ii) before the item was furnished, the patient was

informed that payment under this part may not be made for

that item and the patient has agreed to pay for that item.

(B) Sanctions

If a supplier knowingly and willfully fails to make refunds

in violation of subparagraph (A), the Secretary may apply

sanctions against the supplier in accordance with section

1395u(j)(2) of this title.

(C) Notice

Each carrier with a contract in effect under this part with

respect to suppliers of covered items shall send any notice of

denial of payment for covered items by reason of paragraph

(17)(B) and for which payment is not requested on an

assignment-related basis to the supplier and the patient

involved.

(D) Timely basis defined

A refund under subparagraph (A) is considered to be on a

timely basis only if -

(i) in the case of a supplier who does not request

reconsideration or seek appeal on a timely basis, the refund

is made within 30 days after the date the supplier receives a

denial notice under subparagraph (C), or

(ii) in the case in which such a reconsideration or appeal

is taken, the refund is made within 15 days after the date

the supplier receives notice of an adverse determination on

reconsideration or appeal.

(b) Fee schedules for radiologist services

(1) Development

The Secretary shall develop -

(A) a relative value scale to serve as the basis for the

payment for radiologist services under this part, and

(B) using such scale and appropriate conversion factors and

subject to subsection (c)(1)(A) of this section, fee schedules

(on a regional, statewide, locality, or carrier service area

basis) for payment for radiologist services under this part, to

be implemented for such services furnished during 1989.

(2) Consultation

In carrying out paragraph (1), the Secretary shall regularly

consult closely with the Physician Payment Review Commission, the

American College of Radiology, and other organizations

representing physicians or suppliers who furnish radiologist

services and shall share with them the data and data analysis

being used to make the determinations under paragraph (1),

including data on variations in current medicare payments by

geographic area, and by service and physician specialty.

(3) Considerations

In developing the relative value scale and fee schedules under

paragraph (1), the Secretary -

(A) shall take into consideration variations in the cost of

furnishing such services among geographic areas and among

different sites where services are furnished, and

(B) may also take into consideration such other factors

respecting the manner in which physicians in different

specialties furnish such services as may be appropriate to

assure that payment amounts are equitable and designed to

promote effective and efficient provision of radiologist

services by physicians in the different specialties.

(4) Savings

(A) Budget neutral fee schedules

The Secretary shall develop preliminary fee schedules for

1989, which are designed to result in the same amount of

aggregate payments (net of any coinsurance and deductibles

under sections 1395l(a)(1)(J) and 1395l(b) of this title) for

radiologist services furnished in 1989 as would have been made

if this subsection had not been enacted.

(B) Initial savings

The fee schedules established for payment purposes under this

subsection for services furnished in 1989 shall be 97 percent

of the amounts permitted under the preliminary fee schedules

developed under subparagraph (A).

(C) 1990 fee schedules

For radiologist services (other than portable X-ray services)

furnished under this part during 1990, after March 31 of such

year, the conversion factors used under this subsection shall

be 96 percent of the conversion factors that applied under this

subsection as of December 31, 1989.

(D) 1991 fee schedules

For radiologist services (other than portable X-ray services)

furnished under this part during 1991, the conversion factors

used in a locality under this subsection shall, subject to

clause (vii), be reduced to the adjusted conversion factor for

the locality determined as follows:

(i) National weighted average conversion factor

The Secretary shall estimate the national weighted average

of the conversion factors used under this subsection for

services furnished during 1990 beginning on April 1, using

the best available data.

(ii) Reduced national weighted average

The national weighted average estimated under clause (i)

shall be reduced by 13 percent.

(iii) Computation of 1990 locality index relative to national

average

The Secretary shall establish an index which reflects, for

each locality, the ratio of the conversion factor used in the

locality under this subsection to the national weighted

average estimated under clause (i).

(iv) Adjusted conversion factor

The adjusted conversion factor for the professional or

technical component of a service in a locality is the sum of

(!1/2) of the locally-adjusted amount determined under clause

(v) and (!1/2) of the GPCI-adjusted amount determined under

clauses (!3) (vi).

(v) Locally-adjusted amount

For purposes of clause (iv), the locally adjusted amount

determined under this clause is the product of (I) the

national weighted average conversion factor computed under

clause (ii), and (II) the index value established under

clause (iii) for the locality.

(vi) GPCI-adjusted amount

For purposes of clause (iv), the GPCI-adjusted amount

determined under this clause is the sum of -

(I) the product of (a) the portion of the reduced

national weighted average conversion factor computed under

clause (ii) which is attributable to physician work and (b)

the geographic work index value for the locality (specified

in Addendum C to the Model Fee Schedule for Physician

Services (published on September 4, 1990, 55 Federal

Register pp. 36238-36243)); and

(II) the product of (a) the remaining portion of the

reduced national weighted average conversion factor

computed under clause (ii), and (b) the geographic practice

cost index value specified in section 1395u(b)(14)(C)(iv)

of this title for the locality.

In applying this clause with respect to the professional

component of a service, 80 percent of the conversion factor

shall be considered to be attributable to physician work and

with respect to the technical component of the service, 0

percent shall be considered to be attributable to physician

work.

(vii) Limits on conversion factor

The conversion factor to be applied to a locality to the

professional or technical component of a service shall not be

reduced under this subparagraph by more than 9.5 percent

below the conversion factor applied in the locality under

subparagraph (C) to such component, but in no case shall the

conversion factor be less than 60 percent of the national

weighted average of the conversion factors (computed under

clause (i)).

(E) Rule for certain scanning services

In the case of the technical components of magnetic resonance

imaging (MRI) services and computer assisted tomography (CAT)

services furnished after December 31, 1990, the amount

otherwise payable shall be reduced by 10 percent.

(F) Subsequent updating

For radiologist services furnished in subsequent years, the

fee schedules shall be the schedules for the previous year

updated by the percentage increase in the MEI (as defined in

section 1395u(i)(3) of this title) for the year.

(G) Nonparticipating physicians and suppliers

Each fee schedule so established shall provide that the

payment rate recognized for nonparticipating physicians and

suppliers is equal to the appropriate percent (as defined in

section 1395u(b)(4)(A)(iv) of this title) of the payment rate

recognized for participating physicians and suppliers.

(5) Limiting charges of nonparticipating physicians and suppliers

(A) In general

In the case of radiologist services furnished after January

1, 1989, for which payment is made under a fee schedule under

this subsection, if a nonparticipating physician or supplier

furnishes the service to an individual entitled to benefits

under this part, the physician or supplier may not charge the

individual more than the limiting charge (as defined in

subparagraph (B)).

(B) "Limiting charge" defined

In subparagraph (A), the term "limiting charge" means, with

respect to a service furnished -

(i) in 1989, 125 percent of the amount specified for the

service in the appropriate fee schedule established under

paragraph (1),

(ii) in 1990, 120 percent of the amount specified for the

service in the appropriate fee schedule established under

paragraph (1), and

(iii) after 1990, 115 percent of the amount specified for

the service in the appropriate fee schedule established under

paragraph (1).

(C) Enforcement

If a physician or supplier knowingly and willfully bills in

violation of subparagraph (A), the Secretary may apply

sanctions against such physician or supplier in accordance with

section 1395u(j)(2) of this title in the same manner as such

sanctions may apply to a physician.

(6) "Radiologist services" defined

For the purposes of this subsection and section 1395l(a)(1)(J)

of this title, the term "radiologist services" only includes

radiology services performed by, or under the direction or

supervision of, a physician -

(A) who is certified, or eligible to be certified, by the

American Board of Radiology, or

(B) for whom radiology services account for at least 50

percent of the total amount of charges made under this part.

(c) Payment and standards for screening mammography

(1) In general

With respect to expenses incurred for screening mammography (as

defined in section 1395x(jj) of this title), payment may be made

only -

(A) for screening mammography conducted consistent with the

frequency permitted under paragraph (2); and

(B) if the screening mammography is conducted by a facility

that has a certificate (or provisional certificate) issued

under section 263b of this title.

(2) Frequency covered

(A) In general

Subject to revision by the Secretary under subparagraph (B) -

(i) no payment may be made under this part for screening

mammography performed on a woman under 35 years of age;

(ii) payment may be made under this part for only one

screening mammography performed on a woman over 34 years of

age, but under 40 years of age; and

(iii) in the case of a woman over 39 years of age, payment

may not be made under this part for screening mammography

performed within 11 months following the month in which a

previous screening mammography was performed.

(B) Revision of frequency

(i) Review

The Secretary, in consultation with the Director of the

National Cancer Institute, shall review periodically the

appropriate frequency for performing screening mammography,

based on age and such other factors as the Secretary believes

to be pertinent.

(ii) Revision of frequency

The Secretary, taking into consideration the review made

under clause (i), may revise from time to time the frequency

with which screening mammography may be paid for under this

subsection.

(d) Frequency limits and payment for colorectal cancer screening

tests

(1) Screening fecal-occult blood tests

(A) Payment amount

The payment amount for colorectal cancer screening tests

consisting of screening fecal-occult blood tests is equal to

the payment amount established for diagnostic fecal-occult

blood tests under section 1395l(h) of this title.

(B) Frequency limit

No payment may be made under this part for a colorectal

cancer screening test consisting of a screening fecal-occult

blood test -

(i) if the individual is under 50 years of age; or

(ii) if the test is performed within the 11 months after a

previous screening fecal-occult blood test.

(2) Screening flexible sigmoidoscopies

(A) Fee schedule

With respect to colorectal cancer screening tests consisting

of screening flexible sigmoidoscopies, payment under section

1395w-4 of this title shall be consistent with payment under

such section for similar or related services.

(B) Payment limit

In the case of screening flexible sigmoidoscopy services,

payment under this part shall not exceed such amount as the

Secretary specifies, based upon the rates recognized for

diagnostic flexible sigmoidoscopy services.

(C) Facility payment limit

(i) In general

Notwithstanding subsections (i)(2)(A) and (t) of section

1395l of this title, in the case of screening flexible

sigmoidoscopy services furnished on or after January 1, 1999,

that -

(I) in accordance with regulations, may be performed in

an ambulatory surgical center and for which the Secretary

permits ambulatory surgical center payments under this

part, and

(II) are performed in an ambulatory surgical center or

hospital outpatient department,

payment under this part shall be based on the lesser of the

amount under the fee schedule that would apply to such

services if they were performed in a hospital outpatient

department in an area or the amount under the fee schedule

that would apply to such services if they were performed in

an ambulatory surgical center in the same area.

(ii) Limitation on deductible and coinsurance

Notwithstanding any other provision of this subchapter, in

the case of a beneficiary who receives the services described

in clause (i) -

(I) in computing the amount of any applicable deductible

or copayment, the computation of such deductible or

coinsurance shall be based upon the fee schedule under

which payment is made for the services, and

(II) the amount of such coinsurance is equal to 25

percent of the payment amount under the fee schedule

described in subclause (I).

(D) Special rule for detected lesions

If during the course of such screening flexible

sigmoidoscopy, a lesion or growth is detected which results in

a biopsy or removal of the lesion or growth, payment under this

part shall not be made for the screening flexible sigmoidoscopy

but shall be made for the procedure classified as a flexible

sigmoidoscopy with such biopsy or removal.

(E) Frequency limit

No payment may be made under this part for a colorectal

cancer screening test consisting of a screening flexible

sigmoidoscopy -

(i) if the individual is under 50 years of age; or

(ii) if the procedure is performed within the 47 months

after a previous screening flexible sigmoidoscopy or, in the

case of an individual who is not at high risk for colorectal

cancer, if the procedure is performed within the 119 months

after a previous screening colonoscopy.

(3) Screening colonoscopy

(A) Fee schedule

With respect to colorectal cancer screening test consisting

of a screening colonoscopy, payment under section 1395w-4 of

this title shall be consistent with payment amounts under such

section for similar or related services.

(B) Payment limit

In the case of screening colonoscopy services, payment under

this part shall not exceed such amount as the Secretary

specifies, based upon the rates recognized for diagnostic

colonoscopy services.

(C) Facility payment limit

(i) In general

Notwithstanding subsections (i)(2)(A) and (t) of section

1395l of this title, in the case of screening colonoscopy

services furnished on or after January 1, 1999, that are

performed in an ambulatory surgical center or a hospital

outpatient department, payment under this part shall be based

on the lesser of the amount under the fee schedule that would

apply to such services if they were performed in a hospital

outpatient department in an area or the amount under the fee

schedule that would apply to such services if they were

performed in an ambulatory surgical center in the same area.

(ii) Limitation on deductible and coinsurance

Notwithstanding any other provision of this subchapter, in

the case of a beneficiary who receives the services described

in clause (i) -

(I) in computing the amount of any applicable deductible

or coinsurance, the computation of such deductible or

coinsurance shall be based upon the fee schedule under

which payment is made for the services, and

(II) the amount of such coinsurance is equal to 25

percent of the payment amount under the fee schedule

described in subclause (I).

(D) Special rule for detected lesions

If during the course of such screening colonoscopy, a lesion

or growth is detected which results in a biopsy or removal of

the lesion or growth, payment under this part shall not be made

for the screening colonoscopy but shall be made for the

procedure classified as a colonoscopy with such biopsy or

removal.

(E) Frequency limit

No payment may be made under this part for a colorectal

cancer screening test consisting of a screening colonoscopy for

individuals at high risk for colorectal cancer if the procedure

is performed within the 23 months after a previous screening

colonoscopy or for other individuals if the procedure is

performed within the 119 months after a previous screening

colonoscopy or within 47 months after a previous screening

flexible sigmoidoscopy.

(e) Repealed. Pub. L. 101-234, title II, Sec. 201(a), Dec. 13,

1989, 103 Stat. 1981

(f) Reduction in payments for physician pathology services during

1991

(1) In general

For physician pathology services furnished under this part

during 1991, the prevailing charges used in a locality under this

part shall be 7 percent below the prevailing charges used in the

locality under this part in 1990 after March 31.

(2) Limitation

The prevailing charge for the technical and professional

components of an (!4) physician pathology service furnished by a

physician through an independent laboratory shall not be reduced

pursuant to paragraph (1) to the extent that such reduction would

reduce such prevailing charge below 115 percent of the prevailing

charge for the professional component of such service when

furnished by a hospital-based physician in the same locality. For

purposes of the preceding sentence, an independent laboratory is

a laboratory that is independent of a hospital and separate from

the attending or consulting physicians' office.

