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

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

  • Enviado por: El remitente no desea revelar su nombre
  • Idioma: inglés
  • País: Estados Unidos Estados Unidos
  • 258 páginas
publicidad
publicidad

PREEMPTION OF RULE

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 428(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-522, provided that: "The provisions of

section 1834(h)(1)(G) [subsec. (h)(1)(G) of this section] as added

by subsection (a) shall supersede any rule that as of the date of

the enactment of this Act [Dec. 21, 2000] may have applied a 5-year

replacement rule with regard to prosthetic devices."

GAO STUDY AND REPORT ON COSTS OF EMERGENCY AND MEDICAL

TRANSPORTATION SERVICES

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 436], Dec. 21,

2000, 114 Stat. 2763, 2763A-527, provided that:

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

conduct a study on the costs of providing emergency and medical

transportation services across the range of acuity levels of

conditions for which such transportation services are provided.

"(b) Report. - Not later than 18 months 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 for any changes in

methodology or payment level necessary to fairly compensate

suppliers of emergency and medical transportation services and to

ensure the access of beneficiaries under the medicare program under

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

TREATMENT OF TEMPORARY PAYMENT INCREASES AFTER CALENDAR YEAR 2001

Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 547(d)], Dec. 21,

2000, 114 Stat. 2763, 2763A-553, provided that: "The payment

increase provided under the following sections shall not apply

after calendar year 2001 and shall not be taken into account in

calculating the payment amounts applicable for items and services

furnished after such year:

"(1) Section 401(c)(2) [set out as a note under section 1395l

of this title] (relating to covered OPD services).

"(2) Section 422(e)(2) [set out as a note under section 1395rr

of this title] (relating to renal dialysis services paid for on a

composite rate basis).

"(3) Section 423(a)(2)(B) [set out above] (relating to

ambulance services).

"(4) Section 425(b)(2) [set out above] (relating to durable

medical equipment).

"(5) Section 426(b)(2) [set out above] (relating to prosthetic

devices and orthotics and prosthetics)."

STUDY OF DELIVERY OF INTRAVENOUS IMMUNE GLOBULIN (IVIG) OUTSIDE

HOSPITALS AND PHYSICIANS' OFFICES

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 201(n)],

Nov. 29, 1999, 113 Stat. 1536, 1501A-341, required the Secretary of

Health and Human Services to conduct a study of the extent to which

intravenous immune globulin could be delivered and reimbursed under

the medicare program outside of a hospital or physician's office

and to submit a report on such study to Congress within 18 months

after Nov. 29, 1999.

TEMPORARY INCREASE IN PAYMENT RATES FOR DURABLE MEDICAL EQUIPMENT

AND OXYGEN

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 228],

Nov. 29, 1999, 113 Stat. 1536, 1501A-356, provided that:

"(a) In General. - For purposes of payments under section 1834(a)

of the Social Security Act (42 U.S.C. 1395m(a)) for covered items

(as defined in paragraph (13) of that section) furnished during

2001 and 2002, the Secretary of Health and Human Services shall

increase the payment amount in effect (but for this section) for

such items for -

"(1) 2001 by 0.3 percent, and

"(2) 2002 by 0.6 percent.

"(b) Limiting Application to Specified Years. - The payment

amount increase -

"(1) under subsection (a)(1) shall not apply after 2001 and

shall not be taken into account in calculating the payment

amounts applicable for covered items furnished after such year;

and

"(2) under subsection (a)(2) shall not apply after 2002 and

shall not be taken into account in calculating the payment

amounts applicable for covered items furnished after such year."

DEMONSTRATION OF COVERAGE OF AMBULANCE SERVICES UNDER MEDICARE

THROUGH CONTRACTS WITH UNITS OF LOCAL GOVERNMENT

Pub. L. 105-33, title IV, Sec. 4532, Aug. 5, 1997, 111 Stat. 453,

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

Sec. 225], Nov. 29, 1999, 113 Stat. 1536, 1501A-353, provided that:

"(a) Demonstration Project Contracts with Local Governments. -

The Secretary of Health and Human Services shall establish up to 3

demonstration projects under which, at the request of a unit of

local government, the Secretary enters into a contract with the

unit of local government under which -

"(1) the unit of local government furnishes (or arranges for

the furnishing of) ambulance services for which payment may be

made under part B of title XVIII of the Social Security Act [this

part] for individuals residing in the unit of local government

who are enrolled under such part, except that the unit of local

government may not enter into the contract unless the contract

covers at least 80 percent of the individuals residing in the

unit of local government who are enrolled under such part but not

in a Medicare+Choice plan;

"(2) any individual or entity furnishing ambulance services

under the contract meets the requirements otherwise applicable to

individuals and entities furnishing such services under such

part; and

"(3) for each month during which the contract is in effect, the

Secretary makes a capitated payment to the unit of local

government in accordance with subsection (b).

The projects may extend over a period of not to exceed 3 years

each. Not later than July 1, 2000, the Secretary shall publish a

request for proposals for such projects.

"(b) Amount of Payment. -

"(1) In general. - The amount of the monthly payment made for

months occurring during a calendar year to a unit of local

government under a demonstration project contract under

subsection (a) shall be equal to the product of -

"(A) the Secretary's estimate of the number of individuals

covered under the contract for the month; and

"(B) 1/12 of the capitated payment rate for the year

established under paragraph (2).

"(2) Capitated payment rate defined. - In this subsection, the

term 'capitated payment rate' means, with respect to a

demonstration project -

"(A) in its first year, a rate established for the project by

the Secretary, using the most current available data, in a

manner that ensures that aggregate payments under the project

will not exceed the aggregate payment that would have been made

for ambulance services under part B of title XVIII of the

Social Security Act [this part] in the local area of

government's jurisdiction; and

"(B) in a subsequent year, the capitated payment rate

established for the previous year increased by an appropriate

inflation adjustment factor.

"(c) Other Terms of Contract. - The Secretary and the unit of

local government may include in a contract under this section such

other terms as the parties consider appropriate, including -

"(1) covering individuals residing in additional units of local

government (under arrangements entered into between such units

and the unit of local government involved);

"(2) permitting the unit of local government to transport

individuals to non-hospital providers if such providers are able

to furnish quality services at a lower cost than hospital

providers; or

"(3) implementing such other innovations as the unit of local

government may propose to improve the quality of ambulance

services and control the costs of such services.

"(d) Contract Payments in Lieu of Other Benefits. - Payments

under a contract to a unit of local government under this section

shall be instead of the amounts which (in the absence of the

contract) would otherwise be payable under part B of title XVIII of

the Social Security Act [this part] for the services covered under

the contract which are furnished to individuals who reside in the

unit of local government.

"(e) Report on Effects of Capitated Contracts. -

"(1) Study. - The Secretary shall evaluate the demonstration

projects conducted under this section. Such evaluation shall

include an analysis of the quality and cost-effectiveness of

ambulance services furnished under the projects.

"(2) Report. - Not later than January 1, 2000, the Secretary

shall submit a report to Congress on the study conducted under

paragraph (1), and shall include in the report such

recommendations as the Secretary considers appropriate, including

recommendations regarding modifications to the methodology used

to determine the amount of payments made under such contracts and

extending or expanding such projects."

[Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 225],

Nov. 29, 1999, 113 Stat. 1536, 1501A-353, provided that the

amendment made by that section to section 4532 of Pub. L. 105-33,

set out above, is effective as if included in the enactment of the

Balanced Budget Act of 1997, Pub. L. 105-33.]

PAYMENT FREEZE FOR PARENTERAL AND ENTERAL NUTRIENTS, SUPPLIES, AND

EQUIPMENT

Section 4551(b) of Pub. L. 105-33 provided that: "In determining

the amount of payment under part B of title XVIII of the Social

Security Act [this part] with respect to parenteral and enteral

nutrients, supplies, and equipment during each of the years 1998

through 2002, the charges determined to be reasonable with respect

to such nutrients, supplies, and equipment may not exceed the

charges determined to be reasonable with respect to such nutrients,

supplies, and equipment during 1995."

SERVICE STANDARDS FOR PROVIDERS OF OXYGEN AND OXYGEN EQUIPMENT

Section 4552(c) of Pub. L. 105-33 provided that: "The Secretary

shall as soon as practicable establish service standards for

persons seeking payment under part B of title XVIII of the Social

Security Act [this part] for the providing of oxygen and oxygen

equipment to beneficiaries within their homes."

ACCESS TO HOME OXYGEN EQUIPMENT

Section 4552(d) of Pub. L. 105-33 provided that:

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

study issues relating to access to home oxygen equipment and shall,

within 18 months after the date of the enactment of this Act [Aug.

5, 1997], report to the Committees on Commerce and Ways and Means

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

Senate the results of the study, including recommendations (if any)

for legislation.

"(2) Peer review evaluation. - The Secretary of Health and Human

Services shall arrange for peer review organizations established

under section 1154 of the Social Security Act [section 1320c-3 of

this title] to evaluate access to, and quality of, home oxygen

equipment."

USE OF COVERED ITEMS BY DISABLED BENEFICIARIES

Section 131(b) of Pub. L. 103-432 provided that:

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

consultation with representatives of suppliers of durable medical

equipment under part B of the medicare program [this part] and

individuals entitled to benefits under such program on the basis of

disability, shall conduct a study of the effects of the methodology

for determining payments for items of such equipment under such

part on the ability of such individuals to obtain items of such

equipment, including customized items.

"(2) Report. - Not later than one year after the date of the

enactment of this Act [Oct. 31, 1994], the Secretary shall submit a

report to Congress on the study conducted under paragraph (1), and

shall include in the report such recommendations as the Secretary

considers appropriate to assure that disabled medicare

beneficiaries have access to items of durable medical equipment."

CRITERIA FOR TREATMENT OF ITEMS AS PROSTHETIC DEVICES OR ORTHOTICS

AND PROSTHETICS

Section 131(c) of Pub. L. 103-432 provided that not later than

one year after Oct. 31, 1994, Secretary of Health and Human

Services was to submit to Congress a report describing prosthetic

devices or orthotics and prosthetics covered under this part that

do not require individualized or custom fitting and adjustment to

be used by a patient, including recommendations for appropriate

methodology for determining amount of payment for such items.

ADJUSTMENT REQUIRED FOR CERTAIN ITEMS

Section 134(b) of Pub. L. 103-432 provided that:

"(1) In general. - In accordance with section 1834(a)(10)(B) of

the Social Security Act [subsec. (a)(10)(B) of this section] (as

amended by subsection (a)), the Secretary of Health and Human

Services shall determine whether the payment amounts for the items

described in paragraph (2) are not inherently reasonable, and shall

adjust such amounts in accordance with such section if the amounts

are not inherently reasonable.

"(2) Items described. - The items referred to in paragraph (1)

are decubitus care equipment, transcutaneous electrical nerve

stimulators, and any other items considered appropriate by the

Secretary."

LIMITATION ON PREVAILING CHARGE FOR PHYSICIANS' RADIOLOGY SERVICES

FURNISHED DURING 1991; EXCEPTIONS

Section 4102(c) of Pub. L. 101-508, as amended by Pub. L.

103-432, title I, Sec. 126(b)(3), Oct. 31, 1994, 108 Stat. 4415,

provided that:

"(1) In general. - In applying part B of title XVIII of the

Social Security Act [this part], the prevailing charge for

physicians' services, furnished during 1991, which are radiology

services may not exceed the fee schedule amount established under

section 1834(b) of such Act [subsec. (b) of this section] with

respect to such services.

"(2) Exception. - Paragraph (1) shall not apply to nuclear

medicine services."

LIMITATION ON CARRIER ADJUSTMENTS FOR RADIOLOGIST SERVICES

FURNISHED DURING 1991

Section 4102(e) of Pub. L. 101-508 provided that: "For

radiologist services furnished during 1991 for which payment is

made under section 1834(b) of the Social Security Act [subsec. (b)

of this section] -

"(1) a carrier may not make any adjustment, under section

1842(b)(3)(B) of such Act [section 1395u(b)(3)(B) of this title],

in the payment amount for the service under section 1834(b) on

the basis that the payment amount is higher than the charge

applicable, for a comparable service and under comparable

circumstances, to the policyholders and subscribers of the

carrier,

"(2) no payment adjustment may be made under section 1842(b)(8)

of such Act, and

"(3) section 1842(b)(9) of such Act shall not apply."

STUDY OF PAYMENTS FOR PROSTHETIC DEVICES, ORTHOTICS, AND

PROSTHETICS

Section 4153(c) of Pub. L. 101-508, as amended by Pub. L.

103-432, title I, Sec. 135(e)(6), Oct. 31, 1994, 108 Stat. 4424,

directed Comptroller General to conduct a study of feasibility and

desirability of establishing a separate fee schedule for use in

determining the amount of payments for covered items under subsec.

(h) of this section with respect to suppliers of prosthetic

devices, orthotics, and prosthetics who provide professional

services that would take into account the costs to such providers

of providing such services and, not later than 1 year after Nov. 5,

1990, submit a report on the study to Committees on Energy and

Commerce and Ways and Means of House of Representatives and

Committee on Finance of Senate, including any recommendations

regarding payments for prosthetic devices, orthotics, and

prosthetics under the medicare program.

SPECIAL RULE FOR NUCLEAR MEDICINE PHYSICIANS

Section 6105(b) of Pub. L. 101-239, as amended by Pub. L.

101-508, title IV, Sec. 4102(g)(1), Nov. 5, 1990, 104 Stat.

1388-57, provided that: "In applying section 1834(b) of the Social

Security Act [subsec. (b) of this section] with respect to nuclear

medicine services furnished by a physician for whom nuclear

medicine services account for at least 80 percent of the total

amount of charges made under part B of title XVIII of the Social

Security Act [this part] beginning April 1, 1990, and ending

December 31, 1991, there shall be substituted for the fee schedule

otherwise applicable a fee schedule based 1/3 on the fee schedule

computed under such section (without regard to this subsection) and

2/3 on 101 percent of the 1988 prevailing charge for such

services."

SPECIAL RULE FOR INTERVENTIONAL RADIOLOGISTS; "SPLIT BILLING"

Section 6105(c) of Pub. L. 101-239, as amended by Pub. L.

101-508, title IV, Sec. 4102(h), Nov. 5, 1990, 104 Stat. 1388-58,

provided that: "In applying section 1834(b) of the Social Security

Act [subsec. (b) of this section] to radiologist services furnished

in 1990 or 1991, the exception for 'split billing' set forth at

section 5262J of the Medicare Carriers Manual shall apply to

services furnished in 1990 or 1991 in the same manner and to the

same extent as the exception applied to services furnished in

1989."

RENTAL PAYMENTS FOR ENTERAL AND PARENTERAL PUMPS

Section 6112(b) of Pub. L. 101-239 provided that:

"(1) In general. - Except as provided in paragraph (2), the

amount of any monthly rental payment under part B of title XVIII of

the Social Security Act [this part] for an enteral or parenteral

pump furnished on or after April 1, 1990, shall be determined in

accordance with the methodology under which monthly rental payments

for such pumps were determined during 1989.

"(2) Cap on Rental Payments, Servicing, and Repairs. - In the

case of an enteral or parenteral pump described in paragraph (1)

that is furnished on a rental basis during a period of medical need

-

"(A) monthly rental payments shall not be made under part B of

title XVIII of the Social Security Act for more than 15 months

during such period, and

"(B) after monthly rental payments have been made for 15 months

during such period, payment under such part shall be made for

maintenance and servicing of the pump in such amounts as the

Secretary of Health and Human Services determines to be

reasonable and necessary to ensure the proper operation of the

pump."

TREATMENT OF POWER-DRIVEN WHEELCHAIRS AS CUSTOMIZED ITEMS

Section 6112(d)(2) of Pub. L. 101-239 provided that: "The

Secretary of Health and Human Services shall by regulation specify

criteria to be used by carriers in making determinations on a

case-by-case basis as whether to classify power-driven wheelchairs

as a customized item (as described in section 1834(a)(4) of the

Social Security Act [subsec. (a)(4) of this section]) for purposes

of reimbursement under title XVIII of such Act [this subchapter]."

STUDY OF PAYMENT FOR PORTABLE X-RAY SERVICES

Section 6134 of Pub. L. 101-239 directed Secretary of Health and

Human Services to conduct a study of costs of furnishing, and

payments for, portable x-ray services under part B and, not later

than 1 year after Dec. 19, 1989, report to Congress on results of

such study including a recommendation respecting whether payment

for such services should be made in the same manner as for

radiologists' services or on the basis of a separate fee schedule.

GAO STUDY OF STANDARDS FOR USE OF AND PAYMENT FOR ITEMS OF DURABLE

MEDICAL EQUIPMENT

Section 6139 of Pub. L. 101-239 directed Comptroller General to

conduct a study of appropriate uses of items of durable medical

equipment and of appropriate criteria for making determinations of

medical necessity under this subchapter for such items, with

particular emphasis on items (including seat-lift chairs) that may

be subject to abusive billing practices, such study to include an

analysis of appropriate use of forms in making medical necessity

determinations for items of durable medical equipment under such

title, and procedures for identifying items of durable medical

equipment that should no longer be covered under this subchapter,

and to be conducted with a panel convened by the Comptroller

General consisting of specialists in the disciplines of orthopedic

medicine, rehabilitation, arthritis, and geriatric medicine,

representatives of consumer organizations, and representatives of

carriers under the medicare program, with the Comptroller General

to submit not later than Apr. 1, 1991, a report to Committees on

Ways and Means and Energy and Commerce of House of Representatives

and Committee on Finance of Senate on the study including

recommendations.

REPORTS ON MEDICARE BENEFICIARY DRUG EXPENSES

Section 202(i) of Pub. L. 100-360, directed Secretary of Health

and Human Services, by not later than Apr. 1, 1989, to report to

Congress on expenses incurred by medicare beneficiaries for

outpatient prescription drugs, and to provide Director of

Congressional Budget Office with such data from that Survey as

Director might request to make required estimates, prior to repeal

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

1981.

ADDITIONAL STUDIES BY SECRETARY OR COMPTROLLER GENERAL

Section 202(k) of Pub. L. 100-360 directed Secretary of Health

and Human Services to conduct a study, and make a report to

Congress by Jan. 1, 1990, on possibility of including drugs which

have not yet been approved under section 355 or 357 of Title 21,

Food and Drugs, and biological products which have not been

licensed under section 262 of this title but which are commonly

used in the treatment of cancer or in immunosuppressive therapy and

other experimental drugs and biological products as covered

outpatient drugs under medicare program, to conduct a study, and

report to Congress by Jan. 1, 1990, evaluating potential to use

mail service pharmacies to reduce costs to medicare program and to

medicare beneficiaries, to conduct a study, and report to Congress

by Jan. 1, 1993, on methods to improve utilization review of

covered outpatient drugs, and to conduct a longitudinal study, and

report to Congress by Jan. 1, 1993, on use of outpatient

prescription drugs by medicare beneficiaries with respect to

medical necessity, potential for adverse drug interactions, cost

(including whether lower cost drugs could have been used), and

patient stockpiling or wastage, and which further directed

Comptroller General to conduct studies, and report to Congress by

not later than May 1, 1991, on comparing average wholesale prices

with actual pharmacy acquisition costs by type of pharmacy, on

determining the overhead costs of retail pharmacies, and on

discounts given by pharmacies to other third-party insurers, prior

to repeal by Pub. L. 101-234, title II, Sec. 201(a), Dec. 13, 1989,

103 Stat. 1981.

DEVELOPMENT OF STANDARD MEDICARE CLAIMS FORMS

Section 202(l) of Pub. L. 100-360 directed Secretary of Health

and Human Services to develop, in consultation with representatives

of pharmacies and other interested individuals, a standard claims

form (and a standard electronic claims format) to be used in

requests for payment for covered outpatient drugs under medicare

program and other third-party payors, prior to repeal by Pub. L.

101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981.

STUDIES AND REPORTS ON SCREENING MAMMOGRAPHY

Section 204(f) of Pub. L. 100-360 directed Physician Payment

Review Commission to study and report, by July 1, 1989, to

Committees on Ways and Means and Energy and Commerce of the House

of Representatives and Committee on Finance of the Senate

concerning the cost of providing screening mammography in a variety

of settings and at different volume levels, prior to repeal by Pub.

L. 101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981.

DEADLINE FOR ESTABLISHMENT OF FEE SCHEDULES FOR RADIOLOGIST

SERVICES; REPORT TO CONGRESS

Section 4049(b)(1) of Pub. L. 100-203, as amended by Pub. L.

100-360, title IV, Sec. 411(f)(8)(E), July 1, 1988, 102 Stat. 780;

Pub. L. 101-508, title IV, Sec. 4118(g)(3), Nov. 5, 1990, 104 Stat.

1388-70, directed Secretary of Health and Human Services to propose

the relative value scale and fee schedules for radiologist services

(under subsec. (b) of this section) by not later than Aug. 1, 1988.

STUDY AND EVALUATION

Section 4062(c) of Pub. L. 100-203, as amended by Pub. L.