(g) Payment for outpatient critical access hospital services

(1) In general

The amount of payment for outpatient critical access hospital

services of a critical access hospital is the reasonable costs of

the hospital in providing such services, unless the hospital

makes the election under paragraph (2).

(2) Election of cost-based hospital outpatient service payment

plus fee schedule for professional services

A critical access hospital may elect to be paid for outpatient

critical access hospital services amounts equal to the sum of the

following, less the amount that such hospital may charge as

described in section 1395cc(a)(2)(A) of this title:

(A) Facility fee

With respect to facility services, not including any services

for which payment may be made under subparagraph (B), the

reasonable costs of the critical access hospital in providing

such services.

(B) Fee schedule for professional services

With respect to professional services otherwise included

within outpatient critical access hospital services, 115

percent of such amounts as would otherwise be paid under this

part if such services were not included in outpatient critical

access hospital services.

(3) Disregarding charges

The payment amounts under this subsection shall be determined

without regard to the amount of the customary or other charge.

(4) No beneficiary cost-sharing for clinical diagnostic

laboratory services

No coinsurance, deductible, copayment, or other cost-sharing

otherwise applicable under this part shall apply with respect to

clinical diagnostic laboratory services furnished as an

outpatient critical access hospital service. Nothing in this

subchapter shall be construed as providing for payment for

clinical diagnostic laboratory services furnished as part of

outpatient critical access hospital services, other than on the

basis described in this subsection.

(5) Coverage of costs for emergency room on-call physicians

In determining the reasonable costs of outpatient critical

access hospital services under paragraphs (1) and (2)(A), the

Secretary shall recognize as allowable costs, amounts (as defined

by the Secretary) for reasonable compensation and related costs

for emergency room physicians who are on-call (as defined by the

Secretary) but who are not present on the premises of the

critical access hospital involved, and are not otherwise

furnishing physicians' services and are not on-call at any other

provider or facility.

(h) Payment for prosthetic devices and orthotics and prosthetics

(1) General rule for payment

(A) In general

Payment under this subsection for prosthetic devices and

orthotics and prosthetics shall be made in a lump-sum amount

for the purchase of the item in an amount equal to 80 percent

of the payment basis described in subparagraph (B).

(B) Payment basis

Except as provided in subparagraphs (C) and (E), the payment

basis described in this subparagraph is the lesser of -

(i) the actual charge for the item; or

(ii) the amount recognized under paragraph (2) as the

purchase price for the item.

(C) Exception for certain public home health agencies

Subparagraph (B)(i) shall not apply to an item 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) free of

charge or at nominal charges to the public.

(D) Exclusive payment rule

This subsection shall constitute the exclusive provision of

this subchapter for payment for prosthetic devices, orthotics,

and prosthetics under this part or under part A of this

subchapter to a home health agency.

(E) Exception for certain items

Payment for ostomy supplies, tracheostomy supplies, and

urologicals shall be made in accordance with subparagraphs (B)

and (C) of subsection (a)(2) of this section.

(F) Special payment rules for certain prosthetics and

custom-fabricated orthotics

(i) In general

No payment shall be made under this subsection for an item

of custom-fabricated orthotics described in clause (ii) or

for an item of prosthetics unless such item is -

(I) furnished by a qualified practitioner; and

(II) fabricated by a qualified practitioner or a

qualified supplier at a facility that meets such criteria

as the Secretary determines appropriate.

(ii) Description of custom-fabricated item

(I) In general

An item described in this clause is an item of

custom-fabricated orthotics that requires education,

training, and experience to custom-fabricate and that is

included in a list established by the Secretary in

subclause (II). Such an item does not include shoes and

shoe inserts.

(II) List of items

The Secretary, in consultation with appropriate experts

in orthotics (including national organizations representing

manufacturers of orthotics), shall establish and update as

appropriate a list of items to which this subparagraph

applies. No item may be included in such list unless the

item is individually fabricated for the patient over a

positive model of the patient.

(iii) Qualified practitioner defined

In this subparagraph, the term "qualified practitioner"

means a physician or other individual who -

(I) is a qualified physical therapist or a qualified

occupational therapist;

(II) in the case of a State that provides for the

licensing of orthotics and prosthetics, is licensed in

orthotics or prosthetics by the State in which the item is

supplied; or

(III) in the case of a State that does not provide for

the licensing of orthotics and prosthetics, is specifically

trained and educated to provide or manage the provision of

prosthetics and custom-designed or -fabricated orthotics,

and is certified by the American Board for Certification in

Orthotics and Prosthetics, Inc. or by the Board for

Orthotist/Prosthetist Certification, or is credentialed and

approved by a program that the Secretary determines, in

consultation with appropriate experts in orthotics and

prosthetics, has training and education standards that are

necessary to provide such prosthetics and orthotics.

(iv) Qualified supplier defined

In this subparagraph, the term "qualified supplier" means

any entity that is accredited by the American Board for

Certification in Orthotics and Prosthetics, Inc. or by the

Board for Orthotist/Prosthetist Certification, or accredited

and approved by a program that the Secretary determines has

accreditation and approval standards that are essentially

equivalent to those of such Board.

(G) Replacement of prosthetic devices and parts

(i) In general

Payment shall be made for the replacement of prosthetic

devices which are artificial limbs, or for the replacement of

any part of such devices, without regard to continuous use or

useful lifetime restrictions if an ordering physician

determines that the provision of a replacement device, or a

replacement part of such a device, is necessary because of

any of the following:

(I) A change in the physiological condition of the

patient.

(II) An irreparable change in the condition of the

device, or in a part of the device.

(III) The condition of the device, or the part of the

device, requires repairs and the cost of such repairs would

be more than 60 percent of the cost of a replacement

device, or, as the case may be, of the part being replaced.

(ii) Confirmation may be required if device or part being

replaced is less than 3 years old

If a physician determines that a replacement device, or a

replacement part, is necessary pursuant to clause (i) -

(I) such determination shall be controlling; and

(II) such replacement device or part shall be deemed to

be reasonable and necessary for purposes of section

1395y(a)(1)(A) of this title;

except that if the device, or part, being replaced is less

than 3 years old (calculated from the date on which the

beneficiary began to use the device or part), the Secretary

may also require confirmation of necessity of the replacement

device or replacement part, as the case may be.

(2) Purchase price recognized

For purposes of paragraph (1), the amount that is recognized

under this paragraph as the purchase price for prosthetic

devices, orthotics, and prosthetics is the amount described in

subparagraph (C) of this paragraph, determined as follows:

(A) Computation of local purchase price

Each carrier under section 1395u of this title shall compute

a base local purchase price for the item as follows:

(i) The carrier shall compute a base local purchase price

for each item equal to the average reasonable charge in the

locality for the purchase of the item for the 12-month period

ending with June 1987.

(ii) The carrier shall compute a local purchase price, with

respect to the furnishing of each particular item -

(I) in 1989 and 1990, equal to the base local purchase

price computed under clause (i) increased by the percentage

increase in the consumer price index for all urban

consumers (United States city average) for the 6-month

period ending with December 1987, or

(II) in 1991, 1992 or 1993, equal to the local purchase

price computed under this clause for the previous year

increased by the applicable percentage increase for the

year.

(B) Computation of regional purchase price

With respect to the furnishing of a particular item in each

region (as defined by the Secretary), the Secretary shall

compute a regional purchase price -

(i) for 1992, equal to the average (weighted by relative

volume of all claims among carriers) of the local purchase

prices for the carriers in the region computed under

subparagraph (A)(ii)(II) for the year, and

(ii) for each subsequent year, equal to the regional

purchase price computed under this subparagraph for the

previous year increased by the applicable percentage increase

for the year.

(C) Purchase price recognized

For purposes of paragraph (1) and subject to subparagraph

(D), the amount that is recognized under this paragraph as the

purchase price for each item furnished -

(i) in 1989, 1990, or 1991, is 100 percent of the local

purchase price computed under subparagraph (A)(ii);

(ii) in 1992, is the sum of (I) 75 percent of the local

purchase price computed under subparagraph (A)(ii)(II) for

1992, and (II) 25 percent of the regional purchase price

computed under subparagraph (B) for 1992;

(iii) in 1993, is the sum of (I) 50 percent of the local

purchase price computed under subparagraph (A)(ii)(II) for

1993, and (II) 50 percent of the regional purchase price

computed under subparagraph (B) for 1993; and

(iv) in 1994 or a subsequent year, is the regional purchase

price computed under subparagraph (B) for that year.

(D) Range on amount recognized

The amount that is recognized under subparagraph (C) as the

purchase price for an item furnished -

(i) in 1992, may not exceed 125 percent, and may not be

lower than 85 percent, of the average of the purchase prices

recognized under such subparagraph for all the carrier

service areas in the United States in that year; and

(ii) in a subsequent year, may not exceed 120 percent, and

may not be lower than 90 percent, of the average of the

purchase prices recognized under such subparagraph for all

the carrier service areas in the United States in that year.

(3) Applicability of certain provisions relating to durable

medical equipment

Paragraphs (12), (15), and (17) and subparagraphs (A) and (B)

of paragraph (10) and paragraph (11) of subsection (a) of this

section shall apply to prosthetic devices, orthotics, and

prosthetics in the same manner as such provisions apply to

covered items under such subsection.

(4) Definitions

In this subsection -

(A) the term "applicable percentage increase" means -

(i) for 1991, 0 percent;

(ii) for 1992 and 1993, the percentage increase in the

consumer price index for all urban consumers (United States

city average) for the 12-month period ending with June of the

previous year;

(iii) for 1994 and 1995, 0 percent;

(iv) for 1996 and 1997, the percentage increase in the

consumer price index for all urban consumers (United States

city average) for the 12-month period ending with June of the

previous year;

(v) for each of the years 1998 through 2000, 1 percent;

(vi) for 2001, the percentage increase in the consumer

price index for all urban consumers (U.S. city average) for

the 12-month period ending with June 2000;

(vii) for 2002, 1 percent; and

(viii) for a subsequent year, the percentage increase in

the consumer price index for all urban consumers (United

States city average) for the 12-month period ending with June

of the previous year;

(B) the term "prosthetic devices" has the meaning given such

term in section 1395x(s)(8) of this title, except that such

term does not include parenteral and enteral nutrition

nutrients, supplies, and equipment and does not include an

implantable item for which payment may be made under section

1395l(t) of this title; and

(C) the term "orthotics and prosthetics" has the meaning

given such term in section 1395x(s)(9) of this title, but does

not include intraocular lenses or medical supplies (including

catheters, catheter supplies, ostomy bags, and supplies related

to ostomy care) furnished by a home health agency under section

1395x(m)(5) of this title.

(i) Payment for surgical dressings

(1) In general

Payment under this subsection for surgical dressings (described

in section 1395x(s)(5) of this title) shall be made in a lump sum

amount for the purchase of the item in an amount equal to 80

percent of the lesser of -

(A) the actual charge for the item; or

(B) a payment amount determined in accordance with the

methodology described in subparagraphs (B) and (C) of

subsection (a)(2) of this section (except that in applying such

methodology, the national limited payment amount referred to in

such subparagraphs shall be initially computed based on local

payment amounts using average reasonable charges for the

12-month period ending December 31, 1992, increased by the

covered item updates described in such subsection for 1993 and

1994).

(2) Exceptions

Paragraph (1) shall not apply to surgical dressings that are -

(A) furnished as an incident to a physician's professional

service; or

(B) furnished by a home health agency.

(j) Requirements for suppliers of medical equipment and supplies

(1) Issuance and renewal of supplier number

(A) Payment

Except as provided in subparagraph (C), no payment may be

made under this part after October 31, 1994, for items

furnished by a supplier of medical equipment and supplies

unless such supplier obtains (and renews at such intervals as

the Secretary may require) a supplier number.

(B) Standards for possessing a supplier number

A supplier may not obtain a supplier number unless -

(i) for medical equipment and supplies furnished on or

after October 31, 1994, and before January 1, 1996, the

supplier meets standards prescribed by the Secretary in

regulations issued on June 18, 1992; and

(ii) for medical equipment and supplies furnished on or

after January 1, 1996, the supplier meets revised standards

prescribed by the Secretary (in consultation with

representatives of suppliers of medical equipment and

supplies, carriers, and consumers) that shall include

requirements that the supplier -

(I) comply with all applicable State and Federal

licensure and regulatory requirements;

(II) maintain a physical facility on an appropriate site;

(III) have proof of appropriate liability insurance; and

(IV) meet such other requirements as the Secretary may

specify.

(C) Exception for items furnished as incident to a physician's

service

Subparagraph (A) shall not apply with respect to medical

equipment and supplies furnished incident to a physician's

service.

(D) Prohibition against multiple supplier numbers

The Secretary may not issue more than one supplier number to

any supplier of medical equipment and supplies unless the

issuance of more than one number is appropriate to identify

subsidiary or regional entities under the supplier's ownership

or control.

(E) Prohibition against delegation of supplier determinations

The Secretary may not delegate (other than by contract under

section 1395u of this title) the responsibility to determine

whether suppliers meet the standards necessary to obtain a

supplier number.

(2) Certificates of medical necessity

(A) Limitation on information provided by suppliers on

certificates of medical necessity

(i) In general

Effective 60 days after October 31, 1994, a supplier of

medical equipment and supplies may distribute to physicians,

or to individuals entitled to benefits under this part, a

certificate of medical necessity for commercial purposes

which contains no more than the following information

completed by the supplier:

(I) An identification of the supplier and the beneficiary

to whom such medical equipment and supplies are furnished.

(II) A description of such medical equipment and

supplies.

(III) Any product code identifying such medical equipment

and supplies.

(IV) Any other administrative information (other than

information relating to the beneficiary's medical

condition) identified by the Secretary.

(ii) Information on payment amount and charges

If a supplier distributes a certificate of medical

necessity containing any of the information permitted to be

supplied under clause (i), the supplier shall also list on

the certificate of medical necessity the fee schedule amount

and the supplier's charge for the medical equipment or

supplies being furnished prior to distribution of such

certificate to the physician.

(iii) Penalty

Any supplier of medical equipment and supplies who

knowingly and willfully distributes a certificate of medical

necessity in violation of clause (i) or fails to provide the

information required under clause (ii) is subject to a civil

money penalty in an amount not to exceed $1,000 for each such

certificate of medical necessity so distributed. The

provisions of section 1320a-7a of this title (other than

subsections (a) and (b)) shall apply to civil money penalties

under this subparagraph in the same manner as they apply to a

penalty or proceeding under section 1320a-7a(a) of this

title.

(B) "Certificate of medical necessity" defined

For purposes of this paragraph, the term "certificate of

medical necessity" means a form or other document containing

information required by the carrier to be submitted to show

that an item is reasonable and necessary for the diagnosis or

treatment of illness or injury or to improve the functioning of

a malformed body member.

(3) Coverage and review criteria

The Secretary shall annually review the coverage and

utilization of items of medical equipment and supplies to

determine whether such items should be made subject to coverage

and utilization review criteria, and if appropriate, shall

develop and apply such criteria to such items.

(4) Limitation on patient liability

If a supplier of medical equipment and supplies (as defined in

paragraph (5)) -

(A) furnishes an item or service to a beneficiary for which

no payment may be made by reason of paragraph (1);

(B) furnishes an item or service to a beneficiary for which

payment is denied in advance under subsection (a)(15) of this

section; or

(C) furnishes an item or service to a beneficiary for which

payment is denied under section 1395y(a)(1) of this title;

any expenses incurred for items and services furnished to an

individual by such a supplier not on an assigned basis shall be

the responsibility of such supplier. The individual shall have no

financial responsibility for such expenses and the supplier shall

refund on a timely basis to the individual (and shall be liable

to the individual for) any amounts collected from the individual

for such items or services. The provisions of subsection (a)(18)

of this section shall apply to refunds required under the

previous sentence in the same manner as such provisions apply to

refunds under such subsection.

(5) "Medical equipment and supplies" defined

The term "medical equipment and supplies" means -

(A) durable medical equipment (as defined in section 1395x(n)

of this title);

(B) prosthetic devices (as described in section 1395x(s)(8)

of this title);

(C) orthotics and prosthetics (as described in section

1395x(s)(9) of this title);

(D) surgical dressings (as described in section 1395x(s)(5)

of this title);

(E) such other items as the Secretary may determine; and

(F) for purposes of paragraphs (1) and (3) -

(i) home dialysis supplies and equipment (as described in

section 1395x(s)(2)(F) of this title),

(ii) immunosuppressive drugs (as described in section

1395x(s)(2)(J) of this title),

(iii) therapeutic shoes for diabetics (as described in

section 1395x(s)(12) of this title),

(iv) oral drugs prescribed for use as an anticancer

therapeutic agent (as described in section 1395x(s)(2)(Q) of

this title), and

(v) self-administered erythropoetin (as described in

section 1395x(s)(2)(P) of this title).

(k) Payment for outpatient therapy services and comprehensive

outpatient rehabilitation services

(1) In general

With respect to services described in section 1395l(a)(8) or

1395l(a)(9) of this title for which payment is determined under

this subsection, the payment basis shall be -

(A) for services furnished during 1998, the amount determined

under paragraph (2); or

(B) for services furnished during a subsequent year, 80

percent of the lesser of -

(i) the actual charge for the services, or

(ii) the applicable fee schedule amount (as defined in

paragraph (3)) for the services.

(2) Payment in 1998 based upon adjusted reasonable costs

The amount under this paragraph for services is the lesser of -

(A) the charges imposed for the services, or

(B) the adjusted reasonable costs (as defined in paragraph

(4)) for the services,

less 20 percent of the amount of the charges imposed for such

services.

(3) Applicable fee schedule amount

In this subsection, the term "applicable fee schedule amount"

means, with respect to services furnished in a year, the amount

determined under the fee schedule established under section

1395w-4 of this title for such services furnished during the year

or, if there is no such fee schedule established for such

services, the amount determined under the fee schedule

established for such comparable services as the Secretary

specifies.

(4) Adjusted reasonable costs

In paragraph (2), the term "adjusted reasonable costs" means,

with respect to any services, reasonable costs determined for

such services, reduced by 10 percent. The 10-percent reduction

shall not apply to services described in section 1395l(a)(8)(B)

of this title (relating to services provided by hospitals).

(5) Uniform coding

For claims for services submitted on or after April 1, 1998,

for which the amount of payment is determined under this

subsection, the claim shall include a code (or codes) under a

uniform coding system specified by the Secretary that identifies

the services furnished.

(6) Restraint on billing

The provisions of subparagraphs (A) and (B) of section

1395u(b)(18) of this title shall apply to therapy services for

which payment is made under this subsection in the same manner as

they apply to services provided by a practitioner described in

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

(l) Establishment of fee schedule for ambulance services

(1) In general

The Secretary shall establish a fee schedule for payment for

ambulance services whether provided directly by a supplier or

provider or under arrangement with a provider under this part

through a negotiated rulemaking process described in title 5 and

in accordance with the requirements of this subsection.

(2) Considerations

In establishing such fee schedule, the Secretary shall -

(A) establish mechanisms to control increases in expenditures

for ambulance services under this part;

(B) establish definitions for ambulance services which link

payments to the type of services provided;

(C) consider appropriate regional and operational

differences;

(D) consider adjustments to payment rates to account for

inflation and other relevant factors; and

(E) phase in the application of the payment rates under the

fee schedule in an efficient and fair manner, except that such

phase-in shall provide for full payment of any national mileage

rate for ambulance services provided by suppliers that are paid

by carriers in any of the 50 States where payment by a carrier

for such services for all such suppliers in such State did not,

prior to the implementation of the fee schedule, include a

separate amount for all mileage within the county from which

the beneficiary is transported.

(3) Savings

In establishing such fee schedule, the Secretary shall -

(A) ensure that the aggregate amount of payments made for

ambulance services under this part during 2000 does not exceed

the aggregate amount of payments which would have been made for

such services under this part during such year if the

amendments made by section 4531(a) of the Balanced Budget Act

of 1997 continued in effect, except that in making such

determination the Secretary shall assume an update in such

payments for 2002 equal to percentage increase in the consumer

price index for all urban consumers (U.S. city average) for the

12-month period ending with June of the previous year reduced

in the case of 2002 by 1.0 percentage points; and

(B) set the payment amounts provided under the fee schedule

for services furnished in 2001 and each subsequent year at

amounts equal to the payment amounts under the fee schedule for

services furnished during the previous year, increased by the

percentage increase in the consumer price index for all urban

consumers (U.S. city average) for the 12-month period ending

with June of the previous year reduced in the case of 2002 by

1.0 percentage points.

(4) Consultation

In establishing the fee schedule for ambulance services under

this subsection, the Secretary shall consult with various

national organizations representing individuals and entities who

furnish and regulate ambulance services and share with such

organizations relevant data in establishing such schedule.

(5) Limitation on review

There shall be no administrative or judicial review under

section 1395ff of this title or otherwise of the amounts

established under the fee schedule for ambulance services under

this subsection, including matters described in paragraph (2).

(6) Restraint on billing

The provisions of subparagraphs (A) and (B) of section

1395u(b)(18) of this title shall apply to ambulance services for

which payment is made under this subsection in the same manner as

they apply to services provided by a practitioner described in

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

(7) Coding system

The Secretary may require the claim for any services for which

the amount of payment is determined under this subsection to

include a code (or codes) under a uniform coding system specified

by the Secretary that identifies the services furnished.

(8) (!5) Services furnished by critical access hospitals

Notwithstanding any other provision of this subsection, the

Secretary shall pay the reasonable costs incurred in furnishing

ambulance services if such services are furnished -

(A) by a critical access hospital (as defined in section

1395x(mm)(1) of this title), or

(B) by an entity that is owned and operated by a critical

access hospital,

but only if the critical access hospital or entity is the only

provider or supplier of ambulance services that is located within

a 35-mile drive of such critical access hospital.

(8) (!5) Transitional assistance for rural providers

In the case of ground ambulance services furnished on or after

July 1, 2001, and before January 1, 2004, for which the

transportation originates in a rural area (as defined in section

1395ww(d)(2)(D) of this title) or in a rural census tract of a

metropolitan statistical area (as determined under the most

recent modification of the Goldsmith Modification, originally

published in the Federal Register on February 27, 1992 (57 Fed.

Reg. 6725)), the fee schedule established under this subsection

shall provide that, with respect to the payment rate for mileage

for a trip above 17 miles, and up to 50 miles, the rate otherwise

established shall be increased by not less than 1/2 of the

additional payment per mile established for the first 17 miles of

such a trip originating in a rural area.

(m) Payment for telehealth services

(1) In general

The Secretary shall pay for telehealth services that are

furnished via a telecommunications system by a physician (as

defined in section 1395x(r) of this title) or a practitioner

(described in section 1395u(b)(18)(C) of this title) to an

eligible telehealth individual enrolled under this part

notwithstanding that the individual physician or practitioner

providing the telehealth service is not at the same location as

the beneficiary. For purposes of the preceding sentence, in the

case of any Federal telemedicine demonstration program conducted

in Alaska or Hawaii, the term "telecommunications system"

includes store-and-forward technologies that provide for the

asynchronous transmission of health care information in single or

multimedia formats.

(2) Payment amount

(A) Distant site

The Secretary shall pay to a physician or practitioner

located at a distant site that furnishes a telehealth service

to an eligible telehealth individual an amount equal to the

amount that such physician or practitioner would have been paid

under this subchapter had such service been furnished without

the use of a telecommunications system.

(B) Facility fee for originating site

With respect to a telehealth service, subject to section

1395l(a)(1)(U) of this title, there shall be paid to the

originating site a facility fee equal to -

(i) for the period beginning on October 1, 2001, and ending

on December 31, 2001, and for 2002, $20; and

(ii) for a subsequent year, the facility fee specified in

clause (i) or this clause for the preceding year increased by

the percentage increase in the MEI (as defined in section

1395u(i)(3) of this title) for such subsequent year.

(C) Telepresenter not required

Nothing in this subsection shall be construed as requiring an

eligible telehealth individual to be presented by a physician

or practitioner at the originating site for the furnishing of a

service via a telecommunications system, unless it is medically

necessary (as determined by the physician or practitioner at

the distant site).

(3) Limitation on beneficiary charges

(A) Physician and practitioner

The provisions of section 1395w-4(g) of this title and

subparagraphs (A) and (B) of section 1395u(b)(18) of this title

shall apply to a physician or practitioner receiving payment

under this subsection in the same manner as they apply to

physicians or practitioners under such sections.

(B) Originating site

The provisions of section 1395u(b)(18) of this title shall

apply to originating sites receiving a facility fee in the same

manner as they apply to practitioners under such section.

(4) Definitions

For purposes of this subsection:

(A) Distant site

The term "distant site" means the site at which the physician

or practitioner is located at the time the service is provided

via a telecommunications system.

(B) Eligible telehealth individual

The term "eligible telehealth individual" means an individual

enrolled under this part who receives a telehealth service

furnished at an originating site.

(C) Originating site

(i) In general

The term "originating site" means only those sites

described in clause (ii) at which the eligible telehealth

individual is located at the time the service is furnished

via a telecommunications system and only if such site is

located -

(I) in an area that is designated as a rural health

professional shortage area under section 254e(a)(1)(A) of

this title;

(II) in a county that is not included in a Metropolitan

Statistical Area; or

(III) from an entity that participates in a Federal

telemedicine demonstration project that has been approved

by (or receives funding from) the Secretary of Health and

Human Services as of December 31, 2000.

(ii) Sites described

The sites referred to in clause (i) are the following

sites:

(I) The office of a physician or practitioner.

(II) A critical access hospital (as defined in section

1395x(mm)(1) of this title).

(III) A rural health clinic (as defined in section

1395x(aa)(s) (!6) of this title).

(IV) A Federally qualified health center (as defined in

section 1395x(aa)(4) of this title).

(V) A hospital (as defined in section 1395x(e) of this

title).

(D) Physician

The term "physician" has the meaning given that term in

section 1395x(r) of this title.

(E) Practitioner

The term "practitioner" has the meaning given that term in

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

(F) Telehealth service

(i) In general

The term "telehealth service" means professional

consultations, office visits, and office psychiatry services

(identified as of July 1, 2000, by HCPCS codes 99241-99275,

99201-99215, 90804-90809, and 90862 (and as subsequently

modified by the Secretary)), and any additional service

specified by the Secretary.

(ii) Yearly update

The Secretary shall establish a process that provides, on

an annual basis, for the addition or deletion of services

(and HCPCS codes), as appropriate, to those specified in

clause (i) for authorized payment under paragraph (1).

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1834, as added and

amended Pub. L. 100-203, title IV, Secs. 4049(a)(2), 4062(b), Dec.

22, 1987, 101 Stat. 1330-91, 1330-100; Pub. L. 100-360, title II,

Secs. 202(b)(4), 203(c)(1)(F), 204(b), title IV, Sec. 411(a)(3)(A),

(B)(ii), (C)(ii), (f)(8)(A), (B)(ii), (D), (g)(1)(A), (B), July 1,

1988, 102 Stat. 704, 722, 726, 768, 779, 781; Pub. L. 100-485,

title VI, Sec. 608(d)(21)(C), (22)(A), Oct. 13, 1988, 102 Stat.

2420; Pub. L. 101-234, title II, Sec. 201(a), title III, Sec.

301(b)(1), (c)(1), Dec. 13, 1989, 103 Stat. 1981, 1985; Pub. L.

101-239, title VI, Secs. 6102(f)(1), 6105(a), 6112(a), (c), (d)(1),

(e)(2), 6116(b)(2), 6140, Dec. 19, 1989, 103 Stat. 2188, 2210,

2214-2216, 2220, 2224; Pub. L. 101-508, title IV, Secs. 4102(a),

(d), (f), 4104(a), 4152(a)(1), (b), (c)(1)-(4)(B)(i), (e), (f)(1),

(g)(1), 4153(a)(1), (2)(D), 4163(b), Nov. 5, 1990, 104 Stat.

1388-55, 1388-57, 1388-59, 1388-74, 1388-77 to 1388-81, 1388-83,

1388-97; Pub. L. 103-66, title XIII, Secs. 13542(a), 13543(a), (b),

13544(a)(1), (2), (b)(1), 13545(a), 13546, Aug. 10, 1993, 107 Stat.