100-360, title IV, Sec. 411(g)(1)(C), July 1, 1988, 102 Stat. 782,

provided that:

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

impact of the amendments made by this section [enacting this

section, amending sections 1395f, 1395k, 1395l, and 1395cc of this

title, and repealing section 1395zz of this title] on the

availability of covered items and shall evaluate the

appropriateness of the volume adjustment for oxygen and oxygen

equipment under section 1834(a)(5)(C) of the Social Security Act

[subsec. (a)(5)(C) of this section] (as amended by subsection (b)

of this section). The Secretary shall report to Congress, by not

later than January 1, 1991, on such impact and on the evaluation

and shall include in such report recommendations for changes in

payment methodology for covered items under section 1834(a) of such

Act.

"(2) Before January 1, 1991, the Secretary may not conduct any

demonstration project respecting alternative methods of payment for

covered items under title XVIII of the Social Security Act [this

subchapter].

"(3) In this subsection, the term 'covered item' has the meaning

given such term in section 1834(a)(13) of the Social Security Act

[subsec. (a)(13) of this section] (as amended by subsection (b) of

this section).

"(4) The Secretary shall, upon written request and payment of a

reasonable copying fee which the Secretary may establish, provide

the data and information used in determining the payment amounts

for covered items under section 1834(a) of the Social Security Act

[subsec. (a) of this section], but only in a form which does not

permit identification of individual suppliers.

"(5) The Comptroller General shall conduct a study on the

appropriateness of the level of payments allowed for covered items

under the medicare program, and shall report to Congress on the

results of such study (including recommendations on the transition

to regional or national rates) by not later than January 1, 1991.

Entities furnishing such items which fail to provide the

Comptroller General with reasonable access to necessary records to

carry out the study under this paragraph are subject to exclusion

from the medicare program under section 1128(a) of the Social

Security Act [section 1320a-7(a) of this title]."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395f, 1395k, 1395l,

1395u, 1395w-4, 1395y, 1395bb, 1395cc, 1395pp, 1395ww, 1395ddd,

1396a of this title.

-FOOTNOTE-

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

(!2) So in original. Two pars. (17) have been enacted.

(!3) So in original. Probably should be "clause".

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

(!5) So in original. Two pars. (8) have been enacted.

(!6) So in original. Probably should be section "1395x(aa)(2)".

-End-

-CITE-

42 USC Sec. 1395n 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. 1395n. Procedure for payment of claims of providers of

services

-STATUTE-

(a) Conditions for payment for services described in section

1395k(a)(2) of this title

Except as provided in subsections (b), (c), and (e) of this

section, payment for services described in section 1395k(a)(2) of

this title furnished an individual may be made only to providers of

services which are eligible therefor under section 1395cc(a) of

this title, and only if -

(1) written request, signed by such individual, except in cases

in which the Secretary finds it impracticable for the individual

to do so, is filed for such payment in such form, in such manner

and by such person or persons as the Secretary may by regulation

prescribe, no later than the close of the period of 3 calendar

years following the year in which such services are furnished

(deeming any services furnished in the last 3 calendar months of

any calendar year to have been furnished in the succeeding

calendar year) except that, where the Secretary deems that

efficient administration so requires, such period may be reduced

to not less than 1 calendar year; and

(2) a physician certifies (and recertifies, where such services

are furnished over a period of time, in such cases, with such

frequency, and accompanied by such supporting material,

appropriate to the case involved, as may be provided by

regulations) that -

(A) in the case of home health services (i) such services are

or were required because the individual is or was confined to

his home (except when receiving items and services referred to

in section 1395x(m)(7) of this title) and needs or needed

skilled nursing care (other than solely venipuncture for the

purpose of obtaining a blood sample) on an intermittent basis

or physical or speech therapy or, in the case of an individual

who has been furnished home health services based on such a

need and who no longer has such a need for such care or

therapy, continues or continued to need occupational therapy,

(ii) a plan for furnishing such services to such individual has

been established and is periodically reviewed by a physician,

and (iii) such services are or were furnished while the

individual is or was under the care of a physician;

(B) in the case of medical and other health services, except

services described in subparagraphs (B), (C), and (D) of

section 1395x(s)(2) of this title, such services are or were

medically required;

(C) in the case of outpatient physical therapy services or

outpatient occupational therapy services, (i) such services are

or were required because the individual needed physical therapy

services or occupational therapy services, respectively, (ii) a

plan for furnishing such services has been established by a

physician or by the qualified physical therapist or qualified

occupational therapist, respectively, providing such services

and is periodically reviewed by a physician, and (iii) such

services are or were furnished while the individual is or was

under the care of a physician;

(D) in the case of outpatient speech pathology services, (i)

such services are or were required because the individual

needed speech pathology services, (ii) a plan for furnishing

such services has been established by a physician or by the

speech pathologist providing such services and is periodically

reviewed by a physician, and (iii) such services are or were

furnished while the individual is or was under the care of a

physician;

(E) in the case of comprehensive outpatient rehabilitation

facility services, (i) such services are or were required

because the individual needed skilled rehabilitation services,

(ii) a plan for furnishing such services has been established

and is periodically reviewed by a physician, and (iii) such

services are or were furnished while the individual is or was

under the care of a physician; and

(F) in the case of partial hospitalization services, (i) the

individual would require inpatient psychiatric care in the

absence of such services, (ii) an individualized, written plan

for furnishing such services has been established by a

physician and is reviewed periodically by a physician, and

(iii) such services are or were furnished while the individual

is or was under the care of a physician.

For purposes of this section, the term "provider of services"

shall include a clinic, rehabilitation agency, or public health

agency if, in the case of a clinic or rehabilitation agency, such

clinic or agency meets the requirements of section 1395x(p)(4)(A)

of this title (or meets the requirements of such section through

the operation of section 1395x(g) of this title), or if, in the

case of a public health agency, such agency meets the

requirements of section 1395x(p)(4)(B) of this title (or meets

the requirements of such section through the operation of section

1395x(g) of this title), but only with respect to the furnishing

of outpatient physical therapy services (as therein defined) or

(through the operation of section 1395x(g) of this title) with

respect to the furnishing of outpatient occupational therapy

services.

To the extent provided by regulations, the certification and

recertification requirements of paragraph (2) shall be deemed

satisfied where, at a later date, a physician makes a certification

of the kind provided in subparagraph (A) or (B) of paragraph (2)

(whichever would have applied), but only where such certification

is accompanied by such medical and other evidence as may be

required by such regulations. With respect to the physician

certification required by paragraph (2) for home health services

furnished to any individual by a home health agency (other than an

agency which is a governmental entity) and with respect to the

establishment and review of a plan for such services, the Secretary

shall prescribe regulations which shall become effective no later

than July 1, 1981, and which prohibit a physician who has a

significant ownership interest in, or a significant financial or

contractual relationship with, such home health agency from

performing such certification and from establishing or reviewing

such plan, except that such prohibition shall not apply with

respect to a home health agency which is a sole community home

health agency (as determined by the Secretary). For purposes of the

preceding sentence, service by a physician as an uncompensated

officer or director of a home health agency shall not constitute

having a significant ownership interest in, or a significant

financial or contractual relationship with, such agency. For

purposes of paragraph (2)(A), an individual shall be considered to

be "confined to his home" if the individual has a condition, due to

an illness or injury, that restricts the ability of the individual

to leave his or her home except with the assistance of another

individual or the aid of a supportive device (such as crutches, a

cane, a wheelchair, or a walker), or if the individual has a

condition such that leaving his or her home is medically

contraindicated. While an individual does not have to be bedridden

to be considered "confined to his home", the condition of the

individual should be such that there exists a normal inability to

leave home, that leaving home requires a considerable and taxing

effort by the individual. Any absence of an individual from the

home attributable to the need to receive health care treatment,

including regular absences for the purpose of participating in

therapeutic, psychosocial, or medical treatment in an adult

day-care program that is licensed or certified by a State, or

accredited, to furnish adult day-care services in the State shall

not disqualify an individual from being considered to be "confined

to his home". Any other absence of an individual from the home

shall not so disqualify an individual if the absence is of

infrequent or of relatively short duration. For purposes of the

preceding sentence, any absence for the purpose of attending a

religious service shall be deemed to be an absence of infrequent or

short duration.

(b) Conditions for payment for services described in section

1395x(s) of this title

(1) Payment may also be made to any hospital for services

described in section 1395x(s) of this title furnished as an

outpatient service by a hospital or by others under arrangements

made by it to an individual entitled to benefits under this part

even though such hospital does not have an agreement in effect

under this subchapter if (A) such services were emergency services,

(B) the Secretary would be required to make such payment if the

hospital had such an agreement in effect and otherwise met the

conditions of payment hereunder, and (C) such hospital has made an

election pursuant to section 1395f(d)(1)(C) of this title with

respect to the calendar year in which such emergency services are

provided. Such payments shall be made only in the amounts provided

under section 1395l(a)(2) of this title and then only if such

hospital agrees to comply, with respect to the emergency services

provided, with the provisions of section 1395cc(a) of this title.

(2) Payment may also be made on the basis of an itemized bill to

an individual for services described in paragraph (1) of this

subsection if (A) payment cannot be made under such paragraph (1)

solely because the hospital does not elect, in accordance with

section 1395f(d)(1)(C) of this title, to claim such payments and

(B) such individual files application (submitted within such time

and in such form and manner, and containing and supported by such

information as the Secretary shall by regulations prescribe) for

reimbursement. The amounts payable under this paragraph shall,

subject to the provisions of section 1395l of this title, be equal

to 80 percent of the hospital's reasonable charges for such

services.

(c) Collection of charges from individuals for services specified

in section 1395x(s) of this title

Notwithstanding the provisions of this section and sections

1395k, 1395l, and 1395cc(a)(1)(A) of this title, a hospital or a

critical access hospital may, subject to such limitations as may be

prescribed by regulations, collect from an individual the customary

charges for services specified in section 1395x(s) of this title

and furnished to him by such hospital as an outpatient, but only if

such charges for such services do not exceed the applicable

supplementary medical insurance deductible, and such customary

charges shall be regarded as expenses incurred by such individual

with respect to which benefits are payable in accordance with

section 1395l(a)(1) of this title. Payments under this subchapter

to hospitals which have elected to make collections from

individuals in accordance with the preceding sentence shall be

adjusted periodically to place the hospital in the same position it

would have been had it instead been reimbursed in accordance with

section 1395l(a)(2) of this title (or, in the case of a critical

access hospital, in accordance with section 1395l(a)(6) of this

title).

(d) Payment to Federal provider of services or other Federal

agencies prohibited

Subject to section 1395qq of this title, no payment may be made

under this part to any Federal provider of services or other

Federal agency, except a provider of services which the Secretary

determines is providing services to the public generally as a

community institution or agency; and no such payment may be made to

any provider of services or other person for any item or service

which such provider or person is obligated by a law of, or a

contract with, the United States to render at public expense.

(e) Payment to fund designated by medical staff or faculty of

medical school

For purposes of services (1) which are inpatient hospital

services by reason of paragraph (7) of section 1395x(b) of this

title or for which entitlement exists by reason of clause (II) of

section 1395k(a)(2)(B)(i) of this title, and (2) for which the

reasonable cost thereof is determined under section 1395x(v)(1)(D)

of this title (or would be if section 1395ww of this title did not

apply), payment under this part shall be made to such fund as may

be designated by the organized medical staff of the hospital in

which such services were furnished or, if such services were

furnished in such hospital by the faculty of a medical school, to

such fund as may be designated by such faculty, but only if -

(A) such hospital has an agreement with the Secretary under

section 1395cc of this title, and

(B) the Secretary has received written assurances that (i) such

payment will be used by such fund solely for the improvement of

care to patients in such hospital or for educational or

charitable purposes and (ii) the individuals who were furnished

such services or any other persons will not be charged for such

services (or if charged provision will be made for return of any

moneys incorrectly collected).

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1835, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 303; amended

Pub. L. 90-248, title I, Secs. 126(b), 129(c)(9)(A), (B), 130(a),

(b), 133(e), Jan. 2, 1968, 81 Stat. 846, 848, 849, 851; Pub. L.

92-603, title II, Secs. 204(b), 227(e)(2), 251(b)(2), 281(f),

283(b), Oct. 30, 1972, 86 Stat. 1377, 1406, 1445, 1456; Pub. L.

94-437, title IV, Sec. 401(a), Sept. 30, 1976, 90 Stat. 1408; Pub.

L. 96-499, title IX, Secs. 930(e), (j), 933(b), 944(a), Dec. 5,

1980, 94 Stat. 2631, 2632, 2635, 2642; Pub. L. 97-35, title XXI,

Secs. 2106(b)(1), 2122(a)(1), Aug. 13, 1981, 95 Stat. 792, 796;

Pub. L. 98-21, title VI, Sec. 602(b), Apr. 20, 1983, 97 Stat. 163;

Pub. L. 98-369, div. B, title III, Secs. 2336(a), (b), 2342(b),

2354(b)(1), (8), (9), July 18, 1984, 98 Stat. 1091, 1094, 1100;

Pub. L. 98-617, Sec. 3(a)(3), Nov. 8, 1984, 98 Stat. 3295; Pub. L.

99-509, title IX, Sec. 9337(c), Oct. 21, 1986, 100 Stat. 2034; Pub.

L. 100-203, title IV, Secs. 4024(b), 4070(b)(3), 4085(i)(4), Dec.

22, 1987, 101 Stat. 1330-74, 1330-115, 1330-132; Pub. L. 100-360,

title II, Secs. 203(d)(1), 205(d), July 1, 1988, 102 Stat. 724,

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

Stat. 1981; Pub. L. 101-239, title VI, Sec. 6003(g)(3)(D)(viii),

Dec. 19, 1989, 103 Stat. 2153; Pub. L. 101-508, title IV, Sec.

4008(m)(2)(D), Nov. 5, 1990, 104 Stat. 1388-53; Pub. L. 105-33,

title IV, Secs. 4201(c)(1), 4615(a), Aug. 5, 1997, 111 Stat. 373,

475; Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 507(a)(1)], Dec.

21, 2000, 114 Stat. 2763, 2763A-532.)

-MISC1-

AMENDMENTS

2000 - Subsec. (a). Pub. L. 106-554, in concluding provisions,

struck out ", and that absences of the individual from home are

infrequent or of relatively short duration, or are attributable to

the need to receive medical treatment" after "taxing effort by the

individual" and inserted at end "Any absence of an individual from

the home attributable to the need to receive health care treatment,

including regular absences for the purpose of participating in

therapeutic, psychosocial, or medical treatment in an adult

day-care program that is licensed or certified by a State, or

accredited, to furnish adult day-care services in the State shall

not disqualify an individual from being considered to be 'confined

to his home'. Any other absence of an individual from the home

shall not so disqualify an individual if the absence is of

infrequent or of relatively short duration. For purposes of the

preceding sentence, any absence for the purpose of attending a

religious service shall be deemed to be an absence of infrequent or

short duration."

1997 - Subsec. (a)(2)(A). Pub. L. 105-33, Sec. 4615(a), inserted

"(other than solely venipuncture for the purpose of obtaining a

blood sample)" after "skilled nursing care".

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

"critical access" for "rural primary care" in two places.

1990 - Subsec. (c). Pub. L. 101-508 substituted "a hospital or a

rural primary care hospital may" for "a hospital may" in first

sentence, substituted "section 1395l(a)(2) of this title (or, in

the case of a rural primary care hospital, in accordance with

section 1395l(a)(6) of this title)" for "section 1395l(a)(2) of

this title" in second sentence, and struck out at end "A rural

primary care hospital shall be considered a hospital for purposes

of this subsection."

1989 - Subsec. (a)(2)(G), (H). Pub. L. 101-234 repealed Pub. L.

100-360, Secs. 203(d)(1), 205(d), 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. 101-239 inserted at end "A rural primary

care hospital shall be considered a hospital for purposes of this

subsection."

1988 - Subsec. (a)(2)(G). Pub. L. 100-360, Sec. 203(d)(1), added

subpar. (G) relating to home intravenous drug therapy services.

Subsec. (a)(2)(H). Pub. L. 100-360, Sec. 205(d), added subpar.

(H) relating to in-home care provided to chronically dependent

individuals.

1987 - Subsec. (a). Pub. L. 100-203, Sec. 4024(b), inserted two

sentences at end clarifying "confined to his home" for purposes of

par. (2)(A).

Subsec. (a)(2)(C)(i). Pub. L. 100-203, Sec. 4085(i)(4), struck

out second comma at end.

Subsec. (a)(2)(F). Pub. L. 100-203, Sec. 4070(b)(3), added

subpar. (F).

1986 - Subsec. (a)(2). Pub. L. 99-509, Sec. 9337(c)(2), inserted

in second sentence "(or meets the requirements of such section

through the operation of section 1395x(g) of this title)" in two

places, and "or (through the operation of section 1395x(g) of this

title) with respect to the furnishing of outpatient occupational

therapy services".

Subsec. (a)(2)(C). Pub. L. 99-509, Sec. 9337(c)(1), inserted "or

outpatient occupational therapy services" in introductory

provisions, "or occupational therapy services, respectively," in

cl. (i), and "or qualified occupational therapist, respectively,"

in cl. (ii).

1984 - Subsec. (a). Pub. L. 98-369, Sec. 2354(b)(1), as amended

by Pub. L. 98-617, Sec. 3(a)(3), in concluding provisions,

substituted "contractual" for "contractural".

Pub. L. 98-369, Sec. 2336(b), inserted before period at end of

fourth sentence ", except that such prohibition shall not apply

with respect to a home health agency which is a sole community home

health agency (as determined by the Secretary)".

Pub. L. 98-369, Sec. 2336(a), inserted sentence at end that for

purposes of the preceding sentence, service by a physician as an

uncompensated officer or director of a home health agency shall not

constitute having a significant ownership interest in, or a

significant financial or contractual relationship with, such

agency.

Subsec. (a)(2)(B), (C). Pub. L. 98-369, Sec. 2354(b)(8)(A),

struck out "and" at end.

Subsec. (a)(2)(C)(ii). Pub. L. 98-369, Sec. 2342(b), substituted

"by a physician or by the qualified physical therapist providing

such services and is periodically reviewed by a physician" for ",

and is periodically reviewed, by a physician".

Subsec. (a)(2)(D). Pub. L. 98-369, Sec. 2354(b)(8)(B), realigned

margin of subpar. (D).

Subsec. (e)(2). Pub. L. 98-369, Sec. 2354(b)(9), designated

concluding pars. (1) and (2) as (A) and (B), respectively, and in

par. (B) inserted "(i)" after "written assurances that" and

substituted "(ii) the individuals who" for "(B) the individuals

who" and "return of" for "return for".

1983 - Subsec. (e). Pub. L. 98-21 inserted "(or would be if

section 1395ww of this title did not apply)" after "section

1395(v)(1)(D) of this title".

1981 - Subsec. (a)(2)(A). Pub. L. 97-35, Sec. 2122(a)(1),

substituted "needs or needed skilled nursing care on an

intermittent basis or physical or speech therapy or, in the case of

an individual who has been furnished home health services based on

such a need and who no longer has such a need for such care or

therapy, continues or continued to need occupational therapy" for

"needed skilled nursing care on an intermittent basis, or physical,

occupational, or speech therapy".

Subsec. (a)(2)(D). Pub. L. 97-35, Sec. 2106(b)(1), inserted "and"

after "physician;".

Subsec. (a)(2)(E). Pub. L. 97-35, Sec. 2106(b)(1), substituted a

period for "; and" at the end.

1980 - Subsec. (a). Pub. L. 96-499, Sec. 930(e), inserted

sentence at end authorizing Secretary to prescribe regulations to

prohibit significantly interested physicians from performing

physician certification required by par. (2) for home health

services.

Subsec. (a)(2)(A). Pub. L. 96-499, Sec. 930(j), substituted

"physical, occupational, or speech" for "physical or speech".

Subsec. (a)(2)(D)(ii). Pub. L. 96-499, Sec. 944(a), inserted "by

a physician or by the speech pathologist providing such services",

after "has been established".

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

(E).

1976 - Subsec. (d). Pub. L. 94-437 substituted "Subject to

section 1395qq of this title, no payment" for "No payment".

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

reference to subsec. (e) of this section in introductory

provisions.

Subsec. (a)(1). Pub. L. 92-603, Sec. 281(f), placed a 3-year time

limitation on time within which a written request for payment is

filed, with provision for reduction of limit to 1 year.

Subsec. (a)(2)(C). Pub. L. 92-603, Sec. 251(b)(2), substituted

"because the individual needed physical therapy services" for

"because the individual needed physical therapy services on an

outpatient basis".

Subsec. (a)(2)(D). Pub. L. 92-603, Sec. 283(b), added subpar.

(D).

Subsec. (c). Pub. L. 92-603, Sec. 204(b), substituted "the

applicable supplementary medical insurance deductible" for "$50".

Subsec. (e). Pub. L. 92-603, Sec. 227(e)(2)(B), added subsec.

(e).

1968 - Subsec. (a). Pub. L. 90-248, Secs. 129(c)(9)(A), 130(a),

inserted introductory exception phrase and included reference to

subsec. (c).

Subsec. (a)(2). Pub. L. 90-248, Sec. 133(e)(5), inserted sentence

at end defining "provider of services".

Subsec. (a)(2)(B). Pub. L. 90-248, Secs. 126(b), 133(e)(4),

inserted "except services described in subparagraphs (B) and (C) of

section 1395x(s)(2) of this title," after "health services," and

inserted reference to subpar. (d).