587, 589, 590; Pub. L. 103-432, title I, Secs. 102(e), 126(b)(1),

(2), (4), (5), (g)(1), (10)(B), 131(a), 132(a), (b), 133(a)(1),

134(a)(1), 135(a)(1), (b)(1), (3), (d)(1), (e)(2)-(5), 145(a),

156(a)(2)(C), Oct. 31, 1994, 108 Stat. 4403, 4414-4416, 4419, 4421,

4424, 4427, 4440; Pub. L. 105-33, title IV, Secs. 4101(a), (c),

4104(b)(1), 4105(b)(2), 4201(c)(5), 4312(a), (c), 4316(b),

4531(b)(2), 4541(a)(2), 4551(a), (c)(1), 4552(a), (b), Aug. 5,

1997, 111 Stat. 360, 363, 367, 374, 386, 387, 392, 451, 455,

457-459; Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec.

201(e)(2), title III, Sec. 321(k)(3), title IV, Sec. 403(d)(1)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-340, 1501A-366, 1501A-371;

Pub. L. 106-554, Sec. 1(a)(6) [title I, Secs. 103(b), 104(b), title

II, Secs. 201(a), 202(a), 204(a), 205(a), 221(a), 223(b), title IV,

Secs. 423(a)(1), (b)(1), 425(a), 426(a), 427(a), 428(a)], Dec. 21,

2000, 114 Stat. 2763, 2763A-468, 2763A-469, 2763A-481, 2763A-482,

2763A-486, 2763A-487, 2763A-518 to 2763A-520, 2763A-522.)

-REFTEXT-

REFERENCES IN TEXT

Part A of this subchapter, referred to in subsecs. (a)(1)(C),

(16) and (h)(1)(D), is classified to section 1395c et seq. of this

title.

Section 4531(a) of the Balanced Budget Act of 1997, referred to

in subsec. (l)(3)(A), is section 4531(a) of Pub. L. 105-33, which

amended sections 1395u and 1395x of this title.

-COD-

CODIFICATION

Amendment of subsec. (a)(4) by Pub. L. 101-508, Sec.

4152(c)(4)(B)(i), did not become effective pursuant to Pub. L.

101-508, Sec. 4152(c)(4)(B)(ii), because of action of Secretary in

developing specific criteria for the treatment of wheelchairs as

customized items for purposes of subsec. (a)(4). See Effective Date

of 1990 Amendment note below.

-MISC1-

PRIOR PROVISIONS

A prior section 1395m, act Aug. 14, 1935, ch. 531, title XVIII,

Sec. 1834, as added July 30, 1965, Pub. L. 89-97, title I, Sec.

102(a), 79 Stat. 303, prescribed limitations on payments for home

health services, prior to repeal by Pub. L. 96-499, title IX, Sec.

930(i), Dec. 5, 1980, 94 Stat. 2631, effective with respect to

services furnished on or after July 1, 1981.

AMENDMENTS

2000 - Subsec. (a)(14)(C). Pub. L. 106-554, Sec. 1(a)(6) [title

IV, Sec. 425(a)(2)], substituted "through 2000" for "through 2002"

and struck out "and" at end.

Subsec. (a)(14)(D) to (F). Pub. L. 106-554, Sec. 1(a)(6) [title

IV, Sec. 425(a)(1), (3)], added subpars. (D) and (E) and

redesignated former subpar. (D) as (F).

Subsec. (c). Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec.

104(b)], amended heading and text generally, substituting present

provisions for provisions which had set forth similar standards for

screening mammography but had provided for payment limited to 80

percent of the least of the actual charge, a statutory fee

schedule, if applicable, or the indexed dollar limit described, and

which had set forth provisions relating to reduction of indexed

dollar limit, application of limit in a hospital outpatient

setting, and limitation of charges of nonparticipating physicians.

Subsec. (d)(2)(E)(ii). Pub. L. 106-554, Sec. 1(a)(6) [title I,

Sec. 103(b)(1)], inserted before period at end "or, in the case of

an individual who is not at high risk for colorectal cancer, if the

procedure is performed within the 119 months after a previous

screening colonoscopy".

Subsec. (d)(3). Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec.

103(b)(2)(A)], struck out "for individuals at high risk for

colorectal cancer" after "colonoscopy" in heading.

Subsec. (d)(3)(A). Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec.

103(b)(2)(B)], struck out "for individuals at high risk for

colorectal cancer (as defined in section 1395x(pp)(2) of this

title)" after "screening colonoscopy".

Subsec. (d)(3)(E). Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec.

103(b)(2)(C)], inserted before period at end "or for other

individuals if the procedure is performed within the 119 months

after a previous screening colonoscopy or within 47 months after a

previous screening flexible sigmoidoscopy".

Subsec. (g)(2)(B). Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec.

202(a)], inserted "115 percent of" before "such amounts".

Subsec. (g)(4). Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec.

201(a)], added par. (4).

Subsec. (g)(5). Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec.

204(a)], added par. (5).

Subsec. (h)(1)(F). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

427(a)], added subpar. (F).

Subsec. (h)(1)(G). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

428(a)], added subpar. (G).

Subsec. (h)(4)(A)(v). Pub. L. 106-554, Sec. 1(a)(6) [title IV,

Sec. 426(a)(2)], substituted "through 2000" for "through 2002" and

struck out "and" at end.

Subsec. (h)(4)(A)(vi) to (viii). Pub. L. 106-554, Sec. 1(a)(6)

[title IV, Sec. 426(a)(1), (3)], added cls. (vi) and (vii) and

redesignated former cl. (vi) as (viii).

Subsec. (l)(2)(E). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

423(b)(1)], inserted before period at end ", except that such

phase-in shall provide for full payment of any national mileage

rate for ambulance services provided by suppliers that are paid by

carriers in any of the 50 States where payment by a carrier for

such services for all such suppliers in such State did not, prior

to the implementation of the fee schedule, include a separate

amount for all mileage within the county from which the beneficiary

is transported".

Subsec. (l)(3)(A), (B). Pub. L. 106-554, Sec. 1(a)(6) [title IV,

Sec. 423(a)(1)], substituted "reduced in the case of 2002" for

"reduced in the case of 2001 and 2002".

Subsec. (l)(8). Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec.

221(a)], added par. (8) relating to transitional assistance for

rural providers.

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 205(a)], added par.

(8) relating to services furnished by critical access hospitals.

Subsec. (m). Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec.

223(b)], added subsec. (m).

1999 - Subsec. (a)(13). Pub. L. 106-113, Sec. 1000(a)(6) [title

II, Sec. 201(e)(2)(A)], substituted "1395x(m)(5) of this title, but

not including implantable items for which payment may be made under

section 1395l(t) of this title" for "1395x(m)(5) of this title)".

Subsec. (g). Pub. L. 106-113, Sec. 1000(a)(6) [title IV, Sec.

403(d)(1)], amended heading and text of subsec. (g) generally.

Prior to amendment, text read as follows: "The amount of payment

under this part for outpatient critical access hospital services is

the reasonable costs of the critical access hospital in providing

such services."

Subsec. (h)(4)(A)(i). Pub. L. 106-113, Sec. 1000(a)(6) [title

III, Sec. 321(k)(3)(A)], substituted semicolon for comma at end.

Subsec. (h)(4)(A)(v). Pub. L. 106-113, Sec. 1000(a)(6) [title

III, Sec. 321(k)(3)(B)], substituted "; and" for ", and" at end.

Subsec. (h)(4)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title II,

Sec. 201(e)(2)(B)], inserted "and does not include an implantable

item for which payment may be made under section 1395l(t) of this

title" before the semicolon.

1997 - Subsec. (a)(2)(B)(iv). Pub. L. 105-33, Sec. 4105(b)(2),

inserted before period at end "(reduced by 10 percent, in the case

of a blood glucose testing strip furnished after 1997 for an

individual with diabetes)".

Subsec. (a)(9)(B)(iv). Pub. L. 105-33, Sec. 4552(a)(2)(A),

substituted "1995, 1996, and 1997" for "each subsequent year".

Subsec. (a)(9)(B)(v), (vi). Pub. L. 105-33, Sec. 4552(a)(1),

(2)(B), (3), added cls. (v) and (vi).

Subsec. (a)(9)(D). Pub. L. 105-33, Sec. 4552(b), which directed

amendment of section 1848(a)(9) (42 U.S.C. 1395m(a)(9)) by adding

subpar. (D) at end, was executed by adding subpar. (D) at end of

subsec. (a)(9) of this section, to reflect the probable intent of

Congress.

Subsec. (a)(10)(B). Pub. L. 105-33, Sec. 4316(b), substituted

"The Secretary" for "For covered items furnished on or after

January 1, 1991, the Secretary" and struck out "(other than

subparagraph (D))" before "of section 1395u(b) of this title" and

"as such provisions would otherwise apply to physicians' services

and physicians and a reasonable charge under section 1395u(b) of

this title but for the application of section 1395w-4(i)(3) of this

title. In applying such provisions to payments for an item under

this subsection, the Secretary shall make adjustments to the

payment basis for the item described in paragraph (1)(B) if the

Secretary determines (in accordance with such provisions and on the

basis of prices and costs applicable at the time the item is

furnished) that such payment basis is not inherently reasonable"

before period at end.

Subsec. (a)(14)(B). Pub. L. 105-33, Sec. 4551(a)(1)(B)(i),

substituted "1993, 1994, 1995, 1996, and 1997" for "a subsequent

year".

Subsec. (a)(14)(C), (D). Pub. L. 105-33, Sec. 4551(a)(1)(A),

(B)(ii), (C), added subpars. (C) and (D).

Subsec. (a)(16). Pub. L. 105-33, Sec. 4312(c), inserted at end

"The Secretary, at the Secretary's discretion, may impose the

requirements of the first sentence with respect to some or all

providers of items or services under part A of this subchapter or

some or all suppliers or other persons (other than physicians or

other practitioners, as defined in section 1395u(b)(18)(C) of this

title) who furnish items or services under this part."

Pub. L. 105-33, Sec. 4312(a), added par. (16).

Subsec. (a)(17). Pub. L. 105-33, Sec. 4551(c)(1), added par. (17)

relating to certain upgraded items.

Subsec. (c)(1)(C). Pub. L. 105-33, Sec. 4101(c), in introductory

provisions, struck out ", subject to the deductible established

under section 1395l(b) of this title," before "be equal to 80".

Subsec. (c)(2)(A)(iii). Pub. L. 105-33, Sec. 4101(a)(1), amended

cl. (iii) generally. Prior to amendment, cl. (iii) read as follows:

"In the case of a woman over 39 years of age, but under 50 years of

age, who -

"(I) is at a high risk of developing breast cancer (as

determined pursuant to factors identified by the Secretary),

payment may not be made under this part for a screening

mammography performed within the 11 months following the month in

which a previous screening mammography was performed, or

"(II) is not at a high risk of developing breast cancer,

payment may not be made under this part for a screening

mammography performed within the 23 months following the month in

which a previous screening mammography was performed."

Subsec. (c)(2)(A)(iv), (v). Pub. L. 105-33, Sec. 4101(a)(2),

struck out cls. (iv) and (v), which read as follows:

"(iv) In the case of a woman over 49 years of age, but under 65

years of age, payment may not be made under this part for screening

mammography performed within 11 months following the month in which

a previous screening mammography was performed.

"(v) In the case of a woman over 64 years of age, payment may not

be made for screening mammography performed within 23 months

following the month in which a previous screening mammography was

performed."

Subsec. (d). Pub. L. 105-33, Sec. 4104(b)(1), added subsec. (d).

Subsec. (g). Pub. L. 105-33, Sec. 4201(c)(5), amended heading and

text of subsec. (g) generally. Prior to amendment, text related to

payment for outpatient rural primary care hospital services as

determined, in par. (1), by either the cost-based facility fee plus

professional charges method or the all-inclusive rate method and,

in par. (2), by the prospective payment system.

Subsec. (h)(4)(A)(iv). Pub. L. 105-33, Sec. 4551(a)(2)(B),

substituted "1996 and 1997" for "a subsequent year".

Subsec. (h)(4)(A)(v), (vi). Pub. L. 105-33, Sec. 4551(a)(2)(A),

(C), added cls. (v) and (vi).

Subsec. (k). Pub. L. 105-33, Sec. 4541(a)(2), added subsec. (k).

Subsec. (l). Pub. L. 105-33, Sec. 4531(b)(2), added subsec. (l).

1994 - Subsec. (a)(3)(D). Pub. L. 103-432, Sec. 135(e)(5), struck

out heading and text of subpar. (D). Text read as follows: "If the

reasonable useful lifetime of such an item, as established under

paragraph (7)(C), has been reached during a continuous period of

medical need, or the Secretary determines on the basis of

investigation by the carrier that the item is lost or irreparably

damaged, payment for an item serving as a replacement for such item

shall be made on a monthly basis for the rental of the replacement

item in accordance with subparagraph (A)."

Subsec. (a)(5)(E). Pub. L. 103-432, Sec. 135(d)(1), substituted

"pressure of 56" for "pressure of 55".

Subsec. (a)(7). Pub. L. 103-432, Sec. 135(e)(2), made technical

amendment to directory language of Pub. L. 101-508, Sec.

4152(c)(2). See 1990 Amendment note below.

Subsec. (a)(7)(A)(iii)(II). Pub. L. 103-432, Sec. 135(e)(3),

substituted "clause (vi)" for "clause (v)".

Subsec. (a)(7)(C)(i). Pub. L. 103-432, Sec. 135(e)(4),

substituted "this paragraph" for "this paragraph or paragraph (3)".

Subsec. (a)(10)(B). Pub. L. 103-432, Sec. 134(a)(1), inserted at

end "In applying such provisions to payments for an item under this

subsection, the Secretary shall make adjustments to the payment

basis for the item described in paragraph (1)(B) if the Secretary

determines (in accordance with such provisions and on the basis of

prices and costs applicable at the time the item is furnished) that

such payment basis is not inherently reasonable."

Pub. L. 103-432, Sec. 126(g)(10)(B), substituted "would otherwise

apply to physicians' services" for "apply to physicians' services"

and inserted before period at end "but for the application of

section 1395w-4(i)(3) of this title".

Subsec. (a)(14)(A). Pub. L. 103-432, Sec. 135(a)(1), amended

subpar. (A) generally. Prior to amendment, subpar. (A) read as

follows: "for 1991 and 1992, reduction of 1 percentage point; and".