Subsec. (a)(2)(C). Pub. L. 90-248, Sec. 133(e)(1)-(3), added

subpar. (C).

Subsec. (b). Pub. L. 90-248, Sec. 129(c)(9)(B), added subsec.

(b). Former subsec. (b) redesignated (c), in turn redesignated (d).

Subsec. (c). Pub. L. 90-248, Sec. 130(b), added subsec. (c).

Former subsec. (c), previously designated (b), redesignated (d).

Subsec. (d). Pub. L. 90-248, Secs. 129(c)(9)(B), 130(b),

redesignated former subsec. (b) as (c), in turn as (d),

respectively.

EFFECTIVE DATE OF 2000 AMENDMENT

Amendment by Pub. L. 106-554 applicable to home health services

furnished on or after Dec. 21, 2000, see section 1(a)(6) [title V,

Sec. 507(a)(2)] of Pub. L. 106-554, set out as a note under section

1395f of this title.

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 4615(a) of Pub. L. 105-33 applicable to home

health services furnished after 6-month period beginning after Aug.

5, 1997, see section 4615(b) of Pub. L. 105-33, set out as a note

under section 1395f of this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section

201(c) of Pub. L. 101-234, set out as a note under section 1320a-7a

of this title.

EFFECTIVE DATE OF 1988 AMENDMENT

Amendment by section 203(d)(1) 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 205(d) 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.

EFFECTIVE DATE OF 1987 AMENDMENT

Amendment by section 4024(b) of Pub. L. 100-203 applicable to

items and services provided on or after Jan. 1, 1988, see section

4024(c) of Pub. L. 100-203, set out as a note under section 1395f

of this title.

EFFECTIVE DATE OF 1986 AMENDMENT

Amendment by 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.

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.

Amendment by section 2336(a) of Pub. L. 98-369 applicable to

certifications and plans of care made or established on or after

July 18, 1984, see section 2336(c)(1) of Pub. L. 98-369, set out as

a note under section 1395f of this title.

Section 2342(c) of Pub. L. 98-369 provided that: "The amendments

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

this title] apply to plans of care established on or after the date

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

Amendment by section 2354(b)(1), (8), (9) of Pub. L. 98-369

effective July 18, 1984, but not to be construed as changing or

affecting any right, liability, status, or interpretation which

existed (under the provisions of law involved) before that date,

see section 2354(e)(1) of Pub. L. 98-369, set out as a note under

section 1320a-1 of this title.

EFFECTIVE DATE OF 1983 AMENDMENT

Amendment by Pub. L. 98-21 applicable to items and services

furnished by or under arrangement with a hospital beginning with

its first cost reporting period that begins on or after Oct. 1,

1983, any change in a hospital's cost reporting period made after

November 1982 to be recognized for such purposes only if the

Secretary finds good cause therefor, see section 604(a)(1) of Pub.

L. 98-21, set out as a note under section 1395ww of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Amendment by section 2122(a)(1) of Pub. L. 97-35 applicable to

services furnished pursuant to plans of treatment implemented after

the third month beginning after Aug. 13, 1981, see section 2122(b)

of Pub. L. 97-35, set out as a note under section 1395f of this

title.

EFFECTIVE DATE OF 1980 AMENDMENT

Amendment by section 930(e), (j) of Pub. L. 96-499 effective with

respect to services furnished on or after July 1, 1981, see section

930(s)(1) of Pub. L. 96-499, set out as a note under section 1395x

of this title.

Amendment by section 933(b) of Pub. L. 96-499 effective with

respect to a comprehensive outpatient rehabilitation facility's

first accounting period beginning on or after July 1, 1981, see

section 933(h) of Pub. L. 96-499, set out as a note under section

1395k of this title.

Section 944(b) of Pub. L. 96-499 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to plans

for furnishing services established on or after January 1, 1981."

EFFECTIVE DATE OF 1972 AMENDMENT

Amendment by section 204(b) of Pub. L. 92-603 effective with

respect to calendar years after 1972, see section 204(c) of Pub. L.

92-603, set out as a note under section 1395l of this title.

Amendment by section 227(e)(2) 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(b)(2) of Pub. L. 92-603 applicable with

respect to services furnished on or after Oct. 30, 1972, see

section 251(d)(2) of Pub. L. 92-603, set out as a note under

section 1395x of this title.

Amendment by section 281(f) of Pub. L. 92-603 applicable in the

case of services furnished (or deemed to have been furnished) after

1970, see section 281(g) of Pub. L. 92-603, set out as a note under

section 1395gg of this title.

Section 283(c) of Pub. L. 92-603 provided that: "The provisions

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

title] shall apply with respect to services rendered after December

31, 1972."

EFFECTIVE DATE OF 1968 AMENDMENT

Amendment by section 126(b) of Pub. L. 90-248 applicable with

respect to services furnished after Jan. 2, 1968, see section

126(c) of Pub. L. 90-248, set out as a note under section 1395f of

this title.

Amendment by section 129(c)(9)(A), (B) of Pub. L. 90-248

applicable with respect to services furnished after March 31, 1968,

see section 129(d) of Pub. L. 90-248, set out as a note under

section 1395d of this title.

Section 130(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."

Amendment by section 133(e) of Pub. L. 90-248 applicable with

respect to services furnished after June 30, 1968, see section

133(g) of Pub. L. 90-248, set out as a note under section 1395k of

this title.

REGULATIONS

Secretary of Health and Human Services required to provide, not

later than 90 days after July 18, 1984, for revision of regulations

as may be required to reflect amendment to subsec. (a) by section

2336(b) of Pub. L. 98-369, see section 2336(c)(2) of Pub. L.

98-369, set out as a note under section 1395f of this title.

HOME HEALTH PROSPECTIVE PAYMENT DEMONSTRATION PROJECT

Section 4027 of Pub. L. 100-203, as amended by Pub. L. 100-360,

title IV, Sec. 411(d)(6), July 1, 1988, 102 Stat. 775, directed

Secretary of Health and Human Services to provide for a

demonstration project to develop and test alternative methods of

paying home health agencies on a prospective basis for services

furnished under the medicare and medicaid programs, directed that

the project be designed in a manner to enable the Secretary to

evaluate the effects of various methods of prospective payment

(including payments on a per-visit, per-case, and per-episode

basis) on program expenditures, access to, and quality of, home

health care, and home health agency operations, directed Secretary

to assure that services are first furnished under the project not

later than Apr. 1, 1989, and, for this purpose, authorized

Secretary to reinstate a previously awarded contract, or award a

sole source contract, to carry out the project, provided for

funding, and directed Secretary to submit to Congress, not later

than one year after Dec. 22, 1987, an interim report on the

demonstration project and, not later than four years after Dec. 22,

1987, a final report on results of the project.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1320a-7a, 1395f, 1395k,

1395x, 1395cc, 1395pp, 1395qq, 1395eee, 1395fff, 1395ggg of this

title.

-End-

-CITE-

42 USC Sec. 1395o 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. 1395o. Eligible individuals

-STATUTE-

Every individual who -

(1) is entitled to hospital insurance benefits under part A of

this subchapter, or

(2) has attained age 65 and is a resident of the United States,

and is either (A) a citizen or (B) an alien lawfully admitted for

permanent residence who has resided in the United States

continuously during the 5 years immediately preceding the month

in which he applies for enrollment under this part,

is eligible to enroll in the insurance program established by this

part.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1836, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 304; amended

Pub. L. 92-603, title II, Sec. 201(c)(1), Oct. 30, 1972, 86 Stat.

1372.)

-REFTEXT-

REFERENCES IN TEXT

Part A of this subchapter, referred to in par. (1), is classified

to section 1395c et seq. of this title.

-MISC1-

AMENDMENTS

1972 - Pub. L. 92-603 designed former par. (2)(B) as par. (1),

former par. (1) as introductory clause in par. (2), and former

pars. (2)(A)(i) and (ii) as pars. (2)(A) and (B), and struck out

"(A)" after "(2)".

PERSONS CONVICTED OF SUBVERSIVE ACTIVITIES

Section 104(b)(2) of Pub. L. 89-97 provided that: "An individual

who has been convicted of any offense under (A) chapter 37 [section

792 et seq. of Title 18, Crimes and Criminal Procedure] (relating

to espionage and censorship), chapter 105 [section 2151 et seq. of

Title 18] (relating to sabotage), or chapter 115 [section 2381 et

seq. of Title 18] (relating to treason, sedition, and subversive

activities) of title 18 of the United States Code, or (B) section

4, 112, or 113 of the Internal Security Act of 1950, as amended

[section 783, 822, or 823 of Title 50, War and National Defense],

may not enroll under part B of title XVIII of the Social Security

Act [this part]."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395p, 1395q, 1395r,

1395v of this title; title 25 section 1644.

-End-

-CITE-

42 USC Sec. 1395p 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. 1395p. Enrollment periods

-STATUTE-

(a) Generally; regulations

An individual may enroll in the insurance program established by

this part only in such manner and form as may be prescribed by

regulations, and only during an enrollment period prescribed in or

under this section.

(b) Repealed. Pub. L. 96-499, title IX, Sec. 945(a), Dec. 5, 1980,

94 Stat. 2642

(c) Initial general enrollment period; eligible individuals before

March 1, 1966

In the case of individuals who first satisfy paragraph (1) or (2)

of section 1395o of this title before March 1, 1966, the initial

general enrollment period shall begin on the first day of the

second month which begins after July 30, 1965, and shall end on May

31, 1966. For purposes of this subsection and subsection (d) of

this section, an individual who has attained age 65 and who

satisfies paragraph (1) of section 1395o of this title but not

paragraph (2) of such section shall be treated as satisfying such

paragraph (1) on the first day on which he is (or on filing

application would have been) entitled to hospital insurance

benefits under part A of this subchapter.

(d) Eligible individuals on or after March 1, 1966

In the case of an individual who first satisfies paragraph (1) or

(2) of section 1395o of this title on or after March 1, 1966, his

initial enrollment period shall begin on the first day of the third

month before the month in which he first satisfies such paragraphs

and shall end seven months later. Where the Secretary finds that an

individual who has attained age 65 failed to enroll under this part

during his initial enrollment period (based on a determination by

the Secretary of the month in which such individual attained age

65), because such individual (relying on documentary evidence) was

mistaken as to his correct date of birth, the Secretary shall

establish for such individual an initial enrollment period based on

his attaining age 65 at the time shown in such documentary evidence

(with a coverage period determined under section 1395q of this

title as though he had attained such age at that time).

(e) General enrollment period

There shall be a general enrollment period during the period

beginning on January 1 and ending on March 31 of each year.

(f) Individuals deemed enrolled in medical insurance program

Any individual -

(1) who is eligible under section 1395o of this title to enroll

in the medical insurance program by reason of entitlement to

hospital insurance benefits as described in paragraph (1) of such

section, and

(2) whose initial enrollment period under subsection (d) of

this section begins after March 31, 1973, and

(3) who is residing in the United States, exclusive of Puerto

Rico,

shall be deemed to have enrolled in the medical insurance program

established by this part.

(g) Commencement of enrollment period

All of the provisions of this section shall apply to individuals

satisfying subsection (f) of this section, except that -

(1) in the case of an individual who satisfies subsection (f)

of this section by reason of entitlement to disability insurance

benefits described in section 426(b) of this title, his initial

enrollment period shall begin on the first day of the later of

(A) April 1973 or (B) the third month before the 25th month of

such entitlement, and shall reoccur with each continuous period

of eligibility (as defined in section 1395r(d) of this title) and

upon attainment of age 65;

(2)(A) in the case of an individual who is entitled to monthly

benefits under section 402 or 423 of this title on the first day

of his initial enrollment period or becomes entitled to monthly

benefits under section 402 of this title during the first 3

months of such period, his enrollment shall be deemed to have

occurred in the third month of his initial enrollment period, and

(B) in the case of an individual who is not entitled to

benefits under section 402 of this title on the first day of his

initial enrollment period and does not become so entitled during

the first 3 months of such period, his enrollment shall be deemed

to have occurred in the month in which he files the application

establishing his entitlement to hospital insurance benefits

provided such filing occurs during the last 4 months of his

initial enrollment period; and

(3) in the case of an individual who would otherwise satisfy

subsection (f) of this section but does not establish his

entitlement to hospital insurance benefits until after the last

day of his initial enrollment period (as defined in subsection

(d) of this section), his enrollment shall be deemed to have

occurred on the first day of the earlier of the then current or

immediately succeeding general enrollment period (as defined in

subsection (e) of this section).

(h) Waiver of enrollment period requirements where individual's

rights were prejudiced by administrative error or inaction

In any case where the Secretary finds that an individual's

enrollment or nonenrollment in the insurance program established by

this part or part A of this subchapter pursuant to section 1395i-2

of this title is unintentional, inadvertent, or erroneous and is

the result of the error, misrepresentation, or inaction of an

officer, employee, or agent of the Federal Government, or its

instrumentalities, the Secretary may take such action (including

the designation for such individual of a special initial or

subsequent enrollment period, with a coverage period determined on

the basis thereof and with appropriate adjustments of premiums) as

may be necessary to correct or eliminate the effects of such error,

misrepresentation, or inaction.

(i) Special enrollment periods

(1) In the case of an individual who -

(A) at the time the individual first satisfies paragraph (1) or

(2) of section 1395o of this title, is enrolled in a group health

plan described in section 1395y(b)(1)(A)(v) of this title by

reason of the individual's (or the individual's spouse's) current

employment status, and

(B) has elected not to enroll (or to be deemed enrolled) under

this section during the individual's initial enrollment period,

there shall be a special enrollment period described in paragraph

(3). In the case of an individual not described in the previous

sentence who has not attained the age of 65, at the time the

individual first satisfies paragraph (1) of section 1395o of this

title, is enrolled in a large group health plan (as that term is

defined in section 1395y(b)(1)(B)(iii) of this title) by reason of

the individual's current employment status (or the current

employment status of a family member of the individual), and has

elected not to enroll (or to be deemed enrolled) under this section

during the individual's initial enrollment period, there shall be a

special enrollment period described in paragraph (3)(B).

(2) In the case of an individual who -

(A)(i) has enrolled (or has been deemed to have enrolled) in

the medical insurance program established under this part during

the individual's initial enrollment period, or (ii) is an

individual described in paragraph (1)(A);

(B) has enrolled in such program during any subsequent special

enrollment period under this subsection during which the

individual was not enrolled in a group health plan described in

section 1395y(b)(1)(A)(v) of this title by reason of the

individual's (or individual's spouse's) current employment

status; and

(C) has not terminated enrollment under this section at any

time at which the individual is not enrolled in such a group

health plan by reason of the individual's (or individual's

spouse's) current employment status,

there shall be a special enrollment period described in paragraph

(3). In the case of an individual not described in the previous

sentence who has not attained the age of 65, has enrolled (or has

been deemed to have enrolled) in the medical insurance program

established under this part during the individual's initial

enrollment period, or is an individual described in the second

sentence of paragraph (1), has enrolled in such program during any

subsequent special enrollment period under this subsection during

which the individual was not enrolled in a large group health plan

(as that term is defined in section 1395y(b)(1)(B)(iii) of this

title) by reason of the individual's current employment status (or

the current employment status of a family member of the

individual), and has not terminated enrollment under this section

at any time at which the individual is not enrolled in such a large

group health plan by reason of the individual's current employment

status (or the current employment status of a family member of the

individual), there shall be a special enrollment period described

in paragraph (3)(B).

(3)(A) The special enrollment period referred to in the first

sentences of paragraphs (1) and (2) is the period including each

month during any part of which the individual is enrolled in a

group health plan described in section 1395y(b)(1)(A)(v) of this

title by reason of current employment status ending with the last

day of the eighth consecutive month in which the individual is at

no time so enrolled.

(B) The special enrollment period referred to in the second

sentences of paragraphs (1) and (2) is the period including each

month during any part of which the individual is enrolled in a

large group health plan (as that term is defined in section

1395y(b)(1)(B)(iii) of this title) by reason of the individual's

current employment status (or the current employment status of a

family member of the individual) ending with the last day of the

eighth consecutive month in which the individual is at no time so

enrolled.

(4)(A) In the case of an individual who is entitled to benefits

under part A of this subchapter pursuant to section 426(b) of this

title and -

(i) who at the time the individual first satisfies paragraph

(1) of section 1395o of this title -

(I) is enrolled in a group health plan described in section

1395y(b)(1)(A)(v) of this title by reason of the individual's

current or former employment or by reason of the current or

former employment status of a member of the individual's

family, and

(II) has elected not to enroll (or to be deemed enrolled)

under this section during the individual's initial enrollment

period; and

(ii) whose continuous enrollment under such group health plan

is involuntarily terminated at a time when the enrollment under

the plan is not by reason of the individual's current employment

or by reason of the current employment of a member of the

individual's family,

there shall be a special enrollment period described in

subparagraph (B).

(B) The special enrollment period referred to in subparagraph (A)

is the 6-month period beginning on the first day of the month which

includes the date of the enrollment termination described in

subparagraph (A)(ii).

(j) Special rules for individuals with ALS

In applying this section in the case of an individual who is

entitled to benefits under part A of this subchapter pursuant to

the operation of section 426(h) of this title, the following

special rules apply:

(1) The initial enrollment period under subsection (d) of this

section shall begin on the first day of the first month in which

the individual satisfies the requirement of section 1395o(1) of

this title.

(2) In applying subsection (g)(1) of this section, the initial

enrollment period shall begin on the first day of the first month

of entitlement to disability insurance benefits referred to in

such subsection.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1837, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 304; amended

Pub. L. 89-384, Sec. 3(a), (b), Apr. 8, 1966, 80 Stat. 105; Pub. L.

90-248, title I, Secs. 136(a), 145(a), (b), Jan. 2, 1968, 81 Stat.

853, 859; Pub. L. 92-603, title II, Secs. 201(c)(2), 206(a),

259(a), 260, Oct. 30, 1972, 86 Stat. 1372, 1378, 1448; Pub. L.

96-265, title I, Sec. 103(a)(3), June 9, 1980, 94 Stat. 444; Pub.

L. 96-499, title IX, Sec. 945(a), (b), Dec. 5, 1980, 94 Stat. 2642;

Pub. L. 97-35, title XXI, Sec. 2151(a)(1), (2), Aug. 13, 1981, 95

Stat. 801; Pub. L. 98-369, div. B, title III, Secs. 2338(b),

2354(b)(10), July 18, 1984, 98 Stat. 1092, 1101; Pub. L. 99-272,

title IX, Secs. 9201(c)(1), 9219(a)(2), Apr. 7, 1986, 100 Stat.

171, 182; Pub. L. 99-509, title IX, Sec. 9319(c)(1)-(3), Oct. 21,

1986, 100 Stat. 2011; Pub. L. 99-514, title XVIII, Sec.

1895(b)(12), Oct. 22, 1986, 100 Stat. 2934; Pub. L. 101-239, title

VI, Sec. 6202(b)(4)(C), (c)(1), Dec. 19, 1989, 103 Stat. 2233; Pub.

L. 103-432, title I, Secs. 147(f)(1)(A), 151(c)(2), Oct. 31, 1994,

108 Stat. 4430, 4435; Pub. L. 105-33, title IV, Secs. 4581(b)(1),

4631(a)(2), Aug. 5, 1997, 111 Stat. 465, 486; Pub. L. 106-554, Sec.

1(a)(6) [title I, Sec. 115(b)], Dec. 21, 2000, 114 Stat. 2763,

2763A-474.)

-REFTEXT-

REFERENCES IN TEXT

Part A of this subchapter, referred to in subsecs. (c), (h),

(i)(4)(A), and (j), is classified to section 1395c et seq. of this

title.

-MISC1-

AMENDMENTS

2000 - Subsec. (j). Pub. L. 106-554 added subsec. (j).

1997 - Subsec. (i)(1) to (3). Pub. L. 105-33, Sec. 4631(a)(2),

substituted "1395y(b)(1)(B)(iii) of this title" for

"1395y(b)(1)(B)(iv) of this title" wherever appearing.

Subsec. (i)(4). Pub. L. 105-33, Sec. 4581(b)(1), added par. (4).

1994 - Subsec. (i)(1). Pub. L. 103-432, Sec. 151(c)(2)(A), in

closing provisions substituted "(as that term is defined in section

1395y(b)(1)(B)(iv) of this title) by reason of the individual's

current employment status (or the current employment status of a

family member of the individual)" for "as an active individual (as

those terms are defined in section 1395y(b)(1)(B)(iv) of this

title)".

Subsec. (i)(1)(A). Pub. L. 103-432, Sec. 151(c)(2)(D), inserted

"status" after "current employment".

Subsec. (i)(2). Pub. L. 103-432, Sec. 151(c)(2)(A), (C), in

closing provisions substituted "(as that term is defined in section

1395y(b)(1)(B)(iv) of this title) by reason of the individual's

current employment status (or the current employment status of a

family member of the individual)" for "as an active individual (as

those terms are defined in section 1395y(b)(1)(B)(iv) of this

title)" and "by reason of the individual's current employment

status (or the current employment status of a family member of the

individual)" for "as an active individual".

Subsec. (i)(2)(B), (C). Pub. L. 103-432, Sec. 151(c)(2)(D),

inserted "status" after "current employment".