Subsec. (a)(15). Pub. L. 103-432, Sec. 135(b)(1), amended heading

and text of par. (15) generally. Prior to amendment, text read as

follows:

"(A) Development of list of items by secretary. - The Secretary

shall develop and periodically update a list of items for which

payment may be made under this subsection that the Secretary

determines, on the basis of prior payment experience, are

frequently subject to unnecessary utilization, and shall include in

such list seat-lift mechanisms, transcutaneous electrical nerve

stimulators, and motorized scooters.

"(B) Determinations of coverage in advance. - A carrier shall

determine in advance whether payment for an item included on the

list developed by the Secretary under subparagraph (A) may not be

made because of the application of section 1395y(a)(1) of this

title."

Subsec. (a)(16). Pub. L. 103-432, Sec. 131(a)(2), struck out

heading and text of par. (16). Text read as follows:

"(A) In general. - A supplier of a covered item under this

subsection may not distribute to physicians or to individuals

entitled to benefits under this part for commercial purposes any

completed or partially completed forms or other documents required

by the Secretary to be submitted to show that a covered item is

reasonable and necessary for the diagnosis or treatment of illness

or injury or to improve the functioning of a malformed body member.

"(B) Penalty. - Any supplier of a covered item who knowingly and

willfully distributes a form or other document in violation of

subparagraph (A) is subject to a civil money penalty in an amount

not to exceed $1,000 for each such form or document so distributed.

The provisions of section 1320a-7a of this title (other than

subsections (a) and (b)) shall apply to civil money penalties under

this subparagraph in the same manner as they apply to a penalty or

proceeding under section 1320a-7a(a) of this title."

Subsec. (a)(17), (18). Pub. L. 103-432, Sec. 132(a)(1), (2),

added pars. (17) and (18).

Subsec. (b)(4)(D). Pub. L. 103-432, Sec. 126(b)(2)(A), in

introductory provisions substituted "shall, subject to clause

(vii), be reduced to the adjusted conversion factor for the

locality determined as follows:" for "shall be determined as

follows:".

Subsec. (b)(4)(D)(iv). Pub. L. 103-432, Sec. 126(b)(2)(B),

substituted "Adjusted conversion factor" for "Local adjustment" in

heading and "The adjusted conversion factor for" for "Subject to

clause (vii), the conversion factor to be applied to" in text.

Subsec. (b)(4)(D)(vii). Pub. L. 103-432, Sec. 126(b)(2)(C), (D),

struck out "under this subparagraph" after "applied to a locality"

and inserted "reduced under this subparagraph by" before "more than

9.5 percent".

Subsec. (b)(4)(E). Pub. L. 103-432, Sec. 126(b)(5), inserted

heading "Rule for certain scanning services".

Pub. L. 103-432, Sec. 126(b)(4), made technical amendment to

directory language of Pub. L. 101-508, Sec. 4102(d). See 1990

Amendment note below.

Pub. L. 103-432, Sec. 126(b)(1), redesignated subpar. (E),

relating to subsequent updating, as (F).

Subsec. (b)(4)(F), (G). Pub. L. 103-432, Sec. 126(b)(1),

redesignated subpars. (E), relating to subsequent updating, and (F)

as (F) and (G), respectively.

Subsec. (c)(1)(B). Pub. L. 103-432, Sec. 145(a)(1), substituted

"is conducted by a facility that has a certificate (or provisional

certificate) issued under section 263b of this title" for "meets

the quality standards established under paragraph (3)".

Subsec. (c)(1)(C)(iii). Pub. L. 103-432, Sec. 145(a)(2),

substituted "paragraph (3)" for "paragraph (4)".

Subsec. (c)(3) to (5). Pub. L. 103-432, Sec. 145(a)(3), (4),

redesignated pars. (4) and (5) as (3) and (4), respectively, and

struck out former par. (3) which directed Secretary to establish

standards to assure the safety and accuracy of screening

mammography performed under this part.

Subsec. (f). Pub. L. 103-432, Sec. 126(g)(1), substituted "during

1991" for "during fiscal year 1991" in heading.

Subsec. (g)(1). Pub. L. 103-432, Sec. 102(e)(1)(A), (2),

substituted in introductory provisions "during a year before the

prospective payment system described in paragraph (2) is in effect"

for "during a year before 1993" and inserted at end "The amount of

payment shall be determined under either method without regard to

the amount of the customary or other charge."

Subsec. (g)(1)(B). Pub. L. 103-432, Sec. 156(a)(2)(C), struck out

"and for items and services furnished in connection with obtaining

a second opinion required under section 1320c-13(c)(2) of this

title, or a third opinion, if the second opinion was in

disagreement with the first opinion" after "section 1395x(s)(10)(A)

of this title".

Subsec. (g)(2). Pub. L. 103-432, Sec. 102(e)(1)(B), substituted

"January 1, 1996" for "January 1, 1993".

Subsec. (h)(3). Pub. L. 103-432, Sec. 135(b)(3), substituted

"Paragraphs (12), (15), and (17)" for "Paragraphs (12) and (17)".

Pub. L. 103-432, Sec. 132(b), substituted "Paragraphs (12) and

(17)" for "Paragraph (12)".

Subsec. (j). Pub. L. 103-432, Sec. 131(a)(1), added subsec. (j).

Subsec. (j)(4), (5). Pub. L. 103-432, Sec. 133(a)(1), added par.

(4) and redesignated former par. (4) as (5).

1993 - Subsec. (a)(1)(D). Pub. L. 103-66, Sec. 13545(a),

substituted "45 percent" for "15 percent" after "(as previously

reduced) by".

Subsec. (a)(2)(A)(iii). Pub. L. 103-66, Sec. 13543(b), added cl.

(iii).

Subsec. (a)(2)(C). Pub. L. 103-66, Sec. 13542(a)(1), in cl.

(i)(II), substituted "for 1992, 1993, and 1994" for "for 1992" and

"update for the year" for "update for 1992", and in cl. (ii),

struck out "and" at end of subcl. (I), added subcls. (II) and

(III), and redesignated former subcl. (II) as (IV).

Subsec. (a)(3)(A). Pub. L. 103-66, Sec. 13543(a), substituted

"IPPB machines and ventilators, excluding ventilators that are

either continuous airway pressure devices or intermittent assist

devices with continuous airway pressure devices" for "ventilators,

aspirators, IPPB machines, and nebulizers".

Subsec. (a)(3)(C). Pub. L. 103-66, Sec. 13542(a)(1), in cl.

(i)(II), substituted "for 1992, 1993, and 1994" for "for 1992" and

"update for the year" for "update for 1992", and in cl. (ii),

struck out "and" at end of subcl. (I), added subcls. (II) and

(III), and redesignated former subcl. (II) as (IV).

Subsec. (a)(8)(A)(ii)(III). Pub. L. 103-66, Sec. 13542(a)(2)(A),

substituted "1992, 1993, and 1994" for "1992".

Subsec. (a)(8)(B)(ii) to (iv). Pub. L. 103-66, Sec.

13542(a)(2)(B), added cls. (ii) and (iii) and redesignated former

cl. (ii) as (iv).

Subsec. (a)(9)(A)(ii)(II). Pub. L. 103-66, Sec. 13542(a)(3)(A),

substituted "1991, 1992, 1993, and 1994" for "1991 and 1992".

Subsec. (a)(9)(B)(ii) to (iv). Pub. L. 103-66, Sec.

13542(a)(3)(B), added cls. (ii) and (iii) and redesignated former

cl. (ii) as (iv).

Subsec. (h)(1)(B). Pub. L. 103-66, Sec. 13544(a)(2), substituted

"subparagraphs (C) and (E)" for "subparagraph (C)" in introductory

provisions.

Subsec. (h)(1)(E). Pub. L. 103-66, Sec. 13544(a)(1), added

subpar. (E).

Subsec. (h)(4)(A). Pub. L. 103-66, Sec. 13546, struck out "and"

at end of cl. (i), substituted "1992 and 1993" for "a subsequent

year" in cl. (ii), and added cls. (iii) and (iv).

Subsec. (i). Pub. L. 103-66, Sec. 13544(b)(1), added subsec. (i).

1990 - Subsec. (a). Pub. L. 101-508, Sec. 4153(a)(2)(D)(i),

struck out ", prosthetic devices, orthotics, and prosthetics" after

"medical equipment" in heading.

Subsec. (a)(1)(D). Pub. L. 101-508, Sec. 4152(a)(1), inserted

before period at end ", and, in the case of a transcutaneous

electrical nerve stimulator furnished on or after January 1, 1991,

the Secretary shall further reduce such payment amount (as

previously reduced) by 15 percent".

Subsec. (a)(2)(A). Pub. L. 101-508, Sec. 4153(a)(2)(D)(ii),

substituted "(13)" for "(13)(A)".

Pub. L. 101-508, Sec. 4152(c)(4)(A), inserted "or" after "$150,"

in cl. (i), struck out "or" after "purchase," in cl. (ii), and

struck out cl. (iii) which read as follows: "which is a

power-driven wheelchair (other than a customized wheelchair that is

classified as a customized item under paragraph (4) pursuant to

criteria specified by the Secretary),".

Subsec. (a)(2)(B). Pub. L. 101-508, Sec. 4152(b)(1)(A), (B),

struck out "or" after "1987;" in cl. (i), added cls. (ii) to (iv),

and struck out former cl. (ii) which read as follows: "in a

subsequent year, is the amount specified in this subparagraph for

the preceding year increased by the percentage increase in the

consumer price index for all urban consumers (U.S. city average)

for the 12-month period ending with June of that preceding year."

Subsec. (a)(2)(C). Pub. L. 101-508, Sec. 4152(b)(1)(C), added

subpar. (C).

Subsec. (a)(3)(B). Pub. L. 101-508, Sec. 4152(b)(1)(A), (B),

struck out "or" after "1987;" in cl. (i), added cls. (ii) to (iv),

and struck out former cl. (ii) which read as follows: "in a

subsequent year, is the amount specified in this subparagraph for

the preceding year increased by the percentage increase in the

consumer price index for all urban consumers (U.S. city average)

for the 12-month period ending with June of that preceding year."

Subsec. (a)(3)(C). Pub. L. 101-508, Sec. 4152(b)(1)(C), added

subpar. (C).

Subsec. (a)(3)(D). Pub. L. 101-508, Sec. 4152(c)(3), added

subpar. (D).

Subsec. (a)(4). Pub. L. 101-508, Sec. 4152(c)(4)(B)(i), directed

amendment of par. (4) by inserting at end "In the case of a

wheelchair furnished on or after January 1, 1992, the wheelchair

shall be treated as a customized item for purposes of this

paragraph if the wheelchair has been measured, fitted, or adapted

in consideration of the patient's body size, disability, period of

need, or intended use, and has been assembled by a supplier or

ordered from a manufacturer who makes available customized

features, modifications, or components for wheelchairs that are

intended for an individual patient's use in accordance with

instructions from the patient's physician." The amendment did not

become effective pursuant to Pub. L. 101-508, Sec.

4152(c)(4)(B)(ii). See Effective Date of 1990 Amendment note below.

Subsec. (a)(5)(A). Pub. L. 101-508, Sec. 4152(g)(1)(A),

substituted "(B), (C), and (E)" for "(B) and (C)".

Subsec. (a)(5)(E). Pub. L. 101-508, Sec. 4152(g)(1)(B), added

subpar. (E).

Subsec. (a)(7)(A)(i). Pub. L. 101-508, Sec. 4152(c)(2)(A), as

amended by Pub. L. 103-432, Sec. 135(e)(2), substituted "15 months,

or, in the case of an item for which a purchase agreement has been

entered into under clause (iii), a period of continuous use of

longer than 13 months" for "15 months".

Pub. L. 101-508, Sec. 4152(c)(1), substituted "for each of the

first 3 months of such period" for "for each such month" and ", and

for each of the remaining months of such period is 7.5 percent of

such purchase price;" for semicolon at end.

Subsec. (a)(7)(A)(ii), (iii). Pub. L. 101-508, Sec.

4152(c)(2)(D), as amended by Pub. L. 103-432, Sec. 135(e)(2), added

cls. (ii) and (iii). Former cls. (ii) and (iii) redesignated (iv)

and (v), respectively.

Subsec. (a)(7)(A)(iv). Pub. L. 101-508, Sec. 4152(c)(2)(B), as

amended by Pub. L. 103-432, Sec. 135(e)(2), redesignated cl. (ii)

as (iv), substituted "in the case of an item for which a purchase

agreement has not been entered into under clause (ii) or clause

(iii), during the first 6-month period of medical need that follows

the period of medical need during which payment is made under

clause (i)," for "during the succeeding 6-month period of medical

need," and struck out "and" at end.

Subsec. (a)(7)(A)(v). Pub. L. 101-508, Sec. 4152(c)(2)(C), as

amended by Pub. L. 103-432, Sec. 135(e)(2), redesignated cl. (iii)

as (v), inserted at beginning "in the case of an item for which a

purchase agreement has not been entered into under clause (ii) or

clause (iii),", and substituted "; and" for period at end.

Subsec. (a)(7)(A)(vi). Pub. L. 101-508, Sec. 4152(c)(2)(E), as

amended by Pub. L. 103-432, Sec. 135(e)(2), added cl. (vi).

Subsec. (a)(7)(C). Pub. L. 101-508, Sec. 4152(c)(2)(F), as

amended by Pub. L. 103-432, Sec. 135(e)(2), added subpar. (C).

Subsec. (a)(8)(A)(ii). Pub. L. 101-508, Sec. 4152(b)(2)(A), added

subcl. (II), redesignated former subcl. (II) as (III), struck out

"1991 or" before "1992", and substituted "the covered item update

for the year" for "the percentage increase in the consumer price

index for all urban consumers (U.S. city average) for the 12-month

period ending with June of the previous year".

Subsec. (a)(8)(B). Pub. L. 101-508, Sec. 4152(b)(2)(B), amended

subpar. (B) generally. Prior to amendment, subpar. (B) read as

follows: "With respect to the furnishing of a particular item in

each region (as defined by the Secretary), the Secretary shall

compute a regional purchase price -

"(i) for 1991 and for 1992, equal to the average (weighted by

relative volume of all claims among carriers) of the local

purchase prices for the carriers in the region computed under

subparagraph (A)(ii)(II) for the year, and

"(ii) for each subsequent year, equal to the regional purchase

price computed under this subparagraph for the previous year

increased by the percentage increase in the consumer price index

for all urban consumers (U.S. city average) for the 12-month

period ending with June of the previous year."