Subsec. (i)(3)(A). Pub. L. 103-432, Sec. 151(c)(2)(D), inserted

"status" after "current employment".

Pub. L. 103-432, Sec. 147(f)(1)(A), substituted "including each

month during any part of which the individual is enrolled" for

"beginning with the first day of the first month in which the

individual is no longer enrolled" and "ending with the last day of

the eighth consecutive month in which the individual is at no time

so enrolled" for "and ending seven months later".

Subsec. (i)(3)(B). Pub. L. 103-432, Sec. 151(c)(2)(B),

substituted "in a large group health plan (as that term is defined

in section 1395y(b)(1)(B)(iv) of this title) by reason of the

individual's current employment status (or the current employment

status of a family member of the individual)" for "as an active

individual in a large group health plan (as such terms are defined

in section 1395y(b)(1)(B)(iv) of this title)".

Pub. L. 103-432, Sec. 147(f)(1)(A), substituted "including each

month during any part of which the individual is enrolled" for

"beginning with the first day of the first month in which the

individual is no longer enrolled" and "ending with the last day of

the eighth consecutive month in which the individual is at no time

so enrolled" for "and ending seven months later".

1989 - Subsec. (i)(1). Pub. L. 101-239, Sec. 6202(c)(1)(A),

redesignated subpars. (B) and (C) as (A) and (B), respectively,

struck out former subpar. (A) which read as follows: "has attained

the age of 65,", and inserted "not described in the previous

sentence" after "In the case of an individual" in second sentence.

Pub. L. 101-239, Sec. 6202(b)(4)(C), substituted "section

1395y(b)(1)(A)(v)" and "section 1395y(b)(1)(B)(iv)" for "section

1395y(b)(3)(A)(iv)" and "section 1395y(b)(4)(B)", respectively.

Subsec. (i)(2). Pub. L. 101-239, Sec. 6202(c)(1)(B), substituted

"(1)(A)" for "(1)(B)" in subpar. (B)(i), redesignated subpars. (B)

and (C) as (A) and (B), respectively, struck out former subpar. (A)

which read as follows: "has attained the age of 65;", and inserted

"not described in the previous sentence" after "In the case of an

individual" in second sentence.

Pub. L. 101-239, Sec. 6202(b)(4)(C), substituted "section

1395y(b)(1)(A)(v)" and "section 1395y(b)(1)(B)(iv)" for "section

1395y(b)(3)(A)(iv)" and "section 1395y(b)(4)(B)", respectively.

Subsec. (i)(3). Pub. L. 101-239, Sec. 6202(b)(4)(C), substituted

"section 1395y(b)(1)(A)(v)" and "section 1395y(b)(1)(B)(iv)" for

"section 1395y(b)(3)(A)(iv)" and "section 1395y(b)(4)(B)",

respectively.

1986 - Subsec. (i)(1). Pub. L. 99-509, Sec. 9319(c)(1), inserted

sentence at end providing for a special enrollment period described

in paragraph (3)(B) for individuals not age 65, enrolled in a large

health plan, and having elected not to enroll during initial

enrollment period.

Subsec. (i)(1)(A). Pub. L. 99-514 realigned margins of subpar.

(A).

Pub. L. 99-272, Sec. 9219(a)(2)(A), amended subpar. (A)

generally, substituting "has attained the age of 65" for "meets the

conditions described in clauses (i) and (iii) of section

1395y(b)(3)(A) of this title".

Subsec. (i)(2). Pub. L. 99-509, Sec. 9319(c)(2), inserted

sentence at end providing for a special enrollment period described

in paragraph (3)(B) for individuals not age 65, enrolled or deemed

enrolled in the medical insurance program established under this

part, or is an individual described in the second sentence of

paragraph (1), has enrolled in such program during a subsequent

special enrollment period during which the individual was not

enrolled in a large group health plan, and has not terminated

enrollment.

Subsec. (i)(2)(A). Pub. L. 99-272, Sec. 9219(a)(2)(B), amended

subpar. (A) generally, substituting "has attained the age of 65;"

for "meets the conditions described in clauses (i) and (iii) of

section 1395y(b)(3)(A) of this title,".

Subsec. (i)(2)(B). Pub. L. 99-272, Sec. 9219(a)(2)(B), amended

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

follows: "has enrolled (or has been deemed to have enrolled) in the

medical insurance program established under this part during the

individual's initial enrollment period and any subsequent special

enrollment period under this subsection during which the individual

was not enrolled in a group health plan described in section

1395y(b)(3)(A)(iv) of this title by reason of the individual's (or

individual's spouse's) current employment, and".

Subsec. (i)(2)(C), (D). Pub. L. 99-272, Sec. 9219(a)(2)(B), added

subpar. (C) and redesignated former subpar. (C) as (D).

Subsec. (i)(3). Pub. L. 99-509, Sec. 9319(c)(3), designated

existing provisions as subpar. (A), inserted "the first sentences

of" after "referred to in", and added subpar. (B).

Pub. L. 99-272, Sec. 9201(c)(1), amended par. (3) generally,

striking out provision that special enrollment period could be

period beginning with first day of third month before month in

which the individual attains age of 70 and ending seven months

later.

1984 - Subsec. (g)(1). Pub. L. 98-369, Sec. 2354(b)(10),

substituted "section 426(b) of this title" for "section

426(a)(2)(B) of this title" and "section 1395r(d) of this title"

for "section 1395(e) of this title".

Subsec. (i). Pub. L. 98-369, Sec. 2338(b), added subsec. (i).

1981 - Subsec. (e). Pub. L. 97-35, Sec. 2151(a)(1), substituted

"during the period beginning on January 1 and ending on March 31 of

each year" for "which is any period after the period described in

subsection (d) of this section".

Subsec. (g)(3). Pub. L. 97-35, Sec. 2151(a)(2), substituted "the

earlier of the then current or immediately succeeding general

enrollment period (as defined in subsection (e) of this section)"

for "the month in which the individual files an application

establishing such entitlement".

1980 - Subsec. (b). Pub. L. 96-499, Sec. 945(a), struck out

subsec. (b) which provided that no individual could enroll under

this part more than twice.

Subsec. (e). Pub. L. 96-499, Sec. 945(b)(1), substituted "which

is any period after the period described in subsection (d) of this

section" for ", after the period described in subsection (c) of

this section, during the period beginning on January 1 and ending

on March 31 of each year beginning with 1969".

Subsec. (g)(1). Pub. L. 96-265 substituted "the 25th month" for

"the 25th consecutive month".

Subsec. (g)(3). Pub. L. 96-499, Sec. 945(b)(2), substituted "the

month in which the individual files an application establishing

such entitlement" for "the earlier of the then current or

immediately succeeding general enrollment period (as defined in

subsection (e) of this section)".

1972 - Subsec. (b). Pub. L. 92-603, Sec. 260, struck out

provisions preventing enrollment under this part more than three

years after first opportunity for such enrollment.

Subsec. (c). Pub. L. 92-603, Sec. 201(c)(2)(A), (B), substituted

"paragraph (1) or (2)" for "paragraphs (1) and (2)", and

substituted provisions relating to the treatment of an individual

who has attained age 65 and who satisfies paragraph (1) of section

1395o of this title but not paragraph (2) of such section, for

provisions relating to the treatment of an individual who satisfies

paragraph (2) of section 1395o of this title solely by reason of

subparagraph (B) thereof.

Subsec. (d). Pub. L. 92-603, Sec. 201(c)(2)(C), substituted

"paragraph (1) or (2)" for "paragraphs (1) and (2)".

Subsecs. (f), (g). Pub. L. 92-603, Sec. 206(a), added subsecs.

(f) and (g).

Subsec. (h). Pub. L. 92-603, Sec. 259(a), added subsec. (h).

1968 - Subsec. (b)(1). Pub. L. 90-248, Sec. 145(a), permitted an

individual enrolling in supplementary medical insurance program for

first time to enroll at any time in a general enrollment period

which begins within 3 years of close of his initial enrollment

period.

Subsec. (d). Pub. L. 90-248, Sec. 136(a), inserted last sentence

providing that if an individual who has attained age 65 failed to

enroll in program because, relying on erroneous documentary

evidence, he was mistaken about his age, he may enroll using date

of attainment of age 65 that he alleges under documentary evidence.

Subsec. (e). Pub. L. 90-248, Sec. 145(b), provided for an annual

general enrollment period for supplementary medical insurance

program beginning January 1 and ending March 31 of each year,

commencing in 1969.

1966 - Subsec. (c). Pub. L. 89-384, Sec. 3(a), delayed

eligibility date from January 1, 1966, to March 1, 1966, and

closing date for enrollment period from March 31, 1966, to May 31,

1966.

Subsec. (d). Pub. L. 89-384, Sec. 3(b), substituted March 1,

1966, for January 1, 1966.

EFFECTIVE DATE OF 2000 AMENDMENT

Amendment by Pub. L. 106-554 applicable to benefits for months

beginning July 1, 2001, see section 1(a)(6) [title I, Sec. 115(c)]

of Pub. L. 106-554, set out as a note under section 426 of this

title.

EFFECTIVE DATE OF 1997 AMENDMENT

Section 4581(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section and sections 1395q and

1395r of this title] shall apply to involuntary terminations of

coverage under a group health plan occurring on or after the date

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

EFFECTIVE DATE OF 1994 AMENDMENT

Section 147(f)(1)(C) of Pub. L. 103-432 provided that: "The

amendments made by subparagraphs (A) and (B) [amending this section

and section 1395q of this title] shall take effect on the first day

of the first month that begins after the expiration of the 120-day

period that begins on the date of the enactment of this Act [Oct.

31, 1994]."

Section 151(c)(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. 103-66.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by section 6202(b)(4)(C) of Pub. L. 101-239 applicable

to items and services furnished after Dec. 19, 1989, see section

6202(b)(5) of Pub. L. 101-239, set out as a note under section 162

of Title 26, Internal Revenue Code.

Section 6202(c)(3) of Pub. L. 101-239 provided that: "The

amendments made by this subsection [amending this section and

section 1395r of this title] shall apply to enrollments occurring

after, and premiums for months after, the second calendar quarter

beginning after the date of the enactment of this Act [Dec. 19,

1989]."

EFFECTIVE DATE OF 1986 AMENDMENTS

Amendment by Pub. L. 99-514 effective, except as otherwise

provided, as if included in enactment of the Consolidated Omnibus

Budget Reconciliation Act of 1985, Pub. L. 99-272, see section

1895(e) of Pub. L. 99-514, set out as a note under section 162 of

Title 26, Internal Revenue Code.

Amendment by Pub. L. 99-509 applicable to enrollments occurring

on or after Jan. 1, 1987, see section 9319(f)(2) of Pub. L. 99-509,

set out as a note under section 1395y of this title.

Section 9201(d)(2) of Pub. L. 99-272 provided that: "The

amendments made by subsections (b) and (c) [amending this section,

section 1395q of this title, and sections 623 and 631 of Title 29,

Labor] shall become effective on May 1, 1986."

Section 9219(a)(3)(B) of Pub. L. 99-272 provided that:

"(i) The amendments made by paragraph (2) [amending this section]

shall apply to enrollments in months beginning with the first

effective month (as defined in clause (ii)), except that in the

case of any individual who would have a special enrollment period

under section 1837(i) of the Social Security Act [subsec. (i) of

this section] that would have begun after November 1984 and before

the first effective month, the period shall be deemed to begin with

the first day of the first effective month.

"(ii) For purposes of clause (i), the term 'first effective

month' means the first month that begins more than 90 days after

the date of the enactment of this Act [Apr. 7, 1986]."

EFFECTIVE DATE OF 1984 AMENDMENT

Section 2338(d)(2) of Pub. L. 98-369 provided that:

"(A) The amendments made by subsections (b) and (c) [amending

this section and section 1395q of this title] shall apply to

enrollments in months beginning with the first effective month,

except that in the case of any individual who would have had a

special enrollment period under section 1837(i) of the Social

Security Act [subsec. (i) of this section] that would have begun

before such first effective month, such period shall be deemed to

begin with the first day of such first effective month.

"(B) For purposes of subparagraph (A), the term 'first effective

month' means the first month which begins more than 90 days after

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

Amendment by section 2354(b)(10) 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 1981 AMENDMENT

Section 2151(b) of Pub. L. 97-35 provided that: "The amendments

made by this section [amending this section and sections 1395q and

1395r of this title] shall not apply to enrollments pursuant to

written requests for enrollment filed before October 1, 1981."

EFFECTIVE DATE OF 1980 AMENDMENTS

Section 945(d) of Pub. L. 96-499 provided that: "The amendments

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

sections 1395q and 1395r of this title] shall apply to enrollments

occurring on or after April 1, 1981."

Amendment by Pub. L. 96-265 applicable with respect to hospital

insurance or supplementary medical insurance benefits for services

provided on or after the first day of the sixth month which begins

after June 9, 1980, see section 103(c) of Pub. L. 96-265, set out

as a note under section 426 of this title.

EFFECTIVE DATE OF 1972 AMENDMENT

Section 259(b) of Pub. L. 92-603 provided that: "The amendment

made by subsection (a) [amending this section] shall be effective

as of July 1, 1966."

EFFECTIVE DATE OF 1968 AMENDMENT

Section 136(b) of Pub. L. 90-248 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

individuals enrolling under part B of title XVIII [this part] in

months beginning after the date of the enactment of this Act [Jan.

2, 1968]."

Section 145(e) of Pub. L. 90-248 provided that: "The amendments

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

section 1395q of this title] shall become effective April 1, 1968.

Notwithstanding the provisions of section 2 of Public Law 90-97,

the amendments made by subsection (d) [amending section 1395r of

this title] shall become effective December 1, 1968."

EXTENSION THROUGH MARCH 31, 1968 OF 1967 GENERAL ENROLLMENT PERIOD

Pub. L. 90-97, Sec. 1, Sept. 30, 1967, 81 Stat. 249, extended the

general enrollment period under subsec. (e) of this section,

beginning Oct. 1, 1967, and ending Dec. 31, 1967, for purposes of

enrolling in the insurance program established under part B of

title XVIII of such Act [this part] and of terminating such

enrollment as provided in section 1395q(b)(1) of this title,

through Mar. 31, 1968.

ENROLLMENT BEFORE OCT. 1, 1966, OF ELIGIBLE INDIVIDUALS FAILING FOR

GOOD CAUSE TO ENROLL BEFORE JUNE 1, 1966; COMMENCEMENT OF COVERAGE

PERIOD

Section 102(b) of Pub. L. 89-97, as amended by section 3(c) of

Pub. L. 89-384, provided that: "If -

"(1) an individual was eligible to enroll under section 1837(c)

of the Social Security Act [subsec. (c) of this section] before

June 1, 1966, but failed to enroll before such date, and

"(2) it is shown to the satisfaction of the Secretary of

Health, Education, and Welfare [now Health and Human Services]

that there was good cause for such failure to enroll before June

1, 1966,

such individual may enroll pursuant to this subsection at any time

before October 1, 1966. The determination of what constitutes good

cause for purposes of the preceding sentence shall be made in

accordance with regulations of the Secretary. In the case of any

individual who enrolls pursuant to this subsection, the coverage

period (within the meaning of section 1838 of the Social Security

Act [section 1395q of this title]) shall begin on the first day of

the 6th month after the month in which he enrolls."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 426, 1395i-2, 1395i-2a,

1395q, 1395r, 1395v, 1395gg of this title; title 25 section 1644.

-End-

-CITE-

42 USC Sec. 1395q 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. 1395q. Coverage period

-STATUTE-

(a) Commencement

The period during which an individual is entitled to benefits

under the insurance program established by this part (hereinafter

referred to as his "coverage period") shall begin on whichever of

the following is the latest:

(1) July 1, 1966 or (in the case of a disabled individual who

has not attained age 65) July 1, 1973; or

(2)(A) in the case of an individual who enrolls pursuant to

subsection (d) of section 1395p of this title before the month in

which he first satisfies paragraph (1) or (2) of section 1395o of

this title, the first day of such month, or

(B) in the case of an individual who enrolls pursuant to such

subsection (d) in the month in which he first satisfies such

paragraph, the first day of the month following the month in

which he so enrolls, or

(C) in the case of an individual who enrolls pursuant to such

subsection (d) in the month following the month in which he first

satisfies such paragraph, the first day of the second month

following the month in which he so enrolls, or

(D) in the case of an individual who enrolls pursuant to such

subsection (d) more than one month following the month in which

he satisfies such paragraph, the first day of the third month

following the month in which he so enrolls, or

(E) in the case of an individual who enrolls pursuant to

subsection (e) of section 1395p of this title, the July 1

following the month in which he so enrolls; or

(3)(A) in the case of an individual who is deemed to have

enrolled on or before the last day of the third month of his

initial enrollment period, the first day of the month in which he

first meets the applicable requirements of section 1395o of this

title or July 1, 1973, whichever is later, or

(B) in the case of an individual who is deemed to have enrolled

on or after the first day of the fourth month of his initial

enrollment period, as prescribed under subparagraphs (B), (C),

(D), and (E) of paragraph (2) of this subsection.

(b) Continuation

An individual's coverage period shall continue until his

enrollment has been terminated -

(1) by the filing of notice that the individual no longer

wishes to participate in the insurance program established by

this part, or

(2) for nonpayment of premiums.

The termination of a coverage period under paragraph (1) shall

(except as otherwise provided in section 1395v(e) of this title)

take effect at the close of the month following the month in which

the notice is filed. The termination of a coverage period under

paragraph (2) shall take effect on a date determined under

regulations, which may be determined so as to provide a grace

period in which overdue premiums may be paid and coverage

continued. The grace period determined under the preceding sentence

shall not exceed 90 days; except that it may be extended to not to

exceed 180 days in any case where the Secretary determines that

there was good cause for failure to pay the overdue premiums within

such 90-day period.

Where an individual who is deemed to have enrolled for medical

insurance pursuant to section 1395p(f) of this title files a notice

before the first day of the month in which his coverage period

begins advising that he does not wish to be so enrolled, the

termination of the coverage period resulting from such deemed

enrollment shall take effect with the first day of the month the

coverage would have been effective. Where an individual who is

deemed enrolled for medical insurance benefits pursuant to section

1395p(f) of this title files a notice requesting termination of his

deemed coverage in or after the month in which such coverage

becomes effective, the termination of such coverage shall take

effect at the close of the month following the month in which the

notice is filed.

(c) Termination

In the case of an individual satisfying paragraph (1) of section

1395o of this title whose entitlement to hospital insurance

benefits under part A of this subchapter is based on a disability

rather than on his having attained the age of 65, his coverage

period (and his enrollment under this part) shall be terminated as

of the close of the last month for which he is entitled to hospital

insurance benefits.

(d) Payment of expenses incurred during coverage period

No payments may be made under this part with respect to the

expenses of an individual unless such expenses were incurred by

such individual during a period which, with respect to him, is a

coverage period.

(e) Commencement of coverage for special enrollment periods

Notwithstanding subsection (a) of this section, in the case of an

individual who enrolls during a special enrollment period pursuant

to section 1395p(i)(3) or 1395p(i)(4)(B) of this title -

(1) in any month of the special enrollment period in which the

individual is at any time enrolled in a plan (specified in

subparagraph (A) or (B), as applicable, of section 1395p(i)(3) of

this title or specified in section 1395p(i)(4)(A)(i) of this

title) or in the first month following such a month, the coverage

period shall begin on the first day of the month in which the

individual so enrolls (or, at the option of the individual, on

the first day of any of the following three months), or

(2) in any other month of the special enrollment period, the

coverage period shall begin on the first day of the month

following the month in which the individual so enrolls.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1838, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 305; amended

Pub. L. 90-248, title I, Sec. 145(c), Jan. 2, 1968, 81 Stat. 859;

Pub. L. 92-603, title II, Secs. 201(c)(3), 206(b), (c), 257(a),

Oct. 30, 1972, 86 Stat. 1373, 1378, 1447; Pub. L. 96-499, title IX,

Secs. 945(c)(1), 947(b), Dec. 5, 1980, 94 Stat. 2642, 2643; Pub. L.

97-35, title XXI, Secs. 2106(b)(2), 2151(a)(3), Aug. 13, 1981, 95

Stat. 792, 802; Pub. L. 98-369, div. B, title III, Sec. 2338(c),

July 18, 1984, 98 Stat. 1092; Pub. L. 99-272, title IX, Sec.

9201(c)(2), Apr. 7, 1986, 100 Stat. 171; Pub. L. 99-509, title IX,

Sec. 9344(b)(1), Oct. 21, 1986, 100 Stat. 2042; Pub. L. 103-432,

title I, Sec. 147(f)(1)(B), Oct. 31, 1994, 108 Stat. 4430; Pub. L.

105-33, title IV, Sec. 4581(b)(2), Aug. 5, 1997, 111 Stat. 465.)

-REFTEXT-

REFERENCES IN TEXT

Part A of this subchapter, referred to in subsec. (c), is

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

-MISC1-

AMENDMENTS

1997 - Subsec. (e). Pub. L. 105-33 inserted "or 1395p(i)(4)(B)"

after "1395p(i)(3)" in introductory provisions and "or specified in

section 1395p(i)(4)(A)(i) of this title" after "1395p(i)(3) of this

title" in par. (1).

1994 - Subsec. (e). Pub. L. 103-432 amended pars. (1) and (2)

generally. Prior to amendment, pars. (1) and (2) read as follows:

"(1) in the first month of the special enrollment period, the

coverage period shall begin on the first day of that month, or

"(2) in a month after the first month of the special enrollment

period, the coverage period shall begin on the first day of the

month following the month in which the individual so enrolls."

1986 - Subsec. (b). Pub. L. 99-509 substituted "month following

the month" for "calendar quarter following the calendar quarter" in

second and sixth sentences.

Subsec. (e). Pub. L. 99-272 amended subsec. (e) generally. Prior

to amendment, subsec. (e) read as follows: "Notwithstanding

subsection (a) of this section, in the case of an individual who

enrolls during a special enrollment period pursuant to -

"(1) subparagraph (A) of section 1395p(i)(3) of this title -

"(A) before the month in which he attains the age of 70, the

coverage period shall begin on the first day of the month in

which he has attained the age of 70, or

"(B) in or after the month in which he attains the age of 70,

the coverage period shall begin on the first day of the month

following the month in which he so enrolls; or

"(2) subparagraph (B) of section 1395p(i)(3) of this title -

"(A) in the first month of the special enrollment period, the

coverage period shall begin on the first day of such month, or

"(B) in a month after the first month of the special

enrollment period, the coverage period shall begin on the first

day of the month following the month in which he so enrolls."

1984 - Subsec. (e). Pub. L. 98-369, Sec. 2338(c), added subsec.

(e).

1981 - Subsec. (a)(2)(E). Pub. L. 97-35, Sec. 2151(a)(3),

substituted "the July 1 following" for "the first day of the third

month following".

Subsec. (b). Pub. L. 97-35, Sec. 2106(b)(2), struck out provision

that notice filed by an individual enrolled pursuant to section

1395p(f) of this title shall not be considered a disenrollment for

purposes of section 1395p(b) of this title.

1980 - Subsec. (a)(2)(E). Pub. L. 96-499, Sec. 945(c)(1),

substituted "the first day of the third month" for "the July 1".

Subsec. (b). Pub. L. 96-499, Sec. 947(b), inserted "(except as

otherwise provided in section 1395v(e) of this title)".

1972 - Subsec. (a)(1). Pub. L. 92-603, Sec. 201(c)(3)(A),

inserted "or (in the case of a disabled individual who has not

attained age 65) July 1, 1973" after "July 1, 1966".

Subsec. (a)(2). Pub. L. 92-603, Sec. 201(c)(3)(B), substituted in

subpar. (A) "paragraph (1) or (2)" for "paragraphs (1) and (2)" and

in subpars. (B) to (D) "paragraph" for "paragraphs".

Subsec. (a)(3). Pub. L. 92-603, Sec. 206(b), added par. (3).

Subsec. (b). Pub. L. 92-603, Secs. 206(c), 257(a), inserted

provisions relating to an individual who is deemed to have enrolled

for medical insurance pursuant to section 1395p(f) of this title

and an individual who is deemed enrolled for medical insurance

benefits pursuant to section 1395p(f) of this title and struck out

provisions limiting the allowable grace period to 90 days and

inserted provision for extension of such period of up to 180 days

where failure to pay premiums is due to good cause.

Subsecs. (c), (d). Pub. L. 92-603, Sec. 202(c)(3)(C), added

subsec. (c) and redesignated former subsec. (c) as (d).

1968 - Subsec. (b). Pub. L. 90-248 struck out ", during a general

enrollment period described in section 1395p(e) of this title,"

after "notice" in par. (1), and substituted in first sentence

following par. (2) "the calendar quarter following the calendar

quarter" for "December 31 of the year".

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by Pub. L. 105-33 applicable to involuntary

terminations of coverage under a group health plan occurring on or

after Aug. 5, 1997, see section 4581(c) of Pub. L. 105-33, set out

as a note under section 1395p of this title.

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by Pub. L. 103-432 effective on first day of first

month beginning after expiration of the 120-day period that begins

on Oct. 31, 1994, see section 147(f)(1)(C) of Pub. L. 103-432, set

out as a note under section 1395p of this title.

EFFECTIVE DATE OF 1986 AMENDMENTS

Section 9344(b)(2) of Pub. L. 99-509 provided that: "The

amendments made by paragraph (1) [amending this section] shall

apply to notices filed on or after July 1, 1987."

Amendment by Pub. L. 99-272 effective May 1, 1986, see section

9201(d)(2) of Pub. L. 99-272, set out as a note under section 1395p

of this title.

EFFECTIVE DATE OF 1984 AMENDMENT

For effective date of amendment by Pub. L. 98-369, see section

2338(d)(2) of Pub. L. 98-369, set out as a note under section 1395p

of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Amendment by section 2106(b)(2) of Pub. L. 97-35 effective Apr.

1, 1981, see section 2106(c) of Pub. L. 97-35, set out as a note

under section 1395l of this title.

Amendment by section 2151(a)(3) of Pub. L. 97-35 not applicable

to enrollments pursuant to written requests for enrollment filed

before Oct. 1, 1981, see section 2151(b) of Pub. L. 97-35, set out

as a note under section 1395p of this title.

EFFECTIVE DATE OF 1980 AMENDMENT

Amendment by section 945(c)(1) of Pub. L. 96-499 applicable to

enrollments occurring on or after Apr. 1, 1981, see section 945(d)

of Pub. L. 96-499, set out as a note under section 1395p of this

title.

Amendment by section 947(b) of Pub. L. 96-499 applicable to

notices filed after third calendar month beginning after Dec. 5,

1980, see section 947(d) of Pub. L. 96-499, set out as a note under

section 1395v of this title.

EFFECTIVE DATE OF 1972 AMENDMENT

Section 257(b) of Pub. L. 92-603 provided that: "The amendments

made by subsection (a) [amending this section] shall apply with

respect to nonpayment of premiums which become due and payable on

or after the date of the enactment of this Act [Oct. 30, 1972] or

which became payable within the 90-day period immediately preceding

such date; and for purposes of such amendments any premium which

became due and payable within such 90-day period shall be

considered a premium becoming due and payable on the date of the

enactment of this Act."

EFFECTIVE DATE OF 1968 AMENDMENT

Amendment by Pub. L. 90-248 effective Apr. 1, 1968, see section

145(e) of Pub. L. 90-248, set out as a note under section 1395p of

this title.

COVERAGE PERIOD; TERMINATION DATES

Pub. L. 90-97, Sec. 3(a), Sept. 30, 1967, 81 Stat. 249, provided

that: "In the case of any individual who, pursuant to section

1838(b)(1) of the Social Security Act [subsec. (b)(1) of this

section], terminates his enrollment in the insurance program

established under part B of title XVIII of such Act [this part],

his coverage period (as defined in section 1838(a) of such Act)

[subsec. (a) of this section] -

"(1) shall terminate at the close of December 31, 1967, if he

filed his notice of termination before January 1, 1968, or

"(2) shall terminate at the close of March 31, 1968, if he

filed his notice of termination after December 31, 1967, and

before April 1, 1968.

An individual whose coverage period terminated pursuant to

paragraph (1) at the close of December 31, 1967, may,

notwithstanding section 1837(b)(2) of such Act [section 1395p(b)(2)

of this title], enroll in such program before April 1, 1968, and

for purposes of sections 1838(a)(2)(E) [subsec. (a)(2)(E) of this

section] and 1837(b)(2) of such Act [section 1395p(b)(2) of this

title] such enrollment shall be deemed an enrollment under section

1837(e) of such Act [section 1395p(e) of this title] and a second

enrollment under such part."

EXTENSION OF 1967 GENERAL ENROLLMENT PERIOD THROUGH MARCH 31, 1968

Extension of the general enrollment period under section 1395p(e)

of this title through March 31, 1968, see section 1 of Pub. L.

90-97, Sept. 30, 1967, 81 Stat. 249, set out as a note under

section 1395p of this title.

COVERAGE PERIOD FOR INDIVIDUALS BECOMING ELIGIBLE IN MARCH 1966 WHO

ENROLL IN MAY 1966

Pub. L. 89-384, Sec. 3(d), Apr. 8, 1966, 80 Stat. 105, provided

that: "In the case of an individual who first satisfies paragraphs

(1) and (2) of section 1836 of the Social Security Act [section

1395o of this title] in March, 1966, and who enrolls pursuant to

subsection (d) of section 1837 of such Act [section 1395p of this

title] in May 1966, his coverage period shall, notwithstanding

section 1838(a)(2)(D) of such Act [subsec. (a)(2)(D) of this

section], begin on July 1, 1966."

COMMENCEMENT OF COVERAGE PERIOD OF CERTAIN ENROLLEES

Commencement of coverage period upon enrollment before Oct. 1,

1966 of eligible individuals failing for good cause to enroll

before June 1, 1966, see section 102(b) of Pub. L. 89-97, set out

as a note under section 1395p of this title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395i-2, 1395p, 1395w-21

of this title.

-End-

-CITE-

42 USC Sec. 1395r 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. 1395r. Amount of premiums for individuals enrolled under this

part

-STATUTE-

(a) Determination of monthly actuarial rates and premiums

(1) The Secretary shall, during September of 1983 and of each

year thereafter, determine the monthly actuarial rate for enrollees

age 65 and over which shall be applicable for the succeeding

calendar year. Such actuarial rate shall be the amount the

Secretary estimates to be necessary so that the aggregate amount

for such calendar year with respect to those enrollees age 65 and

older will equal one-half of the total of the benefits and

administrative costs which he estimates will be payable from the

Federal Supplementary Medical Insurance Trust Fund for services

performed and related administrative costs incurred in such

calendar year with respect to such enrollees. In calculating the

monthly actuarial rate, the Secretary shall include an appropriate

amount for a contingency margin.

(2) The monthly premium of each individual enrolled under this

part for each month after December 1983 shall be the amount

determined under paragraph (3), adjusted as required in accordance

with subsections (b), (c), and (f) of this section, and to reflect

80 percent of any reduction elected under section 1395w-24(f)(1)(E)

of this title.

(3) The Secretary, during September of each year, shall determine

and promulgate a monthly premium rate for the succeeding calendar

year that (except as provided in subsection (g) of this section) is

equal to 50 percent of the monthly actuarial rate for enrollees age

65 and over, determined according to paragraph (1), for that

succeeding calendar year. Whenever the Secretary promulgates the

dollar amount which shall be applicable as the monthly premium rate

for any period, he shall, at the time such promulgation is

announced, issue a public statement setting forth the actuarial

assumptions and bases employed by him in arriving at the amount of

an adequate actuarial rate for enrollees age 65 and older as

provided in paragraph (1).

(4) The Secretary shall also, during September of 1983 and of

each year thereafter, determine the monthly actuarial rate for

disabled enrollees under age 65 which shall be applicable for the

succeeding calendar year. Such actuarial rate shall be the amount

the Secretary estimates to be necessary so that the aggregate

amount for such calendar year with respect to disabled enrollees

under age 65 which will equal one-half of the total of the benefits

and administrative costs which he estimates will be payable from

the Federal Supplementary Medical Insurance Trust Fund for services

performed and related administrative costs incurred in such

calendar year with respect to such enrollees. In calculating the

monthly actuarial rate under this paragraph, the Secretary shall

include an appropriate amount for a contingency margin.

(b) Increase in monthly premium

In the case of an individual whose coverage period began pursuant

to an enrollment after his initial enrollment period (determined

pursuant to subsection (c) or (d) of section 1395p of this title)

and not pursuant to a special enrollment period under section

1395p(i)(4) of this title, the monthly premium determined under

subsection (a) of this section shall be increased by 10 percent of

the monthly premium so determined for each full 12 months (in the

same continuous period of eligibility) in which he could have been

but was not enrolled. For purposes of the preceding sentence, there

shall be taken into account (1) the months which elapsed between

the close of his initial enrollment period and the close of the

enrollment period in which he enrolled, plus (in the case of an

individual who reenrolls) (2) the months which elapsed between the

date of termination of a previous coverage period and the close of

the enrollment period in which he reenrolled, but there shall not

be taken into account months for which the individual can

demonstrate that the individual was enrolled in a group health plan

described in section 1395y(b)(1)(A)(v) of this title by reason of

the individual's (or the individual's spouse's) current employment

status or months during which the individual has not attained the

age of 65 and for which the individual can demonstrate that the

individual was enrolled in a large group health plan (as that term

is defined in section 1395y(b)(1)(B)(iii) of this title) by reason

of the individual's current employment status (or the current

employment status of a family member of the individual). Any

increase in an individual's monthly premium under the first

sentence of this subsection with respect to a particular continuous

period of eligibility shall not be applicable with respect to any

other continuous period of eligibility which such individual may

have.

(c) Premiums rounded to nearest multiple of ten cents

If any monthly premium determined under the foregoing provisions

of this section is not a multiple of 10 cents, such premium shall

be rounded to the nearest multiple of 10 cents.

(d) "Continuous period of eligibility" defined

For purposes of subsection (b) of this section (and section

1395p(g)(1) of this title), an individual's "continuous period of

eligibility" is the period beginning with the first day on which he

is eligible to enroll under section 1395o of this title and ending

with his death; except that any period during all of which an

individual satisfied paragraph (1) of section 1395o of this title

and which terminated in or before the month preceding the month in

which he attained age 65 shall be a separate "continuous period of

eligibility" with respect to such individual (and each such period

which terminates shall be deemed not to have existed for purposes

of subsequently applying this section).

(e) State payment of part B late enrollment premium increases

(1) Upon the request of a State (or any appropriate State or

local governmental entity specified by the Secretary), the

Secretary may enter into an agreement with the State (or such

entity) under which the State (or such entity) agrees to pay on a

quarterly or other periodic basis to the Secretary (to be deposited

in the Treasury to the credit of the Federal Supplementary Medical

Insurance Trust Fund) an amount equal to the amount of the part B

late enrollment premium increases with respect to the premiums for

eligible individuals (as defined in paragraph (3)(A)).

(2) No part B late enrollment premium increase shall apply to an

eligible individual for premiums for months for which the amount of

such an increase is payable under an agreement under paragraph (1).

(3) In this subsection:

(A) The term "eligible individual" means an individual who is

enrolled under this part B and who is within a class of

individuals specified in the agreement under paragraph (1).

(B) The term "part B late enrollment premium increase" means

any increase in a premium as a result of the application of

subsection (b) of this section.

(f) Limitation on increase in monthly premium

For any calendar year after 1988, if an individual is entitled to

monthly benefits under section 402 or 423 of this title or to a

monthly annuity under section 3(a), 4(a), or 4(f) of the Railroad

Retirement Act of 1974 [45 U.S.C. 231b(a), 231c(a), (f)] for

November and December of the preceding year, and if the monthly

premium of the individual under this section for December and for

January is deducted from those benefits under section 1395s(a)(1)

of this title or section 1395s(b)(1) of this title, the monthly

premium otherwise determined under this section for an individual

for that year shall not be increased, pursuant to this subsection,

to the extent that such increase would reduce the amount of

benefits payable to that individual for that December below the

amount of benefits payable to that individual for that November

(after the deduction of the premium under this section). For

purposes of this subsection, retroactive adjustments or payments

and deductions on account of work shall not be taken into account

in determining the monthly benefits to which an individual is

entitled under section 402 or 423 of this title or under the

Railroad Retirement Act of 1974 [45 U.S.C. 231 et seq.].

(g) Exclusions from estimate of benefits and administrative costs

In estimating the benefits and administrative costs which will be

payable from the Federal Supplementary Medical Insurance Trust Fund

for a year for purposes of determining the monthly premium rate

under subsection (a)(3) of this section, the Secretary shall

exclude an estimate of any benefits and administrative costs

attributable to the application of section 1395x(v)(1)(L)(viii) of

this title or to the establishment under section

1395x(v)(1)(L)(i)(V) of this title of a per visit limit at 106

percent of the median (instead of 105 percent of the median), but

only to the extent payment for home health services under this

subchapter is not being made under section 1395fff of this title

(relating to prospective payment for home health services).

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1839, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 305; amended

Pub. L. 90-248, title I, Sec. 145(d), Jan. 2, 1968, 81 Stat. 859;

Pub. L. 92-603, title II, Secs. 201(c)(4), (5), 203 (a)-(d), Oct.

30, 1972, 86 Stat. 1373, 1376, 1377; Pub. L. 94-182, title I, Sec.

104(a), Dec. 31, 1975, 89 Stat. 1052; Pub. L. 95-216, title II,

Sec. 205(e), Dec. 20, 1977, 91 Stat. 1529; Pub. L. 96-499, title

IX, Sec. 945(c)(2), Dec. 5, 1980, 94 Stat. 2642; Pub. L. 97-35,

title XXI, Sec. 2151(a)(4), Aug. 13, 1981, 95 Stat. 802; Pub. L.

97-248, title I, Sec. 124(a), (b), Sept. 3, 1982, 96 Stat. 364;

Pub. L. 97-448, title III, Sec. 309(b)(8), Jan. 12, 1983, 96 Stat.

2409; Pub. L. 98-21, title VI, Sec. 606(a)(1)-(3)(C), Apr. 20,

1983, 97 Stat. 169, 170; Pub. L. 98-369, div. B, title III, Secs.

2302(a), (b), 2338(a), July 18, 1984, 98 Stat. 1063, 1091; Pub. L.

98-617, Sec. 3(b)(4), Nov. 8, 1984, 98 Stat. 3295; Pub. L. 99-272,

title IX, Secs. 9219(a)(1), 9313, Apr. 7, 1986, 100 Stat. 182, 194;

Pub. L. 99-509, title IX, Secs. 9001(c), 9319(c)(4), Oct. 21, 1986,

100 Stat. 1970, 2012; Pub. L. 100-203, title IV, Sec. 4080, Dec.

22, 1987, 101 Stat. 1330-126; Pub. L. 100-360, title II, Sec.

211(a)-(c)(1), July 1, 1988, 102 Stat. 733, 738; Pub. L. 100-485,

title VI, Sec. 608(d)(9), Oct. 13, 1988, 102 Stat. 2415; Pub. L.

101-234, title II, Sec. 202(a), Dec. 13, 1989, 103 Stat. 1981; Pub.

L. 101-239, title VI, Secs. 6202(b)(4)(C), (c)(2), 6301, Dec. 19,

1989, 103 Stat. 2233, 2234, 2258; Pub. L. 101-508, title IV, Sec.

4301, Nov. 5, 1990, 104 Stat. 1388-125; Pub. L. 103-66, title XIII,

Sec. 13571, Aug. 10, 1993, 107 Stat. 609; Pub. L. 103-432, title I,

Secs. 144, 151(c)(3), Oct. 31, 1994, 108 Stat. 4427, 4435; Pub. L.

105-33, title IV, Secs. 4571(a), (b)(1), 4581(a), 4582, 4631(a)(2),

Aug. 5, 1997, 111 Stat. 464, 465, 486; Pub. L. 105-277, div. J,

title V, Sec. 5101(e), Oct. 21, 1998, 112 Stat. 2681-915; Pub. L.

106-554, Sec. 1(a)(6) [title VI, Sec. 606(a)(2)(B)(i)], Dec. 21,

2000, 114 Stat. 2763, 2763A-557.)

-REFTEXT-

REFERENCES IN TEXT

The Railroad Retirement Act of 1974, referred to in subsec. (f),

is act Aug. 29, 1935, ch. 812, as amended generally by Pub. L.

93-445, title I, Sec. 101, Oct. 16, 1974, 88 Stat. 1305, which is

classified generally to subchapter IV (Sec. 231 et seq.) of chapter

9 of Title 45, Railroads. For further details and complete

classification of this Act to the Code, see Codification note set

out preceding section 231 of Title 45, section 231t of Title 45,

and Tables.

-MISC1-

AMENDMENTS

2000 - Subsec. (a)(2). Pub. L. 106-554 substituted "shall be the

amount determined under paragraph (3), adjusted as required in

accordance with subsections (b), (c), and (f) of this section, and

to reflect 80 percent of any reduction elected under section

1395w-24(f)(1)(E) of this title." for "shall, except as provided in

subsections (b), (c), and (f) of this section, be the amount

determined under paragraph (3)."

1998 - Subsec. (a)(3). Pub. L. 105-277, Sec. 5101(e)(1), inserted

"(except as provided in subsection (g) of this section)" after

"year that".

Subsec. (g). Pub. L. 105-277, Sec. 5101(e)(2), added subsec. (g).

1997 - Subsec. (a)(2). Pub. L. 105-33, Sec. 4571(b)(1)(A),

substituted "subsections (b), (c), and (f)" for "subsections (b)

and (e)".

Subsec. (a)(3). Pub. L. 105-33, Sec. 4571(b)(1)(B), in last

sentence, inserted "rate" after "monthly premium" and struck out

"and the derivation of the dollar amounts specified in this

paragraph" before period at end.