Subsec. (a)(8)(C). Pub. L. 101-508, Sec. 4152(b)(2)(C)(ii),

struck out "and subject to subparagraph (D)" after "and (7)" in

introductory provisions.

Subsec. (a)(8)(C)(ii). Pub. L. 101-508, Sec. 4152(b)(2)(C)(i),

(iii), in subcl. (I) substituted "67 percent" for "75 percent" and

in subcl. (II) substituted "33 percent" for "25 percent" and

"national limited purchase price" for "regional purchase price".

Subsec. (a)(8)(C)(iii). Pub. L. 101-508, Sec. 4152(b)(2)(C)(i),

(iv), in subcl. (I) substituted "33 percent" for "50 percent" and

"subparagraph (A)(ii)(III)" for "subparagraph (A)(ii)(II)" and in

subcl. (II) substituted "67 percent" for "50 percent" and "national

limited purchase price" for "regional purchase price".

Subsec. (a)(8)(C)(iv). Pub. L. 101-508, Sec. 4152(b)(2)(C)(i),

substituted "national limited purchase price" for "regional

purchase price".

Subsec. (a)(8)(D). Pub. L. 101-508, Sec. 4152(b)(2)(D), struck

out subpar. (D) which read as follows: "The amount that is

recognized under subparagraph (C) as the purchase price for an item

furnished -

"(i) in 1991, may not exceed 125 percent, and may not be lower

than 85 percent, of the average of the purchase prices recognized

under such subparagraph for all the carrier service areas in the

United States in that year; and

"(ii) in a subsequent year, may not exceed 120 percent, and may

not be lower than 90 percent, of the average of the purchase

prices recognized under such subparagraph for all the carrier

service areas in the United States in that year."

Subsec. (a)(9)(A)(ii)(II). Pub. L. 101-508, Sec. 4152(b)(3)(A),

substituted "the covered item increase for the year" for "the

percentage increase in the consumer price index for all urban

consumers (U.S. city average) for the 12-month period ending with

June of the previous year".

Subsec. (a)(9)(B). Pub. L. 101-508, Sec. 4152(b)(3)(B), amended

subpar. (B) generally. Prior to amendment, subpar. (B) read as

follows: "With respect to the furnishing of an item in each region

(as defined by the Secretary), the Secretary shall compute a

regional monthly payment rate -

"(i) for 1991 and 1992, equal to the average (weighted by

relative volume of all claims among carriers) of the local

monthly payment rates for the carriers in the region computed

under subparagraph (A)(ii)(II) for the year, and

"(ii) for each subsequent year, equal to the regional monthly

payment rates computed under this subparagraph for the previous

year increased by the percentage increase in the consumer price

index for all urban consumers (U.S. city average) for the

12-month period ending with June of the previous year."

Subsec. (a)(9)(C)(ii). Pub. L. 101-508, Sec. 4152(b)(3)(C)(i),

(ii), in subcl. (I) substituted "67 percent" for "75 percent" and

in subcl. (II) substituted "33 percent" for "25 percent" and

"national limited monthly payment rate" for "regional monthly

payment rate".

Subsec. (a)(9)(C)(iii). Pub. L. 101-508, Sec. 4152(b)(3)(C)(i),

(iii), in subcl. (I) substituted "33 percent" for "50 percent" and

in subcl. (II) substituted "67 percent" for "50 percent", "national

limited monthly payment rate" for "regional monthly payment rate",

and "subparagraph (B)(ii)" for "subparagraph (B)(i)".

Subsec. (a)(9)(C)(iv). Pub. L. 101-508, Sec. 4152(b)(3)(C)(i),

substituted "national limited monthly payment rate" for "regional

monthly payment rate".

Subsec. (a)(9)(D). Pub. L. 101-508, Sec. 4152(b)(3)(D), struck

out subpar. (D) which read as follows: "The amount that is

recognized under subparagraph (C) as the base monthly payment

amount for an item furnished -

"(i) in 1991, may not exceed 125 percent, and may not be lower

than 85 percent, of the average of the base monthly payment

amounts recognized under such subparagraph for all the carrier

service areas in the United States in that year; and

"(ii) in a subsequent year, may not exceed 120 percent, and may

not be lower than 90 percent, of the average of the base monthly

payment amounts recognized under such subparagraph for all the

carrier service areas in the United States in that year."

Subsec. (a)(12). Pub. L. 101-508, Sec. 4152(b)(5), struck out

"defined for purposes of paragraphs (8)(B) and (9)(B)" after "one

or more entire regions".

Subsec. (a)(13). Pub. L. 101-508, Sec. 4153(a)(2)(D)(iii),

substituted "means durable medical equipment (as defined in section

1395x(n) of this title), including such equipment described in

section 1395x(m)(5) of this title)." for "means -

"(A) durable medical equipment (as defined in section 1395x(n)

of this title), including such equipment described in section

1395x(m)(5) of this title;

"(B) prosthetic devices (described in section 1395x(s)(8) of

this title), but not including parenteral and enteral nutrition

nutrients, supplies, and equipment; and

"(C) orthotics and prosthetics (described in section

1395x(s)(9) of this title);

but does not include intraocular lenses or medical supplies

(including catheters, catheter supplies, ostomy bags, and supplies

related to ostomy care) furnished by a home health agency under

section 1395x(m)(5) of this title."

Subsec. (a)(14). Pub. L. 101-508, Sec. 4152(b)(4), added par.

(14).

Subsec. (a)(15). Pub. L. 101-508, Sec. 4152(e), added par. (15).

Subsec. (a)(16). Pub. L. 101-508, Sec. 4152(f)(1), added par.

(16).

Subsec. (b)(1)(B). Pub. L. 101-508, Sec. 4163(b)(1), inserted

"and subject to subsection (c)(1)(A) of this section" after

"conversion factors".

Pub. L. 101-508, Sec. 4102(f), inserted "locality," after

"statewide,".

Subsec. (b)(4)(D). Pub. L. 101-508, Sec. 4102(a)(2), added

subpar. (D). Former subpar. (D) redesignated (E) relating to

subsequent updating.

Subsec. (b)(4)(E). Pub. L. 101-508, Sec. 4102(d), as amended by

Pub. L. 103-432, Sec. 126(b)(4), added subpar. (E) relating to rule

for certain scanning services.

Pub. L. 101-508, Sec. 4102(a)(1), redesignated subpar. (D),

relating to subsequent updating, as (E). Former subpar. (E)

redesignated (F).

Subsec. (b)(4)(F). Pub. L. 101-508, Sec. 4102(a)(1), redesignated

subpar. (E) as (F).

Subsec. (c). Pub. L. 101-508, Sec. 4163(b)(2), added subsec. (c).

Subsec. (f). Pub. L. 101-508, Sec. 4104(a), amended subsec. (f)

generally, substituting provisions relating to reduction in

payments for physician pathology services during 1991 for

provisions directing Secretary to provide for application of a fee

schedule with respect to such services.

Subsec. (h). Pub. L. 101-508, Sec. 4153(a)(1), added subsec. (h).

1989 - Subsec. (a)(1)(D). Pub. L. 101-239, Sec. 6112(c), added

subpar. (D).

Subsec. (a)(2)(A)(iii). Pub. L. 101-239, Sec. 6112(d)(1), added

cl. (iii).

Subsec. (a)(2)(B)(i), (3)(B)(i). Pub. L. 101-239, Sec.

6112(a)(1), inserted "and in 1990" after "1989".

Subsec. (a)(7)(A)(i). Pub. L. 101-239, Sec. 6112(a)(4)(A),

substituted "this clause" for "this subparagraph".

Subsec. (a)(7)(B)(i). Pub. L. 101-239, Sec. 6112(a)(4)(B),

inserted "in" after "rental of the item".

Subsec. (a)(7)(B)(ii). Pub. L. 101-239, Sec. 6112(a)(4)(C),

substituted "clause (i) shall apply in the same manner as it

applies to items furnished during 1989" for "the payment amount

recognized under subparagraph (A)(i) shall not be more than the

maximum amount established under clause (i), and shall not be less

than the minimum amount established under such clause, for 1989,

each such amount increased by the percentage increase in the

consumer price index for all urban consumers (U.S. city average)

for the 12-month period ending with June 1989".

Subsec. (a)(8)(A)(ii)(I). Pub. L. 101-239, Sec. 6112(a)(2)(A),

inserted "and 1990" after "1989".

Subsec. (a)(8)(A)(ii)(II). Pub. L. 101-239, Sec. 6112(a)(2)(B),

substituted "1991 or 1992" for "1990, 1991, or 1992".

Subsec. (a)(8)(D)(i). Pub. L. 101-239, Sec. 6140(1), substituted

"1991, may not exceed 125 percent, and may not be lower than 85

percent" for "1991, may not exceed 130 percent, and may not be

lower than 80 percent".

Subsec. (a)(8)(D)(ii). Pub. L. 101-239, Sec. 6140(2), substituted

"120 percent, and may not be lower than 90 percent" for "125

percent, and may not be lower than 85 percent".

Subsec. (a)(9)(A)(ii)(I). Pub. L. 101-239, Sec. 6112(a)(3)(A),

inserted "and 1990" after "1989".

Subsec. (a)(9)(A)(ii)(II). Pub. L. 101-239, Sec. 6112(a)(3)(B),

substituted "1991 and 1992" for "1990, 1991, and 1992".

Subsec. (a)(9)(D)(i). Pub. L. 101-239, Sec. 6140(1), substituted

"1991, may not exceed 125 percent, and may not be lower than 85

percent" for "1991, may not exceed 130 percent, and may not be

lower than 80 percent".

Subsec. (a)(9)(D)(ii). Pub. L. 101-239, Sec. 6140(2), substituted

"120 percent, and may not be lower than 90 percent" for "125

percent, and may not be lower than 85 percent".

Subsec. (a)(13). Pub. L. 101-239, Sec. 6112(e)(2), inserted

before period at end "or medical supplies (including catheters,

catheter supplies, ostomy bags, and supplies related to ostomy

care) furnished by a home health agency under section 1395x(m)(5)

of this title".

Subsec. (b)(1)(B). Pub. L. 101-234, Sec. 201(a), repealed Pub. L.

100-360, Sec. 204(b)(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. (b)(4)(A). Pub. L. 101-234, Sec. 301(b)(1), (c)(1),

amended subpar. (A) identically, substituting "coinsurance and

deductibles under sections 1395l(a)(1)(J)" for "insurance and

deductibles under section 1395n(a)(1)(I)".

Subsec. (b)(4)(C) to (E). Pub. L. 101-239, Sec. 6105(a), added

subpar. (C) and redesignated former subpars. (C) and (D) as (D) and

(E), respectively.

Subsecs. (c) to (e). Pub. L. 101-234, Sec. 201(a), repealed Pub.

L. 100-360, Secs. 202(b)(4), 203(c)(1)(F), 204(b)(2), and provided

that the provisions of law amended or repealed by such sections are

restored or revived as if such sections had not been enacted, see

1988 Amendment notes below.

Subsec. (f). Pub. L. 101-239, Sec. 6102(f)(1), added subsec. (f).

Subsec. (g). Pub. L. 101-239, Sec. 6116(b)(2), added subsec. (g).

1988 - Pub. L. 100-360, Sec. 411(g)(1)(A), inserted "items and"

in section catchline.

Subsec. (a)(1)(C). Pub. L. 100-360, Sec. 411(g)(1)(B)(i),

inserted "or under part A of this subchapter to a home health

agency" before period at end.

Subsec. (a)(2)(A). Pub. L. 100-360, Sec. 411(g)(1)(B)(iii),

struck out "rental" before "payments" in concluding provisions.

Subsec. (a)(2)(B)(i). Pub. L. 100-360, Sec. 411(g)(1) (B)(iii),

substituted "reasonable" for "allowed".

Subsec. (a)(3)(A). Pub. L. 100-360, Sec. 411(g)(1)(B)(iv), struck

out the extra space appearing in text of original act after

"ventilators".

Subsec. (a)(3)(B)(i). Pub. L. 100-360, Sec. 411(g)(1) (B)(iii),

substituted "reasonable" for "allowable".

Subsec. (a)(4). Pub. L. 100-360, Sec. 411(g)(1) (B)(v)-(vii),

inserted ", and for that reason cannot be grouped with similar

items for purposes of payment under this subchapter," after

"individual patient", inserted cl. (A) and (B) designations, and in

cl. (B), substituted "servicing" for "service" in two places.

Subsec. (a)(7)(A)(ii). Pub. L. 100-360, Sec. 411(g)(1) (B)(vii),

inserted "maintenance and" before "servicing".

Subsec. (a)(7)(A)(iii). Pub. L. 100-360, Sec. 411(g)(1) (B)(vii),

(viii), substituted "maintenance and servicing" for "service and

maintenance", and in subcl. (I) substituted "fee or fees

established by the Secretary" for "fee established by the carrier".

Subsec. (a)(7)(B)(i). Pub. L. 100-360, Sec. 411(a)(3)(A),

(C)(ii), provided that subsec. (a)(7)(B)(i) of this section, as

inserted by section 4062(b) of Pub. L. 100-203, is deemed to have a

reference to "1987" immediately after "December".

Subsec. (a)(8)(A)(i)(I). Pub. L. 100-360, Sec. 411(g)(1)

(B)(iii), substituted "reasonable" for "allowable".

Subsec. (a)(8)(B). Pub. L. 100-360, Sec. 411(g)(1)(B)(xi), as

amended Pub. L. 100-485, Sec. 608(d)(22)(A)(i), substituted "(as

defined by the Secretary)" for "(as defined in section

1395ww(d)(2)(D) of this title)", and in cl. (i) struck out the

comma after "1991".

Subsec. (a)(9)(A)(ii)(I). Pub. L. 100-360, Sec. 411(g)(1)

(B)(ix), substituted "6-month" for "12-month".

Subsec. (a)(9)(A)(ii)(II). Pub. L. 100-360, Sec. 411(g)(1)

(B)(x), substituted ", 1991, and 1992" for "and to 1991".

Subsec. (a)(9)(B). Pub. L. 100-360, Sec. 411(g)(1)(B)(xi), as

amended by Pub. L. 100-485, Sec. 608(d)(22)(A)(i), substituted "(as

defined by the Secretary)" for "(as defined in section

1395ww(d)(2)(D) of this title)", and in cl. (i) struck out the

comma after "1991".