Pub. L. 105-33, Sec. 4571(a), substituted "The Secretary, during

September of each year, shall determine and promulgate a monthly

premium rate for the succeeding calendar year that is equal to 50

percent of the monthly actuarial rate for enrollees age 65 and

over, determined according to paragraph (1), for that succeeding

calendar year." for "The Secretary shall, during September of 1983

and of each year thereafter, determine and promulgate the monthly

premium applicable for individuals enrolled under this part for the

succeeding calendar year. The monthly premium shall (except as

otherwise provided in subsection (e) of this section) be equal to

the smaller of -

"(A) the monthly actuarial rate for enrollees age 65 and over,

determined according to paragraph (1) of this subsection, for

that calendar year, or

"(B) the monthly premium rate most recently promulgated by the

Secretary under this paragraph, increased by a percentage

determined as follows: The Secretary shall ascertain the primary

insurance amount computed under section 415(a)(1) of this title,

based upon average indexed monthly earnings of $900, that applied

to individuals who became eligible for and entitled to old-age

insurance benefits on November 1 of the year before the year of

the promulgation. He shall increase the monthly premium rate by

the same percentage by which that primary insurance amount is

increased when, by reason of the law in effect at the time the

promulgation is made, it is so computed to apply to those

individuals for the following November 1."

Subsec. (b). Pub. L. 105-33, Sec. 4631(a)(2), substituted

"1395y(b)(1)(B)(iii) of this title" for "1395y(b)(1)(B)(iv) of this

title" in second sentence.

Pub. L. 105-33, Sec. 4571(b)(1)(C), struck out "or (e)" after

"determined under subsection (a)" in first sentence.

Pub. L. 105-33, Sec. 4581(a), inserted "and not pursuant to a

special enrollment period under section 1395p(i)(4) of this title"

after "section 1395p of this title)" in first sentence.

Subsec. (e). Pub. L. 105-33, Sec. 4571(b)(1)(D), (E),

redesignated subsec. (g) as (e) and struck out former subsec. (e)

which read as follows:

"(1)(A) Notwithstanding the provisions of subsection (a) of this

section, the monthly premium for each individual enrolled under

this part for each month after after December 1995 and prior to

January 1999 shall be an amount equal to 50 percent of the monthly

actuarial rate for enrollees age 65 and over, as determined under

subsection (a)(1) of this section and applicable to such month.

"(B) Notwithstanding the provisions of subsection (a) of this

section, the monthly premium for each individual enrolled under

this part for each month in -

"(i) 1991 shall be $29.90,

"(ii) 1992 shall be $31.80,

"(iii) 1993 shall be $36.60,

"(iv) 1994 shall be $41.10, and

"(v) 1995 shall be $46.10.

"(2) Any increases in premium amounts taking effect prior to

January 1998 by reason of paragraph (1) shall be taken into account

for purposes of determining increases thereafter under subsection

(a)(3) of this section."

Subsec. (e)(1). Pub. L. 105-33, Sec. 4582, inserted "(or any

appropriate State or local governmental entity specified by the

Secretary)" after "request of a State" and inserted "(or such

entity)" after "agreement with the State" and after "which the

State".

Subsec. (g). Pub. L. 105-33, Sec. 4571(b)(1)(E), redesignated

subsec. (g) as (e).

1994 - Subsec. (b). Pub. L. 103-432, Sec. 151(c)(3), in second

sentence, inserted "status" after "current employment" and

substituted "(as that term is defined in section 1395y(b)(1)(B)(iv)

of this title) by reason of the individual's current employment

status (or the current employment status of a family member of the

individual)" for "as an active individual (as those terms are

defined in section 1395y(b)(1)(B)(iv) of this title)".

Subsec. (g). Pub. L. 103-432, Sec. 144, added subsec. (g).

1993 - Subsec. (e)(1)(A). Pub. L. 103-66, Sec. 13571(1),

substituted "after December 1995 and prior to January 1999 shall be

an amount equal to 50 percent" for "December 1983 and prior to

January 1991 shall be an amount equal to 50 percent".

Subsec. (e)(2). Pub. L. 103-66, Sec. 13571(2), substituted "1998"

for "1991".

1990 - Subsec. (e)(1). Pub. L. 101-508 designated existing

provisions as subpar. (A) and added subpar. (B).

1989 - Subsec. (a). Pub. L. 101-234 repealed Pub. L. 100-360,

Sec. 211(c)(1)(A)-(D), 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 notes below.

Subsec. (b). Pub. L. 101-239, Sec. 6202(c)(2), struck out "during

which the individual has attained the age of 65 and" after "into

account months" in second sentence.

Pub. L. 101-239, Sec. 6202(b)(4)(C), substituted "section

1395y(b)(1)(A)(v)" and "section 1395y(b)(1)(B)(iv)" for "section

1395y(b)(3)(A)(iv)" and "section 1395y(b)(4)(B)", respectively.

Pub. L. 101-234 repealed Pub. L. 100-360, Sec. 211(c)(1)(E), 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.

Subsec. (e). Pub. L. 101-239, Sec. 6301, substituted "1991" for

"1990" wherever appearing.

Subsec. (e)(1). Pub. L. 101-234 repealed Pub. L. 100-360, Sec.

211(c)(1)(F), 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.

Subsec. (g). Pub. L. 101-234 repealed Pub. L. 100-360, Sec.

211(a), and provided that the provisions of law amended or repealed

by such section are restored or revised as if such section had not

been enacted, see 1988 Amendment note below.

1988 - Subsec. (a)(1). Pub. L. 100-360, Sec. 211(c)(1)(A), (B),

inserted "(other than costs relating to the amendments made by the

Medicare Catastrophic Coverage Act of 1988)" before period at end

of second sentence, and ", but shall not take into account any

amounts in the Trust Fund that may be attributable to receipts or

outlays relating to the Medicare Catastrophic Coverage Account"

before period at end of last sentence.

Subsec. (a)(2). Pub. L. 100-360, Sec. 211(c)(1)(C), substituted

", (e), and (g)" for "and (e)".

Subsec. (a)(3). Pub. L. 100-360, Sec. 211(c)(1)(D), substituted

"subsections (e) and (g)" for "subsection (e)" in introductory

provisions.

Subsec. (a)(4). Pub. L. 100-360, Sec. 211(c)(1)(A), (B), inserted

"(other than costs relating to the amendments made by the Medicare

Catastrophic Coverage Act of 1988)" before period at end of second

sentence, and ", but shall not take into account any amounts in the

Trust Fund that may be attributable to receipts or outlays relating

to the Medicare Catastrophic Coverage Account" before period at end

of last sentence.

Subsec. (b). Pub. L. 100-360, Sec. 211(c)(1)(E), substituted

"otherwise determined under this section (without regard to

subsections (f) and (g)(6) of this section)" for "determined under

subsection (a) or (e) of this section".

Subsec. (e)(1). Pub. L. 100-360, Sec. 211(c)(1)(F), inserted

"except as provided in subsection (g) of this section," after

"subsection (a) of this section".

Subsec. (f). Pub. L. 100-485, Sec. 608(d)(8)(B), substituted "for

that December below the amount of benefits payable to that

individual for that November" for "for that January below the

amount of benefits payable to that individual for that December".

Pub. L. 100-360, Sec. 211(b), amended subsec. (f) generally,

substituting a single paragraph for former pars. (1) and (2).

Subsec. (g). Pub. L. 100-360, Sec. 211(a), added subsec. (g)

relating to adjustment in medicare part B premium.

Subsec. (g)(1)(B)(iii)(I). Pub. L. 100-485, Sec. 608(d)(9)(A)(i),

substituted "year, over" for "year, and".

Subsec. (g)(1)(B)(iii)(II). Pub. L. 100-485, Sec.

608(d)(9)(A)(ii), substituted "supplemental premium rate" for

"supplemental rate".

Subsec. (g)(7)(A)(ii). Pub. L. 100-485, Sec. 608(d)(9)(A)(iii),

substituted "of each such year" for "of such year".

1987 - Subsec. (e). Pub. L. 100-203, Sec. 4080(1), substituted

"1990" for "1989" wherever appearing.

Subsec. (f)(1). Pub. L. 100-203, Sec. 4080(2), substituted "1987,

or 1988" for "or 1987".

Subsec. (f)(2). Pub. L. 100-203, Sec. 4080(3), substituted "1988,

or 1989" for "or 1988".

1986 - Subsec. (b). Pub. L. 99-509, Sec. 9319(c)(4), inserted "or

months during which the individual has not attained the age of 65

and for which the individual can demonstrate that the individual

was enrolled in a large group health plan as an active individual

(as those terms are defined in section 1395y(b)(4)(B) of this

title)" at end of second sentence.

Pub. L. 99-272, Sec. 9219(a)(1), substituted "months during which

the individual has attained the age of 65 and for which the

individual can demonstrate that the individual was enrolled in a

group health plan described in section 1395y(b)(3)(A)(iv) of this

title" for "months in which the individual has met the conditions

specified in clauses (i) and (iii) of section 1395y(b)(3)(A) of

this title and can demonstrate that the individual was enrolled in

a group health plan described in clause (iv) of such section".

Subsec. (e). Pub. L. 99-272, Sec. 9313(1), substituted "1989" for

"1988" wherever appearing.

Subsec. (f)(1). Pub. L. 99-272, Sec. 9313(2), substituted ",

1986, or 1987" for "or 1986".

Subsec. (f)(2). Pub. L. 99-272, Sec. 9313(3), substituted ",

1987, or 1988" for "or 1987".

Subsec. (f)(2)(A). Pub. L. 99-509, Sec. 9001(c), amended subpar.

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

"the monthly premium amount determined under subsection (a)(2) of

this section for that January reduced by the amount (if any)

necessary to make the monthly benefits under section 402 or 423 of

this title for that December after the deduction of the monthly

premium (disregarding subsection (b) of this section) for that

January at least equal to the monthly benefits under section 402 or

423 of this title for the preceding November after the deduction of

the premium (disregarding subsection (b) of this section) for that

individual for that December, or".

1984 - Subsec. (b). Pub. L. 98-369, Sec. 2338(a), inserted

provision that there shall not be taken into account months in

which the individual has met conditions specified in clauses (i)

and (iii) of section 1395y(b)(3)(A) of this title and can

demonstrate that the individual was enrolled in a group health plan

described in clause (iv) of such section by reason of the

individual's (or the individual's spouse's) current employment.

Subsec. (e). Pub. L. 98-369, Sec. 2302(a), substituted "1988" for

"1986" in pars. (1) and (2).

Subsec. (f). Pub. L. 98-369, Sec. 2302(b), added subsec. (f).

Subsec. (f)(2)(A). Pub. L. 98-617, Sec. 3(b)(4), substituted "for

that December after the deduction" for "for that January after the

deduction" and "for that December" for "for that November".

1983 - Subsec. (a). Pub. L. 98-21, Sec. 606(a)(1), added subsec.

(a) and struck out former subsec. (a) which provided that monthly

premium of each individual enrolled under this part for each month

before 1968 would be $3.

Subsec. (b). Pub. L. 98-21, Sec. 606(a)(3)(A), substituted

"subsection (a) or (e)" for "subsection (b), (c), or (g)".

Pub. L. 98-21, Sec. 606(a)(1), (2), redesignated subsec. (d) as

(b), and struck out former subsec. (b) which provided for

determination by Secretary of monthly premium for each individual

enrolled under this part for each month after 1967 and before July

1, 1973.

Subsec. (c). Pub. L. 98-21, Sec. 606(a)(1), (2), redesignated

subsec. (e) as (c), and struck out former subsec. (c) which

directed Secretary to determine during December of each year after

1972 the monthly actuarial rate for enrollees age 65 and over

applicable to succeeding fiscal year (beginning July 1), provided

for his determination of monthly premium for such period, and

directed him to determine monthly actuarial rate for disabled

enrollees under age 65.

Subsec. (d). Pub. L. 98-21, Sec. 606(a)(3)(B), which directed

that "purposes of subsection (b)" be substituted for "purposes of

subsection (c)" was executed by substituting "purposes of

subsection (b)" for "purposes of subsection (d)", as the probable

intent of Congress in view of previous substitution of "subsection

(d)" for "subsection (c)" by Pub. L. 92-603, Sec. 203(d)(2).

Pub. L. 98-21, Sec. 606(a)(2), redesignated subsec. (f) as (d).

Former subsec. (d) redesignated (b).

Pub. L. 97-448 inserted reference to determination of monthly

premium pursuant to subsec. (g) of this section.

Subsec. (e). Pub. L. 98-21, Sec. 606(a)(2), redesignated subsec.

(g) as (e). Former subsec. (e) redesignated (c).

Subsec. (e)(1). Pub. L. 98-21, Sec. 606(a)(3)(C), substituted

"(a)" for "(c)", "(a)(1)" for "(c)(1)", "December 1983" for "June

1983", and "January 1986" for "July 1985".

Subsec. (e)(2). Pub. L. 98-21, Sec. 606(a)(3)(C)(i), (iii),

substituted "(a)(3)" for "(c)(3)" and "January 1986" for "July

1985".

Subsecs. (f), (g). Pub. L. 98-21, Sec. 606(a)(2), redesignated

subsecs. (f) and (g) as (d) and (e), respectively.

1982 - Subsec. (c)(2). Pub. L. 97-248, Sec. 124(a)(1),

substituted "except as provided in subsections (d) and (g)" for

"except as provided in subsection (d)".

Subsec. (c)(3). Pub. L. 97-248, Sec. 124(a)(2), inserted "(except

as otherwise provided in subsection (g) of this section)".

Subsec. (g). Pub. L. 97-248, Sec. 124(b), added subsec. (g).

1981 - Subsec. (d). Pub. L. 97-35 substituted "the close of the

enrollment period in which he reenrolled" for "the month after the

month in which he reenrolled" in cl. (2).

1980 - Subsec. (d). Pub. L. 96-499 substituted "who reenrolls)

(2) the months which elapsed between the date of termination of a

previous coverage period and the month after the month in which he

reenrolled" for "who enrolls for a second time) (2) the months

which elapsed between the date of the termination of his first

coverage period and the close of the enrollment period in which he

enrolled for the second time".

1977 - Subsec. (c)(3)(B). Pub. L. 95-216 substituted "the monthly

premium rate most recently promulgated by the Secretary under this

paragraph, increased by a percentage determined as follows: The

Secretary shall ascertain the primary insurance amount computed

under section 415(a)(1) of this title, based upon average indexed

monthly earnings of $900, that applied to individuals who became

eligible for and entitled to old-age insurance benefits on May 1 of

the year of the promulgation" for "the monthly premium rate most

recently promulgated by the Secretary under this paragraph or, in

the case of the determination made in December 1971, such rate

promulgated under subsection (b)(2) of this section multiplied by

the ratio of (i) the amount in column IV of the table which, by

reason of the law in effect at the time the promulgation is made,

will be in effect as of May 1 next following such determination

appears (or is deemed to appear) in section 415(a) of this title on

the line which includes the figure '750' in column III of such

table to (ii) the amount in column IV of the table which appeared

(or was deemed to appear) in section 415(a) of this title on the

line which included the figure '750' in column III as of May 1 of

the year in which such determination is made" and inserted "He

shall increase the monthly premium rate by the same percentage by

which that primary insurance amount is increased when, by reason of

the law in effect at the time the promulgation is made, it is so

computed to apply to those individuals on the following May 1."

1975 - Subsec. (c)(3). Pub. L. 94-182 substituted "May 1" for

"June 1" wherever appearing.

1972 - Subsec. (b)(1). Pub. L. 92-603, Sec. 203(a), inserted "and

before July 1, 1973" following "1967".

Subsec. (b)(2). Pub. L. 92-603, Sec. 203(b), substituted "ending

on or before December 31, 1971" for "thereafter".

Subsec. (c). Pub. L. 92-603, Sec. 203(c), added subsec. (c).

Former subsec. (c) redesignated (d).

Subsec. (d). Pub. L. 92-603, Secs. 201(c)(4), 203(c), (d)(1),

redesignated former subsec. (c) as (d), inserted reference to

subsec. (c) after reference to subsec. (b), inserted "(in the same

continuous period of eligibility)" after "for each full 12 months",

and inserted provisions relating to any increase in an individual's

monthly premium under the first sentence of this subsection. Former

subsec. (d) redesignated (e).

Subsec. (e). Pub. L. 92-603, Sec. 203(c), redesignated former

subsec. (d) as (e). Former subsec. (e) redesignated (f).

Pub. L. 92-603, Sec. 201(c)(5), added subsec. (e).

Subsec. (f). Pub. L. 92-603, Sec. 203(c), (d)(2), redesignated

former subsec. (e) as (f) and substituted "subsection (d)" for

"subsection (c)".

1968 - Subsec. (b)(2). Pub. L. 90-248 required Secretary, during

December of each year, beginning in 1968, to determine and announce

amount (whether or not such amount was applicable for premiums for

any prior month) of supplementary medical insurance premium for

12-month period beginning on July 1 of each following year, which

premium is to be such that aggregate premiums will equal one-half

estimated benefit and administrative expenses of supplementary

medical insurance program for such 12-month period, and that at

time of announcement of premium amount, Secretary must make public

actuarial assumptions and bases used in deciding amount of premium.

EFFECTIVE DATE OF 2000 AMENDMENT

Pub. L. 106-554, Sec. 1(a)(6) [title VI, Sec. 606(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-558, provided that: "The amendments

made by subsection (a) [amending this section and sections 1395s,

1395w, 1395w-21, 1395w-23, and 1395w-24 of this title] shall apply

to years beginning with 2003."

EFFECTIVE DATE OF 1997 AMENDMENT

Amendment by section 4581(a) of Pub. L. 105-33 applicable to

involuntary terminations of coverage under a group health plan

occurring on or after Aug. 5, 1997, see section 4581(c) of Pub. L.

105-33, set out as a note under section 1395p of this title.

EFFECTIVE DATE OF 1994 AMENDMENT

Section 151(c)(3) of Pub. L. 103-432 provided that the amendment

made by that section is effective as if included in the enactment

of Pub. L. 103-66.

EFFECTIVE DATE OF 1989 AMENDMENTS

Amendment by section 6202(b)(4)(C) of Pub. L. 101-239 applicable

to items and services furnished after Dec. 19, 1989, see section

6202(b)(5) of Pub. L. 101-239, set out as a note under section 162

of Title 26, Internal Revenue Code.

Amendment by section 6202(c)(2) of Pub. L. 101-239 applicable to

enrollments occurring after, and premiums for months after, second

calendar quarter beginning after Dec. 19, 1989, see section

6202(c)(3) of Pub. L. 101-239, set out as a note under section

1395p of this title.

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, and

applicable to premiums for months beginning after Dec. 31, 1989,

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

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.

Section 211(d) of Pub. L. 100-360, which provided that the

amendments made by section 211 of Pub. L. 100-360 [amending this

section and sections 1395w and 1395mm of this title] applied

(except as otherwise specified in such amendments) to monthly

premiums for months beginning with January 1989, was repealed by

Pub. L. 101-234, title II, Sec. 202(a), Dec. 13, 1989, 103 Stat.

1981.

EFFECTIVE DATE OF 1986 AMENDMENTS

Amendment by section 9001(c) of Pub. L. 99-509 applicable with

respect to monthly premiums under this section for months after

December 1986, see section 9001(d)(3) of Pub. L. 99-509, set out as

a note under section 415 of this title.

Amendment by section 9319(c)(4) of Pub. L. 99-509 applicable to

enrollments occurring on or after Jan. 1, 1987, see section

9319(f)(2) of Pub. L. 99-509 set out as a note under section 1395y

of this title.

Section 9219(a)(3)(A) of Pub. L. 99-272 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to months beginning with January 1983 for premiums for months

beginning with the first month that begins more than 30 days after

the date of the enactment of this Act [Apr. 7, 1986]."

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 2302(c) of Pub. L. 98-369 provided that: "The amendments

made by this section [amending this section] shall apply to

premiums for months beginning with January 1986."

Section 2338(d)(1) of Pub. L. 98-369 provided that: "The

amendment made by subsection (a) [amending this section] shall

apply to months beginning with January 1983 for premiums for months

beginning with the first month which begins more than 30 days after

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

EFFECTIVE DATE OF 1983 AMENDMENTS; TRANSITIONAL RULE

Section 606(c) of Pub. L. 98-21 provided that: "The amendments

made by this section [amending this section and sections 1395i-2,

1395v, 1395w, and 1395mm of this title] shall apply to premiums for

months beginning with January 1984, and for months after June 1983

and before January 1984 -

"(1) the monthly premiums under part A and under part B of

title XVIII of the Social Security Act [parts A and B of this

subchapter] for individuals enrolled under each respective part

shall be the monthly premium under that part for the month of

June 1983, and

"(2) the amount of the Government contributions under section

1844(a)(1) of such Act [section 1395w(a)(1) of this title] shall

be computed on the basis of the actuarially adequate rate which

would have been in effect under part B of title XVIII of such Act

for such months without regard to the amendments made by this

section, but using the amount of the premium in effect for the

month of June 1983."

Amendment by Pub. L. 97-448 effective as if originally included

as a part of this section as this section was amended by the Tax

Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248, see

section 309(c)(2) of Pub. L. 97-448, set out as a note under

section 426-1 of this title.

EFFECTIVE DATE OF 1981 AMENDMENT

Amendment by Pub. L. 97-35 not applicable to enrollments pursuant

to written requests for enrollment filed before Oct. 1, 1981, see

section 2151(b) of Pub. L. 97-35, set out as a note under section

1395p of this title.

EFFECTIVE DATE OF 1980 AMENDMENT

Amendment by Pub. L. 96-499 applicable to enrollments occurring

on or after Apr. 1, 1981, see section 945(d) of Pub. L. 96-499, set

out as a note under section 1395p of this title.

EFFECTIVE DATE OF 1977 AMENDMENT

Amendment by Pub. L. 95-216 effective with respect to monthly

benefits and lump-sum death payments for deaths occurring after

December 1978, see section 206 of Pub. L. 95-216, set out as a note

under section 402 of this title.

EFFECTIVE DATE OF 1975 AMENDMENT

Section 104(b) of Pub. L. 94-182 provided that: "The amendments

made by subsection (a) [amending this section] shall apply with

respect to determinations made under section 1839(c)(3) of the

Social Security Act [subsec. (c)(3) of this section] after the date

of the enactment of this Act [Dec. 31, 1975]."

EFFECTIVE DATE OF 1968 AMENDMENT

Amendment by Pub. L. 90-248 effective Dec. 1, 1968, see section

145(e) of Pub. L. 90-248, set out as a note under section 1395p of

this title.

DETERMINATION OF PREMIUM AMOUNTS BY SECRETARY

Pub. L. 90-97, Sec. 2, Sept. 30, 1967, 81 Stat. 249, provided

that: "Notwithstanding the provisions of section 1839(a) and (b) of

the Social Security Act [subsecs. (a) and (b) of this section] -

"(1) the dollar amount applicable for premiums under part B of

title XVIII of such Act [this part] for each month before April

1968 shall be $3, and

"(2) the Secretary of Health, Education, and Welfare may

determine and promulgate such dollar amount for months after

March 1968 and before January 1970 at any time on or before

December 31, 1967."

PERSONS ENROLLING BEFORE APRIL 1, 1968, WHO DID NOT ENROLL DURING

THEIR INITIAL ENROLLMENT PERIOD

Pub. L. 90-97, Sec. 3(b), Sept. 30, 1967, 81 Stat. 250, provided

that: "In the case of any individual who did not enroll in the

insurance program established under part B of title XVIII of the

Social Security Act [this part] in his initial enrollment period,

but does so enroll before April 1, 1968, the enrollment period in

which he so enrolls shall, for purposes of section 1839(c) of such

Act [subsec. (c) of this section], be deemed to have closed on

December 31, 1967."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395i-2, 1395p, 1395v,

1395w, 1395w-24, 1396u-3 of this title.

-End-

-CITE-

42 USC Sec. 1395s 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. 1395s. Payment of premiums

-STATUTE-

(a) Deductions from section 402 or 423 monthly benefits

(1) In the case of an individual who is entitled to monthly

benefits under section 402 or 423 of this title, his monthly

premiums under this part shall (except as provided in subsections

(b)(1) and (c) of this section) be collected by deducting the

amount thereof from the amount of such monthly benefits. Such

deduction shall be made in such manner and at such times as the

Commissioner of Social Security shall by regulation prescribe. Such

regulations shall be prescribed after consultation with the

Secretary.

(2) The Secretary of the Treasury shall, from time to time,

transfer from the Federal Old-Age and Survivors Insurance Trust

Fund or the Federal Disability Insurance Trust Fund to the Federal

Supplementary Medical Insurance Trust Fund the aggregate amount

deducted under paragraph (1) for the period to which such transfer

relates from benefits under section 402 or 423 of this title which

are payable from such Trust Fund. Such transfer shall be made on

the basis of a certification by the Commissioner of Social Security

and shall be appropriately adjusted to the extent that prior

transfers were too great or too small.

(b) Deductions from railroad retirement annuities or pensions

(1) In the case of an individual who is entitled to receive for a

month an annuity under the Railroad Retirement Act of 1974 [45

U.S.C. 231 et seq.] (whether or not such individual is also

entitled for such month to a monthly insurance benefit under

section 402 of this title), his monthly premiums under this part

shall (except as provided in subsection (c) of this section) be

collected by deducting the amount thereof from such annuity or

pension. Such deduction shall be made in such manner and at such

times as the Secretary shall by regulations prescribe. Such

regulations shall be prescribed only after consultation with the

Railroad Retirement Board.

(2) The Secretary of the Treasury shall, from time to time,

transfer from the Railroad Retirement Account to the Federal

Supplementary Medical Insurance Trust Fund the aggregate amount

deducted under paragraph (1) for the period to which such transfer

relates. Such transfers shall be made on the basis of a

certification by the Railroad Retirement Board and shall be

appropriately adjusted to the extent that prior transfers were too

great or too small.

(c) Portion of monthly premium in excess of deducted amount

If an individual to whom subsection (a) or (b) of this section

applies estimates that the amount which will be available for

deduction under such subsection for any premium payment period will

be less than the amount of the monthly premiums for such period, he

may (under regulations) pay to the Secretary such portion of the

monthly premiums for such period as he desires.

(d) Deductions from civil service retirement annuities

(1) In the case of an individual receiving an annuity under

subchapter III of chapter 83 of title 5 or any other law

administered by the Director of the Office of Personnel Management

providing retirement or survivorship protection, to whom neither

subsection (a) nor subsection (b) of this section applies, his

monthly premiums under this part (and the monthly premiums of the

spouse of such individual under this part if neither subsection (a)

nor subsection (b) of this section applies to such spouse and if

such individual agrees) shall, upon notice from the Secretary of

Health and Human Services to the Director of the Office of

Personnel Management, be collected by deducting the amount thereof

from each installment of such annuity. Such deduction shall be made

in such manner and at such times as the Director of the Office of

Personnel Management may determine. The Director of the Office of

Personnel Management shall furnish such information as the

Secretary of Health and Human Services may reasonably request in

order to carry out his functions under this part with respect to

individuals to whom this subsection applies. A plan described in

section 8903 or 8903a of title 5 may reimburse each annuitant

enrolled in such plan an amount equal to the premiums paid by him

under this part if such reimbursement is paid entirely from funds

of such plan which are derived from sources other than the

contributions described in section 8906 of such title.

(2) The Secretary of the Treasury shall, from time to time, but

not less often than quarterly, transfer from the Civil Service

Retirement and Disability Fund, or the account (if any) applicable

in the case of such other law administered by the Director of the

Office of Personnel Management, to the Federal Supplementary

Medical Insurance Trust Fund the aggregate amount deducted under

paragraph (1) for the period to which such transfer relates. Such

transfer shall be made on the basis of a certification by the

Director of the Office of Personnel Management and shall be

appropriately adjusted to the extent that prior transfers were too

great or too small.

(e) Manner and time of payment prescribed by Secretary

In the case of an individual who participates in the insurance

program established by this part but with respect to whom none of

the preceding provisions of this section applies, or with respect

to whom subsection (c) of this section applies, the premiums shall

be paid to the Secretary at such times, and in such manner, as the

Secretary shall by regulations prescribe.

(f) Deposit of amounts in Treasury

Amounts paid to the Secretary under subsection (c) or (e) of this

section shall be deposited in the Treasury to the credit of the

Federal Supplementary Medical Insurance Trust Fund.

(g) Premium payability period

In the case of an individual who participates in the insurance

program established by this part, premiums shall be payable for the

period commencing with the first month of his coverage period and

ending with the month in which he dies or, if earlier, in which his

coverage under such program terminates.

(h) Exempted monthly benefits

In the case of an individual who is enrolled under the program

established by this part as a member of a coverage group to which

an agreement with a State entered into pursuant to section 1395v of

this title is applicable, subsections (a), (b), (c), and (d) of

this section shall not apply to his monthly premium for any month

in his coverage period which is determined under section 1395v(d)

of this title.

(i) Adjustments for individuals enrolled in Medicare+Choice plans

In the case of an individual enrolled in a Medicare+Choice plan,

the Secretary shall provide for necessary adjustments of the

monthly beneficiary premium to reflect 80 percent of any reduction

elected under section 1395w-24(f)(1)(E) of this title. To the

extent to which the Secretary determines that such an adjustment is

appropriate, with the concurrence of any agency responsible for the

administration of such benefits, such premium adjustment may be

provided directly, as an adjustment to any social security,

railroad retirement, or civil service retirement benefits, or, in

the case of an individual who receives medical assistance under

subchapter XIX of this chapter for medicare costs described in

section 1396d(p)(3)(A)(ii) of this title, as an adjustment to the

amount otherwise owed by the State for such medical assistance.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1840, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 306; amended

Pub. L. 89-384, Sec. 4(c), Apr. 8, 1966, 80 Stat. 106; Pub. L.

90-248, title I, Sec. 166, title IV, Sec. 403(g), Jan. 2, 1968, 81

Stat. 874, 932; Pub. L. 92-603, title II, Secs. 201(c)(6),

263(a)-(d)(3), Oct. 30, 1972, 86 Stat. 1373, 1448, 1449; Pub. L.

93-445, title III, Sec. 306, Oct. 16, 1974, 88 Stat. 1358; Pub. L.

98-369, div. B, title III, Sec. 2354(b)(11), title VI, Sec.

2663(j)(2)(F)(ii), July 18, 1984, 98 Stat. 1101, 1170; Pub. L.

99-53, Sec. 2(g), June 17, 1985, 99 Stat. 94; Pub. L. 100-360,

title II, Sec. 212(b)(1), July 1, 1988, 102 Stat. 740; Pub. L.

100-485, title VI, Sec. 608(d)(10)(B), Oct. 13, 1988, 102 Stat.

2415; Pub. L. 101-234, title II, Sec. 202(a), Dec. 13, 1989, 103

Stat. 1981; Pub. L. 103-296, title I, Sec. 108(c)(2), Aug. 15,

1994, 108 Stat. 1485; Pub. L. 106-554, Sec. 1(a)(6) [title VI, Sec.

606(a)(2)(B)(ii)], Dec. 21, 2000, 114 Stat. 2763, 2763A-557.)

-REFTEXT-

REFERENCES IN TEXT

The Railroad Retirement Act of 1974, referred to in subsec.

(b)(1), is act Aug. 29, 1935, ch. 812, as amended generally by Pub.

L. 93-445, title I, Sec. 101, Oct. 16, 1974, 88 Stat. 1305, which

is classified generally to subchapter IV (Sec. 231 et seq.) of

chapter 9 of Title 45, Railroads. For further details and complete

classification of this Act to the Code, see Codification note set

out preceding section 231 of Title 45, section 231t of Title 45,

and Tables.

-MISC1-

AMENDMENTS

2000 - Subsec. (i). Pub. L. 106-554 added subsec. (i).

1994 - Subsec. (a)(1). Pub. L. 103-296, Sec. 108(c)(2)(A),

substituted "Commissioner of Social Security" for "Secretary" and

inserted at end "Such regulations shall be prescribed after

consultation with the Secretary."

Subsec. (a)(2). Pub. L. 103-296, Sec. 108(c)(2)(B), substituted

"Commissioner of Social Security" for "Secretary of Health and

Human Services".

1989 - Subsec. (i). Pub. L. 101-234 repealed Pub. L. 100-360,

Sec. 212(b)(1), and provided that the provisions of law amended or

repealed by such section are restored or revised as if such section

had not been enacted, see 1988 Amendment note below.

1988 - Subsec. (i). Pub. L. 100-485 substituted "Supplementary"

for "Supplemental".

Pub. L. 100-360 added subsec. (i) relating to transfer to flat

prescription drug premiums to Federal Catastrophic Drug Insurance

Trust Fund.

1985 - Subsec. (d)(1). Pub. L. 99-53 inserted reference to

section 8903a of title 5.

1984 - Subsec. (a)(2). Pub. L. 98-369, Sec. 2663(j)(2)(F)(ii),

substituted "Health and Human Services" for "Health, Education, and

Welfare".

Subsec. (d)(1). Pub. L. 98-369, Sec. 2354(b)(11), substituted

"Director of the Office of Personnel Management" for "Civil Service

Commission".

Pub. L. 98-369, Sec. 2663(j)(2)(F)(ii), substituted "Health and

Human Services" for "Health, Education, and Welfare".

Subsec. (d)(2). Pub. L. 98-369, Sec. 2354(b)(11), substituted

"Director of the Office of Personnel Management" for "Civil Service

Commission".

1974 - Subsec. (b)(1). Pub. L. 93-445 substituted "under the

Railroad Retirement Act of 1974" for "or pension under the Railroad

Retirement Act of 1937".

1972 - Subsec. (a)(1). Pub. L. 92-603, Secs. 201(c)(6)(A),

263(a), substituted "subsections (b)(1) and (c)" for "subsection

(d)" and inserted reference to section 423 of this title.

Subsec. (a)(2). Pub. L. 92-603, Sec. 201(c)(6)(B), inserted

reference to section 423 of this title.

Subsec. (b)(1). Pub. L. 92-603, Sec. 263(b), inserted "(whether

or not such individual is also entitled for such month to a monthly

insurance benefit under section 402 of this title)" after "1937"

and substituted "subsection (c)" for "subsection (d)".

Subsec. (c). Pub. L. 92-603, Sec. 263(c), struck out subsec. (c)

covering individuals entitled both to monthly benefits under

section 402 of this title and to an annuity or pension under

Railroad Retirement Act of 1937 and redesignated former subsec. (d)

as (c).

Subsec. (d). Pub. L. 92-603, Sec. 263(c), redesignated subsec.

(e) as (d). Former subsec. (d) redesignated (c).

Subsec. (e). Pub. L. 92-603, Sec. 263(c), (d)(1), redesignated

subsec. (f) as (e) and substituted "subsection (c)" for "subsection

(d)". Former subsec. (e) redesignated (d).

Subsec. (f). Pub. L. 92-603, Sec. 263(c), (d)(2), redesignated

subsec. (g) as (f) and substituted "subsections (c) or (e)" for

"subsections (d) or (f)". Former subsec. (f) redesignated (e) and

amended.

Subsec. (g). Pub. L. 92-603, Sec. 263(c), redesignated subsec.

(h) as (g). Former subsec. (g) redesignated (f) and amended.

Subsecs. (h), (i). Pub. L. 92-603, Sec. 263(c), (d)(3),

redesignated subsec. (i) as (h) and substituted "(c) and (d)" for

"(c), (d), and (e)". Former subsec. (h) redesignated (g).

1968 - Subsec. (e). Pub. L. 90-248 provided for reimbursement of

civil service retirement annuitants for certain premium payments

under supplementary medical insurance program, and substituted

"subchapter III of chapter 83 of Title 5 or any other law" and

"such other law" for "the Civil Service Retirement Act, or other

Act" and "such other Act", in pars. (1) and (2), respectively.

1966 - Subsec. (i). Pub. L. 89-384 added subsec. (i).

EFFECTIVE DATE OF 2000 AMENDMENT

Amendment by Pub. L. 106-554 applicable to years beginning with

2003, see section 1(a)(6) [title VI, Sec. 606(b)] of Pub. L.

106-554, set out as a note under section 1395r of this title.

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by Pub. L. 103-296 effective Mar. 31, 1995, see section

110(a) of Pub. L. 103-296, set out as a note under section 401 of

this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by 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 AMENDMENT

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.

EFFECTIVE DATE OF 1984 AMENDMENT

Amendment by section 2354(b)(11) of Pub. L. 98-369 effective July

18, 1984, but not to be construed as changing or affecting any

right, liability, status, or interpretation which existed (under

the provisions of law involved) before that date, see section

2354(e)(1) of Pub. L. 98-369, set out as a note under section

1320a-1 of this title.

Amendment by section 2663(j)(2)(F)(ii) of Pub. L. 98-369

effective July 18, 1984, but not to be construed as changing or

affecting any right, liability, status, or interpretation which

existed (under the provisions of law involved) before that date,

see section 2664(b) of Pub. L. 98-369, set out as a note under

section 401 of this title.

EFFECTIVE DATE OF 1974 AMENDMENT

Amendment by Pub. L. 93-445 effective Jan. 1, 1975, see section

603 of Pub. L. 93-445, set out as a note under section 402 of this

title.

EFFECTIVE DATE OF 1972 AMENDMENT

Section 263(f) of Pub. L. 92-603 provided that: "The amendments

made by this section [amending this section and sections 1395t and

1395u of this title] with respect to collection of premiums shall

apply to premiums becoming due and payable after the fourth month

following the month in which this Act is enacted [October 1972]."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 415, 428, 1395i-2, 1395r,

1395t, 1395w-24 of this title.

-End-

-CITE-

42 USC Sec. 1395t 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. 1395t. Federal Supplementary Medical Insurance Trust Fund

-STATUTE-

(a) Creation; deposits; fund transfers

There is hereby created on the books of the Treasury of the

United States a trust fund to be known as the "Federal

Supplementary Medical Insurance Trust Fund" (hereinafter in this

section referred to as the "Trust Fund"). The Trust Fund shall

consist of such gifts and bequests as may be made as provided in

section 401(i)(1) of this title, and such amounts as may be

deposited in, or appropriated to, such fund as provided in this

part.

(b) Board of Trustees; composition; meetings; duties

With respect to the Trust Fund, there is hereby created a body to

be known as the Board of Trustees of the Trust Fund (hereinafter in

this section referred to as the "Board of Trustees") composed of

the Commissioner of Social Security, the Secretary of the Treasury,

the Secretary of Labor, and the Secretary of Health and Human

Services, all ex officio, and of two members of the public (both of

whom may not be from the same political party), who shall be

nominated by the President for a term of four years and subject to

confirmation by the Senate. A member of the Board of Trustees

serving as a member of the public and nominated and confirmed to

fill a vacancy occurring during a term shall be nominated and

confirmed only for the remainder of such term. An individual

nominated and confirmed as a member of the public may serve in such

position after the expiration of such member's term until the

earlier of the time at which the member's successor takes office or

the time at which a report of the Board is first issued under

paragraph (2) after the expiration of the member's term. The

Secretary of the Treasury shall be the Managing Trustee of the

Board of Trustees (hereinafter in this section referred to as the

"Managing Trustee"). The Administrator of the Health Care Financing

Administration shall serve as the Secretary of the Board of

Trustees. The Board of Trustees shall meet not less frequently than

once each calendar year. It shall be the duty of the Board of

Trustees to -

(1) Hold the Trust Fund;

(2) Report to the Congress not later than the first day of

April of each year on the operation and status of the Trust Fund

during the preceding fiscal year and on its expected operation

and status during the current fiscal year and the next 2 fiscal

years;

(3) Report immediately to the Congress whenever the Board is of

the opinion that the amount of the Trust Fund is unduly small;

and

(4) Review the general policies followed in managing the Trust

Fund, and recommend changes in such policies, including necessary

changes in the provisions of law which govern the way in which

the Trust Fund is to be managed.

The report provided for in paragraph (2) shall include a statement

of the assets of, and the disbursements made from, the Trust Fund

during the preceding fiscal year, an estimate of the expected

income to, and disbursements to be made from, the Trust Fund during

the current fiscal year and each of the next 2 fiscal years, and a

statement of the actuarial status of the Trust Fund. Such report

shall also include an actuarial opinion by the Chief Actuarial

Officer of the Health Care Financing Administration certifying that

the techniques and methodologies used are generally accepted within

the actuarial profession and that the assumptions and cost

estimates used are reasonable. Such report shall be printed as a

House document of the session of the Congress to which the report

is made. A person serving on the Board of Trustees shall not be

considered to be a fiduciary and shall not be personally liable for

actions taken in such capacity with respect to the Trust Fund.

(c) Investment of Trust Fund by Managing Trustee

It shall be the duty of the Managing Trustee to invest such

portion of the Trust Fund as is not, in his judgment, required to

meet current withdrawals. Such investments may be made only in

interest-bearing obligations of the United States or in obligations

guaranteed as to both principal and interest by the United States.

For such purpose such obligations may be acquired (1) on original

issue at the issue price, or (2) by purchase of outstanding

obligations at the market price. The purposes for which obligations

of the United States may be issued under chapter 31 of title 31 are

hereby extended to authorize the issuance at par of public-debt

obligations for purchase by the Trust Fund. Such obligations issued

for purchase by the Trust Fund shall have maturities fixed with due

regard for the needs of the Trust Fund and shall bear interest at a

rate equal to the average market yield (computed by the Managing

Trustee on the basis of market quotations as of the end of the

calendar month next preceding the date of such issue) on all

marketable interest-bearing obligations of the United States then

forming a part of the public debt which are not due or callable

until after the expiration of 4 years from the end of such calendar

month; except that where such average market yield is not a

multiple of one-eighth of 1 per centum, the rate of interest on

such obligations shall be the multiple of one-eighth of 1 per

centum nearest such market yield. The Managing Trustee may purchase

other interest-bearing obligations of the United States or

obligations guaranteed as to both principal and interest by the

United States, on original issue or at the market price, only where

he determines that the purchase of such other obligations is in the

public interest.

(d) Authority of Managing Trustee to sell obligations

Any obligations acquired by the Trust Fund (except public-debt

obligations issued exclusively to the Trust Fund) may be sold by

the Managing Trustee at the market price, and such public-debt

obligations may be redeemed at par plus accrued interest.

(e) Interest on or proceeds from sale or redemption of obligations

The interest on, and the proceeds from the sale or redemption of,

any obligations held in the Trust Fund shall be credited to and

form a part of the Trust Fund.