Subsec. (a)(9)(C)(i). Pub. L. 100-360, Sec. 411(g)(1) (B)(xii),

substituted "subparagraph (A)(ii)" for "subparagraph (A)(ii)(I)".

Subsec. (a)(10)(B). Pub. L. 100-360, Sec. 411(g)(1) (B)(xiii),

inserted before period at end "and payments under this subsection

as such provisions apply to physicians' services and physicians and

a reasonable charge under section 1395u(b) of this title".

Subsec. (a)(11)(A). Pub. L. 100-360, Sec. 411(g)(1) (B)(vii),

(xiv), inserted "maintenance and" before "servicing" and

substituted "section 1395u(j)(2) of this title" for "subsection

(j)(2) of this section".

Subsec. (a)(12). Pub. L. 100-360, Sec. 411(g)(1)(B)(xv), as

amended by Pub. L. 100-485, Sec. 608(d)(22)(A)(ii), substituted

"one or more entire regions defined for purposes of paragraphs

(8)(B) and (9)(B)" for "each region (as defined in section

1395ww(d)(2)(D) of this title)".

Subsec. (a)(14). Pub. L. 100-360, Sec. 411(g)(1)(B)(xvi), struck

out par. (14) which read as follows: "In this subsection, any

reference to the term 'carrier' includes a reference, with respect

to durable medical equipment furnished by a home health agency as

part of home health services, to a fiscal intermediary."

Subsec. (b). Pub. L. 100-360, Sec. 411(a)(3)(A), (B)(ii),

(f)(8)(B)(ii), amended Pub. L. 100-203, Sec. 4049(a)(2), see 1987

Amendment note below.

Subsec. (b)(1)(B). Pub. L. 100-360, Sec. 204(b)(1), inserted "and

subject to subsection (e)(1)(A) of this section" after "conversion

factors".

Subsec. (b)(4)(C). Pub. L. 100-360, Sec. 411(f)(8)(D)(ii), as

added by Pub. L. 100-485, Sec. 608(d)(21)(C), substituted "For

radiologist" for "Radiologist" and "1395u(i)(3) of this title" for

"1395u(b)(4)(E)(ii) of this title".

Subsec. (b)(4)(D), (5). Pub. L. 100-360, Sec. 411(f)(8)(D)(i),

inserted "and suppliers" after "physicians" in heading.

Subsec. (b)(5)(C). Pub. L. 100-360, Sec. 411(f)(8)(D)(iii), (iv),

formerly (ii), (iii), as redesignated by Pub. L. 100-485, Sec.

608(d)(21)(C), substituted "bills" for "imposes a charge" and

inserted "in the same manner as such sanctions may apply to a

physician" before period at end.

Subsec. (b)(6). Pub. L. 100-360, Sec. 411(f)(8)(D)(v), formerly

(iv), as redesignated by Pub. L. 100-485, Sec. 608(d)(21)(C),

substituted "and section 1395l(a)(1)(J) of this title" for ",

section 1395l(a)(1)(I) of this title, and section 1395u(h)(1)(B) of

this title".

Pub. L. 100-360, Sec. 411(f)(8)(A), substituted "radiology" for

"radiologic".

Subsec. (b)(6)(B). Pub. L. 100-360, Sec. 411(f)(8)(D)(vi),

formerly (v), as redesignated by Pub. L. 100-485, Sec.

608(d)(21)(C), substituted "the total amount of charges" for

"billings".

Pub. L. 100-360, Sec. 411(f)(8)(A), substituted "radiology" for

"radiologic".

Subsec. (c). Pub. L. 100-360, Sec. 202(b)(4), added subsec. (c)

relating to payment for covered outpatient drugs.

Subsec. (d). Pub. L. 100-360, Sec. 203(c)(1)(F), added subsec.

(d) relating to home intravenous drug therapy services.

Subsec. (e). Pub. L. 100-360, Sec. 204(b)(2), added subsec. (e)

relating to payments and standards for screening mammography.

1987 - Subsec. (b). Pub. L. 100-203, Sec. 4049(a)(2), as amended

by Pub. L. 100-360, Sec. 411(a)(3)(A), (B)(ii), (f)(8)(B)(ii),

added subsec. (b).

EFFECTIVE DATE OF 2000 AMENDMENT

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 103(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-469, provided that: "The amendments

made by this section [amending this section and section 1395x of

this title] shall apply to colorectal cancer screening services

provided on or after July 1, 2001."

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 104(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-470, provided that: "The amendments

made by subsections (a) and (b) [amending this section and section

1395w-4 of this title] shall apply with respect to screening

mammographies furnished on or after January 1, 2002."

Amendment by section 1(a)(6) [title II, Sec. 201(a)] of Pub. L.

106-554 applicable to services furnished on or after Nov. 29, 1999,

see section 1(a)(6) [title II, Sec. 201(c)] of Pub. L. 106-554, set

out as a note under section 1395l of this title.

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 202(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-481, provided that: "The amendment made

by subsection (a) [amending this section] shall apply with respect

to items and services furnished on or after July 1, 2001."

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 204(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-482, provided that: "The amendment made

by subsection (a) [amending this section] shall apply to cost

reporting periods beginning on or after October 1, 2001."

Amendment by section 1(a)(6) [title II, Sec. 205(a)] of Pub. L.

106-554 applicable to services furnished on or after Dec. 21, 2000,

see section 1(a)(6) [title II, Sec. 205(c)] of Pub. L. 106-554, set

out as a note under section 1395l of this title.

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 221(d)], Dec. 21,

2000, 114 Stat. 2763, 2763A-487, provided that: "The amendment made

by subsection (a) [amending this section] shall apply to services

furnished on or after July 1, 2001. In applying such amendment to

services furnished on or after such date and before January 1,

2002, the amount of the rate increase provided under such amendment

shall be equal to $1.25 per mile."

Amendment by section 1(a)(6) [title II, Sec. 223(b)] of Pub. L.

106-554 effective for services furnished on or after Oct. 1, 2001,

see section 1(a)(6) [title II, Sec. 223(e)] of Pub. L. 106-554, set

out as a note under section 1395l of this title.

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 423(b)(2)], Dec.

21, 2000, 114 Stat. 2763, 2763A-518, provided that: "The amendment

made by paragraph (1) [amending this section] shall apply to

services furnished on or after July 1, 2001."

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 428(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-522, provided that: "The amendment made

by subsection (a) [amending this section] shall apply to items

replaced on or after April 1, 2001."

EFFECTIVE DATE OF 1999 AMENDMENT

Amendment by section 1000(a)(6) [title II, Sec. 201(e)(2)] of

Pub. L. 106-113 effective as if included in enactment of the

Balanced Budget Act of 1997, Pub. L. 105-33, except as otherwise

provided, see Sec. 1000(a)(6) [title II, Sec. 201(m)] of Pub. L.

106-113, set out as a note under section 1395l of this title.

Amendment by section 1000(a)(6) [title III, Sec. 321(k)(3)] of

Pub. L. 106-113 effective as if included in the enactment of the

Balanced Budget Act of 1997, Pub. L. 105-33, except as otherwise

provided, see section 1000(a)(6) [title III, Sec. 321(m)] of Pub.

L. 106-113, set out as a note under section 1395d of this title.

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

403(d)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-371, as amended by

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 201(b)(2)], Dec. 21,

2000, 114 Stat. 2763, 2763A-481, provided that: "Paragraphs (1)

through (3) of section 1834(g) of the Social Security Act [subsec.

(g) of this section] (as amended by paragraph (1)) apply for cost

reporting periods beginning on or after October 1, 2000."

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by section 4101(a), (c) of Pub. L. 105-33 applicable to

items and services furnished on or after Jan. 1, 1998, see section

4101(d) of Pub. L. 105-33, set out as a note under section 1395l of

this title.

Amendment by section 4104(b)(1) of Pub. L. 105-33 applicable to

items and services furnished on or after Jan. 1, 1998, see section

4104(e) of Pub. L. 105-33, set out as a note under section 1395l of

this title.

Section 4105(d) of Pub. L. 105-33 provided that:

"(1) In general. - Except as provided in paragraph (2), the

amendments made by this section [amending this section and sections

1395w-4 and 1395x of this title] shall apply to items and services

furnished on or after July 1, 1998.

"(2) Testing strips. - The amendment made by subsection (b)(2)

[amending this section] shall apply with respect to blood glucose

testing strips furnished on or after January 1, 1998."

Amendment by section 4201(c)(5) 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 4312(f)(1) of Pub. L. 105-33 provided that: "The

amendment made by subsection (a) [amending this section] shall

apply to suppliers of durable medical equipment with respect to

such equipment furnished on or after January 1, 1998."

Section 4312(f)(3) of Pub. L. 105-33 provided that: "The

amendments made by subsections (c) through (e) [amending this

section and section 1395x of this title] shall take effect on the

date of the enactment of this Act [Aug. 5, 1997] and may be applied

with respect to items and services furnished on or after January 1,

1998."

Section 4316(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and section 1395u of

this title] shall take effect on the date of the enactment of this

Act [Aug. 5, 1997]."

Amendment by section 4531(b)(2) of Pub. L. 105-33 applicable to

services furnished on or after Jan. 1, 2000, see section 4531(b)(3)

of Pub. L. 105-33, set out as a note under section 1395l of this

title.

Amendment by section 4541(a)(2) of Pub. L. 105-33 applicable to

services furnished on or after Jan. 1, 1998, including portions of

cost reporting periods occurring on or after such date, except that

subsec. (k) of this section inapplicable to services described in

section 1395l(a)(8)(B) of this title that are furnished during

1998, see section 4541(e) of Pub. L. 105-33, set out as a note

under section 1395l of this title.

Section 4551(c)(2) of Pub. L. 105-33 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to purchases or rentals after the effective date of any regulations

issued pursuant to such amendment."

Section 4552(e) of Pub. L. 105-33 provided that:

"(1) Oxygen. - The amendments made by subsection (a) [amending

this section] shall apply to items furnished on and after January

1, 1998.

"(2) Other provisions. - The amendments made by this section

other than subsection (a) [amending this section] shall take effect

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

EFFECTIVE DATE OF 1994 AMENDMENT

Section 126(i) of Pub. L. 103-432 provided that: "Except as

provided in subsection (h) [amending section 1395u of this title,

enacting provisions set out as notes under sections 1395u and

1395w-4 of this title, and amending provisions set out as a note

under section 1395w-4 of this title], the amendments made by this

section and the provisions of this section [amending this section

and sections 1395u, 1395w-1, and 1395w-4 of this title, enacting

provisions set out as notes under sections 1395u and 1395w-4 of

this title, and amending provisions set out as notes under this

section and sections 1395u and 1395w-4 of this title] shall take

effect as if included in the enactment of OBRA-1990 [Pub. L.

101-508]."

Section 131(a)(2) of Pub. L. 103-432 provided that the amendment

made by that section is effective 60 days after Oct. 31, 1994.

Section 132(c) of Pub. L. 103-432 provided that: "The amendments

made by subsections (a) and (b) [amending this section] shall apply

to items furnished after the expiration of the 60-day period that

begins on the date of the enactment of this Act [Oct. 31, 1994]."

Section 133(c) of Pub. L. 103-432 provided that: "The amendments

made by this section [amending this section and sections 1395m and

1395pp of this title] shall apply to items or services furnished on

or after January 1, 1995."

Section 134(a)(2) of Pub. L. 103-432 provided that: "The

amendment made by paragraph (1) [amending this section] shall take

effect on the date of the enactment of this Act [Oct. 31, 1994]."

Section 135(a)(2) of Pub. L. 103-432 provided that: "The

amendment made by paragraph (1) [amending this section] shall be

effective on the date of the enactment of this Act [Oct. 31,

1994]."

Section 135(b)(1) of Pub. L. 103-432 provided that the amendment

made by that section is effective Oct. 31, 1994.

Section 135(b)(3) of Pub. L. 103-432 provided that the amendment

made by that section is effective Oct. 31, 1994.

Section 135(d)(2) of Pub. L. 103-432 provided that: "The

amendment made by paragraph (1) [amending this section] shall be

effective on the date of the enactment of this Act [Oct. 31,

1994]."

Section 135(e)(8) of Pub. L. 103-432 provided that: "The

amendments made by this subsection [amending this section and

provisions set out as notes under this section and section 1395cc

of this title] shall take effect as if included in the enactment of

OBRA-1990 [Pub. L. 101-508]."

Section 145(d) of Pub. L. 103-432 provided that: "The amendments

made by this section [amending this section and sections 1395x to

1395bb of this title] shall apply to mammography furnished by a

facility on and after the first date that the certificate

requirements of section 354(b) of the Public Health Service Act

[section 263b(b) of this title] apply to such mammography conducted

by such facility."

Amendment by section 156(a)(2)(C) of Pub. L. 103-432 applicable

to services provided on or after Oct. 31, 1994, see section

156(a)(3) of Pub. L. 103-432, set out as a note under section

1320c-3 of this title.

EFFECTIVE DATE OF 1993 AMENDMENT

Section 13542(b) of Pub. L. 103-66 provided that: "The amendments

made by this section [amending this section] shall apply to items

furnished on or after January 1, 1994."

Section 13543(c) of Pub. L. 103-66 provided that: "The amendments

made by this section [amending this section] shall apply to items

furnished on or after January 1, 1994."

Section 13544(a)(3) of Pub. L. 103-66 provided that: "The

amendments made by this subsection [amending this section] shall

apply to items furnished on or after January 1, 1994."

Amendment by section 13544(b)(1) of Pub. L. 103-66 applicable to

items furnished on or after Jan. 1, 1994, see section 13544(b)(3)

of Pub. L. 103-66, set out as a note under section 1395l of this

title.

Section 13545(b) of Pub. L. 103-66 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to items

furnished on or after January 1, 1994."

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4102(i) of Pub. L. 101-508 provided that:

"(1) Except as otherwise provided, the amendments made by this

section [amending this section, section 1395w-4 of this title, and

provisions set out as a note below] shall apply to services

furnished on or after January 1, 1991.

"(2) The amendment made by subsection (f) [amending this section]

shall be effective as if included in the enactment of the Omnibus

Budget Reconciliation Act of 1987 [Pub. L. 100-203]."

Amendment by section 4104(a) of Pub. L. 101-508 applicable to

services furnished on or after Jan. 1, 1991, see section 4104(d) of

Pub. L. 101-508, set out as a note under section 1395l of this

title.

Section 4152(a)(3) of Pub. L. 101-508, as amended by Pub. L.

103-432, title I, Sec. 135(e)(1), Oct. 31, 1994, 108 Stat. 4424,

provided that: "The amendments made by this subsection [amending

this section and section 1395x of this title] shall apply to items

furnished on or after January 1, 1991."

Section 4152(c)(4)(B)(ii) of Pub. L. 101-508 provided that: "The

amendment made by clause (i) [amending this section] shall apply to

items furnished on or after January 1, 1992, unless the Secretary

develops specific criteria before that date for the treatment of

wheelchairs as customized items for purposes of section 1834(a)(4)

of the Social Security Act [subsec. (a)(4) of this section] (in

which case the amendment made by such clause shall not become

effective)." [Criteria established by Secretary Nov. 1, 1991, see

56 F.R. 65995, Dec. 20, 1991, 42 CFR Sec. 414.224.]

Section 4152(f)(2) of Pub. L. 101-508 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to forms and documents distributed on or after January 1, 1991."

Section 4152(g)(2) of Pub. L. 101-508 provided that: "The

amendments made by paragraph (1) [amending this section] shall

apply to patients who first receive home oxygen therapy services on

or after January 1, 1991."

Section 4152(i) of Pub. L. 101-508 provided that: "Except as

otherwise provided, the amendments made by this section [amending

this section, section 1395x of this title, and provisions set out

as a note under section 1395f of this title] shall apply to items

furnished on or after January 1, 1991."

Amendment by section 4153(a)(1), (2)(D) of Pub. L. 101-508

applicable to items furnished on or after Jan. 1, 1991, see section

4153(a)(3) of Pub. L. 101-508, set out as a note under section

1395k of this title.

Amendment by section 4163(b) of Pub. L. 101-508 applicable to

screening mammography performed on or after Jan. 1, 1991, see

section 4163(e) of Pub. L. 101-508, set out as a note under section

1395l of this title.

EFFECTIVE DATE OF 1989 AMENDMENTS

Amendment by section 6102(f)(1) of Pub. L. 101-239 applicable to

services furnished on or after Jan. 1, 1991, see section 6102(f)(3)

of Pub. L. 101-239, set out as a note under section 1395l of this

title.

Section 6112(e)(4) of Pub. L. 101-239 provided that: "The

amendments made by this subsection [amending this section and

sections 1395x and 1395cc of this title] shall apply with respect

to items furnished on or after January 1, 1990."

Amendment by section 201(a) of 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.

Section 301(b)(1), (c)(1) of Pub. L. 101-234 provided that the

amendments made by that section are effective as if included in the

enactment of the Omnibus Budget Reconciliation Act of 1987, Pub. L.

100-203.

EFFECTIVE DATE OF 1988 AMENDMENTS

Amendment by Pub. L. 100-485 effective as if included in the

enactment of 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 202(b)(4) of Pub. L. 100-360 applicable to

items dispensed on or after Jan. 1, 1990, see section 202(m)(1) of

Pub. L. 100-360, set out as a note under section 1395u of this

title.

Amendment by section 203(c)(1)(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.

Section 204(e) of Pub. L. 100-360, which provided that the

amendments made by section 204 of Pub. L. 100-360 [amending this

section and sections 1395l, 1395x to 1395z, 1395aa, 1395bb, 1396a,

and 1396n of this title] applied to screening mammography performed

on or after January 1, 1990, and that subsec. (e)(5) of this

section only applied until such time as the Secretary of Health and

Human Services implemented the physician fee schedules based on

relative value scale developed under section 1395w-1(e) of this

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

13, 1989, 103 Stat. 1981.

Except as specifically provided in section 411 of Pub. L.

100-360, amendment by section 411(a)(3)(A), (B)(ii), (C)(ii),

(f)(8)(A), (B)(ii), (D), (g)(1)(A) and (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 4049(b)(2) of Pub. L. 100-203, as amended by Pub. L.

101-239, title VI, Sec. 6102(e)(6)(B), Dec. 19, 1989, 103 Stat.

2188; Pub. L. 101-508, title IV, Sec. 4118(h)(2), Nov. 5, 1990, 104

Stat. 1388-70, provided that: "The amendments made by this section

[amending this section and section 1395l of this title] shall apply

to services performed on or after April 1, 1989."

[Section 4118(h) of Pub. L. 101-508 provided that the amendment

by that section to section 4049(b)(2) 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

Subsection (a) of this section applicable to covered items (other

than oxygen and oxygen equipment) furnished on or after Jan. 1,

1989, and to oxygen and oxygen equipment furnished on or after June

1, 1989, see section 4062(e) of Pub. L. 100-203, as amended, set

out as an Effective Date of 1987 Amendment note under section 1395f

of this title.

REGULATIONS

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 427(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-521, provided that: "Not later than 1

year after the date of the enactment of this Act [Dec. 21, 2000],

the Secretary of Health and Human Services shall promulgate revised

regulations to carry out the amendment made by subsection (a)

[amending this section] using a negotiated rulemaking process under

subchapter III of chapter 5 of title 5, United States Code."

-TRANS-

TRANSFER OF FUNCTIONS

Physician Payment Review Commission (PPRC) was terminated and its

assets and staff transferred to the Medicare Payment Advisory

Commission (MedPAC) by section 4022(c)(2), (3) of Pub. L. 105-33,

set out as a note under section 1395b-6 of this title. Section

4022(c)(2), (3) further provided that MedPAC was to be responsible

for preparation and submission of reports required by law to be

submitted by PPRC, and that, for that purpose, any reference in law

to PPRC was to be deemed, after the appointment of MedPAC, to refer

to MedPAC.

-MISC2-

PAYMENT FOR NEW TECHNOLOGIES

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 104(d)], Dec. 21,

2000, 114 Stat. 2763, 2763A-470, provided that:

"(1) Tests furnished in 2001. -

"(A) Screening. - For a screening mammography (as defined in

section 1861(jj) of the Social Security Act (42 U.S.C.

1395x(jj))) furnished during the period beginning on April 1,

2001, and ending on December 31, 2001, that uses a new

technology, payment for such screening mammography shall be made

as follows:

"(i) In the case of a technology which directly takes a

digital image (without involving film), in an amount equal to

150 percent of the amount of payment under section 1848 of such

Act (42 U.S.C. 1395w-4) for a bilateral diagnostic mammography

(under HCPCS code 76091) for such year.

"(ii) In the case of a technology which allows conversion of

a standard film mammogram into a digital image and subsequently

analyzes such resulting image with software to identify

possible problem areas, in an amount equal to the limit that

would otherwise be applied under section 1834(c)(3) of such Act

(42 U.S.C. 1395m(c)(3)) for 2001, increased by $15.

"(B) Bilateral diagnostic mammography. - For a bilateral

diagnostic mammography furnished during the period beginning on

April 1, 2001, and ending on December 31, 2001, that uses a new

technology described in subparagraph (A), payment for such

mammography shall be the amount of payment provided for under

such subparagraph.

"(C) Allocation of amounts. - The Secretary shall provide for

an appropriate allocation of the amounts under subparagraphs (A)

and (B) between the professional and technical components.

"(D) Implementation of provision. - The Secretary of Health and

Human Services may implement the provisions of this paragraph by

program memorandum or otherwise.

"(2) Consideration of new hcpcs code for new technologies after

2001. - The Secretary shall determine, for such mammographies

performed after 2001, whether the assignment of a new HCPCS code is

appropriate for mammography that uses a new technology. If the

Secretary determines that a new code is appropriate for such

mammography, the Secretary shall provide for such new code for such

tests furnished after 2001.

"(3) New technology described. - For purposes of this subsection,

a new technology with respect to a mammography is an advance in

technology with respect to the test or equipment that results in

the following:

"(A) A significant increase or decrease in the resources used

in the test or in the manufacture of the equipment.

"(B) A significant improvement in the performance of the test

or equipment.

"(C) A significant advance in medical technology that is

expected to significantly improve the treatment of medicare

beneficiaries.

"(4) HCPCS code defined. - The term 'HCPCS code' means a code

under the Health Care Financing Administration Common Procedure

Coding System (HCPCS)."

MEDPAC STUDY AND REPORT ON MEDICARE COVERAGE OF CARDIAC AND

PULMONARY REHABILITATION THERAPY SERVICES

Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 127], Dec. 21, 2000,

114 Stat. 2763, 2763A-479, provided that:

"(a) Study. -

"(1) In general. - The Medicare Payment Advisory Commission

shall conduct a study on coverage of cardiac and pulmonary

rehabilitation therapy services under the medicare program under

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

"(2) Focus. - In conducting the study under paragraph (1), the

Commission shall focus on the appropriate -

"(A) qualifying diagnoses required for coverage of cardiac

and pulmonary rehabilitation therapy services;

"(B) level of physician direct involvement and supervision in

furnishing such services; and

"(C) level of reimbursement for such services.

"(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 such recommendations for legislation and

administrative action as the Commission determines appropriate."

GAO STUDIES ON COSTS OF AMBULANCE SERVICES FURNISHED IN RURAL AREAS

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 221(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-486, provided that:

"(1) Study. - The Comptroller General of the United States shall

conduct a study on each of the matters described in paragraph (2).

"(2) Matters described. - The matters referred to in paragraph

(1) are the following:

"(A) The cost of efficiently providing ambulance services for

trips originating in rural areas, with special emphasis on

collection of cost data from rural providers.

"(B) The means by which rural areas with low population

densities can be identified for the purpose of designating areas

in which the cost of providing ambulance services would be

expected to be higher than similar services provided in more

heavily populated areas because of low usage. Such study shall

also include an analysis of the additional costs of providing

ambulance services in areas designated under the previous

sentence.

"(3) Report. - Not later than June 30, 2002, the Comptroller

General shall submit to Congress a report on the results of the

studies conducted under paragraph (1) and shall include

recommendations on steps that should be taken to assure access to

ambulance services in rural areas."

ADJUSTMENT IN RURAL RATES

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 221(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-487, provided that: "In providing for

adjustments under subparagraph (D) of section 1834(l)(2) of the

Social Security Act (42 U.S.C. 1395m(l)(2)) for years beginning

with 2004, the Secretary of Health and Human Services shall take

into consideration the recommendations contained in the report

under subsection (b)(2) [probably means section 221(b)(3), set out

above] and shall adjust the fee schedule payment rates under such

section for ambulance services provided in low density rural areas

based on the increased cost (if any) of providing such services in

such areas."

STUDY AND REPORT ON ADDITIONAL COVERAGE FOR TELEHEALTH SERVICES

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 223(d)], Dec. 21,

2000, 114 Stat. 2763, 2763A-489, provided that:

"(1) Study. - The Secretary of Health and Human Services shall

conduct a study to identify -

"(A) settings and sites for the provision of telehealth

services that are in addition to those permitted under section

1834(m) of the Social Security Act [subsec. (m) of this section],

as added by subsection (b);

"(B) practitioners that may be reimbursed under such section

for furnishing telehealth services that are in addition to the

practitioners that may be reimbursed for such services under such

section; and

"(C) geographic areas in which telehealth services may be

reimbursed that are in addition to the geographic areas where

such services may be reimbursed under such section.

"(2) Report. - Not later than 2 years after the date of the

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

to Congress a report on the study conducted under paragraph (1)

together with such recommendations for legislation that the

Secretary determines are appropriate."

SPECIAL RULES FOR PAYMENTS FOR 2001

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 423(a)(2)], Dec.

21, 2000, 114 Stat. 2763, 2763A-518, provided that:

"Notwithstanding the amendment made by paragraph (1) [amending this

section], for purposes of making payments for ambulance services

under part B of title XVIII of the Social Security Act [this part],

for services furnished during 2001, the 'percentage increase in the

consumer price index' specified in section 1834(l)(3)(B) of such

Act (42 U.S.C. 1395m(l)(3)(B)) -

"(A) for services furnished on or after January 1, 2001, and

before July 1, 2001, shall be the percentage increase for 2001 as

determined under the provisions of law in effect on the day

before the date of the enactment of this Act [Dec. 21, 2000]; and

"(B) for services furnished on or after July 1, 2001, and

before January 1, 2002, shall be equal to 4.7 percent."

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 425(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-519, provided that: "Notwithstanding

the amendments made by subsection (a) [amending this section], for

purposes of making payments for durable medical equipment under

section 1834(a) of the Social Security Act (42 U.S.C. 1395m(a)),

other than for oxygen and oxygen equipment specified in paragraph

(9) of such section, the payment basis recognized for 2001 under

such section -

"(1) for items furnished on or after January 1, 2001, and

before July 1, 2001, shall be the payment basis for 2001 as

determined under the provisions of law in effect on the day

before the date of the enactment of this Act [Dec. 21, 2000]

(including the application of section 228(a)(1) of BBRA [Pub. L.

106-113, Sec. 1000(a)(6) [title II, Sec. 228(a)(1)], set out as a

note below]); and

"(2) for items furnished on or after July 1, 2001, and before

January 1, 2002, shall be the payment basis that is determined

under such section 1834(a) if such section 228(a)(1) did not

apply and taking into account the amendment made by subsection

(a), increased by a transitional percentage allowance equal to

3.28 percent (to account for the timing of implementation of the

CPI update)."

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 426(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-520, provided that: "Notwithstanding

the amendments made by subsection (a) [amending this section], for

purposes of making payments for prosthetic devices and orthotics

and prosthetics (as defined in subparagraphs (B) and (C) of

paragraph (4) of section 1834(h) of the Social Security Act (42

U.S.C. 1395m(h)) under such section, the payment basis recognized

for 2001 under paragraph (2) of such section -

"(1) for items furnished on or after January 1, 2001, and

before July 1, 2001, shall be the payment basis for 2001 as

determined under the provisions of law in effect on the day

before the date of the enactment of this Act [Dec. 21, 2000]; and

"(2) for items furnished on or after July 1, 2001, and before

January 1, 2002, shall be the payment basis that is determined

under such section taking into account the amendments made by

subsection (a), increased by a transitional percentage allowance

equal to 2.6 percent (to account for the timing of implementation

of the CPI update)."