(f) Transfers to other Funds

There shall be transferred periodically (but not less often than

once each fiscal year) to the Trust Fund from the Federal Old-Age

and Survivors Insurance Trust Fund and from the Federal Disability

Insurance Trust Fund amounts equivalent to the amounts not

previously so transferred which the Secretary of Health and Human

Services shall have certified as overpayments (other than amounts

so certified to the Railroad Retirement Board) pursuant to section

1395gg(b) of this title. There shall be transferred periodically

(but not less often than once each fiscal year) to the Trust Fund

from the Railroad Retirement Account amounts equivalent to the

amounts not previously so transferred which the Secretary of Health

and Human Services shall have certified as overpayments to the

Railroad Retirement Board pursuant to section 1395gg(b) of this

title.

(g) Payments from Trust Fund of amounts provided for by this part

or with respect to administrative expenses

The Managing Trustee shall pay from time to time from the Trust

Fund such amounts as the Secretary of Health and Human Services

certifies are necessary to make the payments provided for by this

part, and the payments with respect to administrative expenses in

accordance with section 401(g)(1) of this title.

(h) Payments from Trust Fund of costs incurred by Director of

Office of Personnel Management

The Managing Trustee shall pay from time to time from the Trust

Fund such amounts as the Secretary of Health and Human Services

certifies are necessary to pay the costs incurred by the Director

of the Office of Personnel Management in making deductions pursuant

to section 1395s(d) of this title. During each fiscal year, or

after the close of such fiscal year, the Director of the Office of

Personnel Management shall certify to the Secretary the amount of

the costs the Director incurred in making such deductions, and such

certified amount shall be the basis for the amount of such costs

certified by the Secretary to the Managing Trustee.

(i) Payments from Trust Fund of costs incurred by Railroad

Retirement Board

The Managing Trustee shall pay from time to time from the Trust

Fund such amounts as the Secretary of Health and Human Services

certifies are necessary to pay the costs incurred by the Railroad

Retirement Board for services performed pursuant to section

1395s(b)(1) and section 1395u(g) of this title. During each fiscal

year or after the close of such fiscal year, the Railroad

Retirement Board shall certify to the Secretary the amount of the

costs it incurred in performing such services and such certified

amount shall be the basis for the amount of such costs certified by

the Secretary to the Managing Trustee.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1841, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 308; amended

Pub. L. 90-248, title I, Sec. 169(a), Jan. 2, 1968, 81 Stat. 875;

Pub. L. 92-603, title I, Sec. 132(e), title II, Sec. 263(d)(4),

(e), Oct. 30, 1972, 86 Stat. 1361, 1449; Pub. L. 95-292, Sec. 5,

June 13, 1978, 92 Stat. 315; Pub. L. 98-21, title I, Sec. 154(c),

title III, Sec. 341(c), Apr. 20, 1983, 97 Stat. 107, 135; Pub. L.

98-369, div. B, title III, Sec. 2354(b)(2), (11), (12), title VI,

Sec. 2663(j)(2)(F)(iii), July 18, 1984, 98 Stat. 1100, 1101, 1170;

Pub. L. 99-272, title IX, Sec. 9213(b), Apr. 7, 1986, 100 Stat.

180; Pub. L. 100-360, title II, Sec. 212(b)(2), (c)(4), July 1,

1988, 102 Stat. 740, 741; Pub. L. 100-647, title VIII, Sec.

8005(a), Nov. 10, 1988, 102 Stat. 3781; Pub. L. 101-234, title II,

Sec. 202(a), Dec. 13, 1989, 103 Stat. 1981; Pub. L. 103-296, title

I, Sec. 108(c)(3), Aug. 15, 1994, 108 Stat. 1485.)

-MISC1-

AMENDMENTS

1994 - Subsec. (b). Pub. L. 103-296 inserted "the Commissioner of

Social Security," after "composed of" in introductory provisions.

1989 - Subsecs. (a), (b). Pub. L. 101-234 repealed Pub. L.

100-360, Sec. 212(b)(2), (c)(4), 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 notes

below.

1988 - Subsec. (a). Pub. L. 100-360, Sec. 212(b)(2), inserted

three sentences at end providing for transfer of supplemental

catastrophic coverage premiums into the Federal Supplementary

Medical Insurance Trust Fund.

Subsec. (b). Pub. L. 100-647 inserted after first sentence "A

member of the Board of Trustees serving as a member of the public

and nominated and confirmed to fill a vacancy occurring during a

term shall be nominated and confirmed only for the remainder of

such term. An individual nominated and confirmed as a member of the

public may serve in such position after the expiration of such

member's term until the earlier of the time at which the member's

successor takes office or the time at which a report of the Board

is first issued under paragraph (2) after the expiration of the

member's term."

Pub. L. 100-360, Sec. 212(c)(4), inserted after sixth sentence

"Such report shall also identify (and treat separately) those

receipts and outlays in the Trust Fund which are also receipts and

outlays in the Medicare Catastrophic Coverage Account created under

section 1395t-2 of this title."

1986 - Subsec. (b). Pub. L. 99-272 struck out provision at end of

penultimate sentence that the certification shall not refer to

economic assumptions underlying Trustee's report.

1984 - Subsec. (c). Pub. L. 98-369, Sec. 2354(b)(2), substituted

"under chapter 31 of title 31" for "under the Second Liberty Bond

Act, as amended".

Subsecs. (f), (g). Pub. L. 98-369, Sec. 2663(j)(2)(F)(iii),

substituted "Health and Human Services" for "Health, Education, and

Welfare" wherever appearing.

Subsec. (h). Pub. L. 98-369, Sec. 2663(j)(2)(F)(iii), substituted

"Health and Human Services" for "Health, Education, and Welfare".

Pub. L. 98-369, Sec. 2354(b)(11), substituted "Director of the

Office of Personnel Management" for "Civil Service Commission" in

two places.

Pub. L. 98-369, Sec. 2354(b)(12), substituted "the Director" for

"it".

Subsec. (i). Pub. L. 98-369, Sec. 2663(j)(2)(F)(iii), substituted

"Health and Human Services" for "Health, Education, and Welfare".

1983 - Subsec. (b). Pub. L. 98-21, Sec. 341(c)(1), substituted

"Secretary of Health and Human Services, all ex officio, and of two

members of the public (both of whom may not be from the same

political party), who shall be nominated by the President for a

term of four years and subject to confirmation by the Senate" for

"Secretary of Health, Education, and Welfare, all ex officio" in

provisions preceding par. (1).

Pub. L. 98-21, Sec. 154(c), inserted at end provision that the

report referred to in par. (2) shall also include an actuarial

opinion by the Chief Actuarial Officer of the Health Care Financing

Administration certifying that the techniques and methodologies

used are generally accepted within the actuarial profession and

that the assumptions and cost estimates used are reasonable, and

provided further that the certification shall not refer to economic

assumptions underlying the Trustee's report.

Pub. L. 98-21, Sec. 341(c)(2), inserted at end provision that a

person serving on the Board of Trustees shall not be considered to

be a fiduciary and shall not be personally liable for actions taken

in such capacity with respect to the Trust Fund.

1978 - Subsec. (b). Pub. L. 95-292 substituted "Administrator of

the Health Care Financing Administration" for "Commissioner of

Social Security" in provisions preceding par. (1).

1972 - Subsec. (a). Pub. L. 92-603, Sec. 132(e), inserted "such

gifts and bequests as may be made as provided in section 401(i)(1)

of this title, and" after "consist of" and before "such amounts".

Subsec. (h). Pub. L. 92-603, Sec. 263(d)(4), substituted

"1395s(d)" for "1395s(e)".

Subsec. (i). Pub. L. 92-603, Sec. 263(e), added subsec. (i).

1968 - Subsec. (b)(2). Pub. L. 90-248 substituted "April" for

"March".

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by Pub. L. 103-296 effective Mar. 31, 1995, see section

110(a) of Pub. L. 103-296, set out as a note under section 401 of

this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by 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 AMENDMENT

Amendment by Pub. L. 100-647 applicable to members of Board of

Trustees of Federal Supplementary Medical Insurance Trust Fund

serving on such Board as members of the public on or after Nov. 10,

1988, see section 8005(b) of Pub. L. 100-647, set out as a note

under section 401 of this title.

EFFECTIVE DATE OF 1984 AMENDMENT

Amendment by section 2354(b)(2), (11), (12) of Pub. L. 98-369

effective July 18, 1984, but not to be construed as changing or

affecting any right, liability, status, or interpretation which

existed (under the provisions of law involved) before that date,

see section 2354(e)(1) of Pub. L. 98-369, set out as a note under

section 1320a-1 of this title.

Amendment by section 2663(j)(2)(F)(iii) of Pub. L. 98-369

effective July 18, 1984, but not to be construed as changing or

affecting any right, liability, status, or interpretation which

existed (under the provisions of law involved) before that date,

see section 2664(b) of Pub. L. 98-369, set out as a note under

section 401 of this title.

EFFECTIVE DATE OF 1983 AMENDMENT

Amendment by sections 154(c) and 341(c) of Pub. L. 98-21

effective Apr. 20, 1983, see sections 154(e) and 341(d) of Pub. L.

98-21, set out as notes under section 401 of this title.

EFFECTIVE DATE OF 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 Apr. 1, 1979, see

section 6 of Pub. L. 95-292, set out as a note under section 426 of

this title.

EFFECTIVE DATE OF 1972 AMENDMENT

Amendment by section 132(e) of Pub. L. 92-603 applicable with

respect to gifts and bequests received after Oct. 30, 1972, see

section 132(f) of Pub. L. 92-603, set out as a note under section

401 of this title.

Amendment by section 263(d)(4), (e) of Pub. L. 92-603 with

respect to collection of premiums applicable to premiums becoming

due and payable after the fourth month following the month of

enactment of Pub. L. 92-603 which was approved on Oct. 30, 1972,

see section 263(f) of Pub. L. 92-603, set out as a note under

section 1395s of this title.

TERMINATION OF REPORTING REQUIREMENTS

For termination, effective May 15, 2000, of provisions of law

requiring submittal to Congress of any annual, semiannual, or other

regular periodic report listed in House Document No. 103-7 (in

which certain reporting requirements under subsec. (b)(2) of this

section are listed in item 7 on page 143), see section 3003 of Pub.

L. 104-66, as amended, and section 1(a)(4) [div. A, Sec. 1402(1)]

of Pub. L. 106-554, set out as notes under section 1113 of Title

31, Money and Finance.

DISPOSAL OF FUNDS IN FEDERAL HOSPITAL INSURANCE CATASTROPHIC

COVERAGE RESERVE FUND

Section 102(c) of Pub. L. 101-234 provided that: "Any balance in

the Federal Hospital Insurance Catastrophic Coverage Reserve Fund

(created under section 1817A(a) of the Social Security Act [former

section 1395i-1a(a) of this title], as inserted by section 112(a)

of MCCA [Pub. L. 100-360]) as of January 1, 1990, shall be

transferred into the Federal Supplementary Medical Insurance Trust

Fund and any amounts payable due to overpayments into such Trust

Fund shall be payable from the Federal Supplementary Medical

Insurance Trust Fund."

DUE DATE FOR 1983 REPORT ON OPERATION AND STATUS OF TRUST FUND

Notwithstanding subsec. (b)(2) of this section, the annual report

of the Board of Trustees of the Trust Fund required for calendar

year 1983 under this section may be filed at any time not later

than forty-five days after Apr. 20, 1983, see section 154(d) of

Pub. L. 98-21, set out as a note under section 401 of this title.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 910, 1320a-7a, 1320b-12,

1395b-1, 1395gg, 1395vv, 1395yy, 1395ggg, 1396m, 1396u-3 of this

title.

-End-

-CITE-

42 USC Secs. 1395t-1, 1395t-2 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part B - Supplementary Medical Insurance Benefits for Aged and

Disabled

-HEAD-

Secs. 1395t-1, 1395t-2. Repealed. Pub. L. 101-234, title II, Sec.

202(a), Dec. 13, 1989, 103 Stat. 1981

-MISC1-

Section 1395t-1, act Aug. 14, 1935, ch. 531, title XVIII, Sec.

1841A, as added July 1, 1988, Pub. L. 100-360, title II, Sec.

212(a), 102 Stat. 739; amended Oct. 13, 1988, Pub. L. 100-485,

title VI, Sec. 608(d)(10)(A), 102 Stat. 2415, provided for the

creation of the Federal Catastrophic Drug Insurance Trust Fund.

Section 1395t-2, act Aug. 14, 1935, ch. 531, title XVIII, Sec.

1841B, as added July 1, 1988, Pub. L. 100-360, title II, Sec. 213,

formerly Sec. 213(a), 102 Stat. 741, as redesignated Oct. 13, 1988,

Pub. L. 100-485, title VI, Sec. 608(d)(11), 102 Stat. 2415,

provided for the creation of the Medicare Catastrophic Coverage

Account.

EFFECTIVE DATE OF REPEAL

Repeal effective Jan. 1, 1990, see section 202(b) of Pub. L.

101-234, set out as an Effective Date of 1989 Amendment note under

section 401 of this title.

-End-

-CITE-

42 USC Sec. 1395u 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. 1395u. Use of carriers for administration of benefits

-STATUTE-

(a) Authority of Secretary to enter into contracts with carriers

In order to provide for the administration of the benefits under

this part with maximum efficiency and convenience for individuals

entitled to benefits under this part and for providers of services

and other persons furnishing services to such individuals, and with

a view to furthering coordination of the administration of the

benefits under part A of this subchapter and under this part, the

Secretary is authorized to enter into contracts with carriers,

including carriers with which agreements under section 1395h of

this title are in effect, which will perform some or all of the

following functions (or, to the extent provided in such contracts,

will secure performance thereof by other organizations); and, with

respect to any of the following functions which involve payments

for physicians' services on a reasonable charge basis, the

Secretary shall to the extent possible enter into such contracts:

(1)(A) make determinations of the rates and amounts of payments

required pursuant to this part to be made to providers of

services and other persons on a reasonable cost or reasonable

charge basis (as may be applicable);

(B) receive, disburse, and account for funds in making such

payments; and

(C) make such audits of the records of providers of services as

may be necessary to assure that proper payments are made under

this part;

(2)(A) determine compliance with the requirements of section

1395x(k) of this title as to utilization review; and

(B) assist providers of services and other persons who furnish

services for which payment may be made under this part in the

development of procedures relating to utilization practices, make

studies of the effectiveness of such procedures and methods for

their improvement, assist in the application of safeguards

against unnecessary utilization of services furnished by

providers of services and other persons to individuals entitled

to benefits under this part, and provide procedures for and

assist in arranging, where necessary, the establishment of groups

outside hospitals (meeting the requirements of section

1395x(k)(2) of this title) to make reviews of utilization;

(3) serve as a channel of communication of information relating

to the administration of this part; and

(4) otherwise assist, in such manner as the contract may

provide, in discharging administrative duties necessary to carry

out the purposes of this part.

(b) Applicability of competitive bidding provisions; findings as to

financial responsibility, etc., of carrier; contractual duties

imposed by contract

(1) Contracts with carriers under subsection (a) of this section

may be entered into without regard to section 5 of title 41 or any

other provision of law requiring competitive bidding.

(2)(A) No such contract shall be entered into with any carrier

unless the Secretary finds that such carrier will perform its

obligations under the contract efficiently and effectively and will

meet such requirements as to financial responsibility, legal

authority, and other matters as he finds pertinent. The Secretary

shall publish in the Federal Register standards and criteria for

the efficient and effective performance of contract obligations

under this section, and opportunity shall be provided for public

comment prior to implementation. In establishing such standards and

criteria, the Secretary shall provide a system to measure a

carrier's performance of responsibilities described in paragraph

(3)(H), subsection (h) of this section, and section 1395w-1(e)(2)

(!1) of this title. The Secretary may not require, as a condition

of entering into or renewing a contract under this section or under

section 1395hh of this title, that a carrier match data obtained

other than in its activities under this part with data used in the

administration of this part for purposes of identifying situations

in which section 1395y(b) of this title may apply.

(B) The Secretary shall establish standards for evaluating

carriers' performance of reviews of initial carrier determinations

and of fair hearings under paragraph (3)(C), under which a carrier

is expected -

(i) to complete such reviews, within 45 days after the date of

a request by an individual enrolled under this part for such a

review, in 95 percent of such requests, and

(ii) to make a final determination, within 120 days after the

date of receipt of a request by an individual enrolled under this

part for a fair hearing under paragraph (3)(C), in 90 percent of

such cases.

(C) In the case of residents of nursing facilities who receive

services described in clause (i) or (ii) of section 1395x(s)(2)(K)

of this title performed by a member of a team, the Secretary shall

instruct carriers to develop mechanisms which permit routine

payment under this part for up to 1.5 visits per month per

resident. In the previous sentence, the term "team" refers to a

physician and includes a physician assistant acting under the

supervision of the physician or a nurse practitioner working in

collaboration with that physician, or both.

(D) In addition to any other standards and criteria established

by the Secretary for evaluating carrier performance under this

paragraph relating to avoiding erroneous payments, the carrier

shall be subject to standards and criteria relating to the

carrier's success in recovering payments made under this part for

items or services for which payment has been or could be made under

a primary plan (as defined in section 1395y(b)(2)(A) of this

title).

(E) With respect to the payment of claims for home health

services under this part that, but for the amendments made by

section 4611 of the Balanced Budget Act of 1997, would be payable

under part A of this subchapter instead of under this part, the

Secretary shall continue administration of such claims through

fiscal intermediaries under section 1395h of this title.

(3) Each such contract shall provide that the carrier -

(A) will take such action as may be necessary to assure that,

where payment under this part for a service is on a cost basis,

the cost is reasonable cost (as determined under section 1395x(v)

of this title);

(B) will take such action as may be necessary to assure that,

where payment under this part for a service is on a charge basis,

such charge will be reasonable and not higher than the charge

applicable, for a comparable service and under comparable

circumstances, to the policyholders and subscribers of the

carrier, and such payment will (except as otherwise provided in

section 1395gg(f) of this title) be made -

(i) on the basis of an itemized bill; or

(ii) on the basis of an assignment under the terms of which

(I) the reasonable charge is the full charge for the service,

(II) the physician or other person furnishing such service

agrees not to charge (and to refund amounts already collected)

for services for which payment under this subchapter is denied

under section 1320c-3(a)(2) of this title by reason of a

determination under section 1320c-3(a)(1)(B) of this title, and

(III) the physician or other person furnishing such service

agrees not to charge (and to refund amounts already collected)

for such service if payment may not be made therefor by reason

of the provisions of paragraph (1) of section 1395y(a) of this

title, and if the individual to whom such service was furnished

was without fault in incurring the expenses of such service,

and if the Secretary's determination that payment (pursuant to

such assignment) was incorrect and was made subsequent to the

third year following the year in which notice of such payment

was sent to such individual; except that the Secretary may

reduce such three-year period to not less than one year if he

finds such reduction is consistent with the objectives of this

subchapter (except in the case of physicians' services and

ambulance service furnished as described in section 1395y(a)(4)

of this title, other than for purposes of section 1395gg(f) of

this title);

but (in the case of bills submitted, or requests for payment

made, after March 1968) only if the bill is submitted, or a

written request for payment is made in such other form as may be

permitted under regulations, no later than the close of the

calendar year following the year in which such service is

furnished (deeming any service furnished in the last 3 months of

any calendar year to have been furnished in the succeeding

calendar year);

(C) will establish and maintain procedures pursuant to which an

individual enrolled under this part will be granted an

opportunity for a fair hearing by the carrier, in any case where

the amount in controversy is at least $100, but less than $500,

when requests for payment under this part with respect to

services furnished him are denied or are not acted upon with

reasonable promptness or when the amount of such payment is in

controversy;

(D) will furnish to the Secretary such timely information and

reports as he may find necessary in performing his functions

under this part;

(E) will maintain such records and afford such access thereto

as the Secretary finds necessary to assure the correctness and

verification of the information and reports under subparagraph

(D) and otherwise to carry out the purposes of this part;

(F) will take such action as may be necessary to assure that

where payment under this part for a service rendered is on a

charge basis, such payment shall be determined on the basis of

the charge that is determined in accordance with this section on

the basis of customary and prevailing charge levels in effect at

the time the service was rendered or, in the case of services

rendered more than 12 months before the year in which the bill is

submitted or request for payment is made, on the basis of such

levels in effect for the 12-month period preceding such year;

(G) will, for a service that is furnished with respect to an

individual enrolled under this part, that is not paid on an

assignment-related basis, and that is subject to a limiting

charge under section 1395w-4(g) of this title -

(i) determine, prior to making payment, whether the amount

billed for such service exceeds the limiting charge applicable

under section 1395w-4(g)(2) of this title;

(ii) notify the physician, supplier, or other person

periodically (but not less often than once every 30 days) of

determinations that amounts billed exceeded such applicable

limiting charges; and

(iii) provide for prompt response to inquiries of physicians,

suppliers, and other persons concerning the accuracy of such

limiting charges for their services;

(H) if it makes determinations or payments with respect to

physicians' services, will implement -

(i) programs to recruit and retain physicians as

participating physicians in the area served by the carrier,

including educational and outreach activities and the use of

professional relations personnel to handle billing and other

problems relating to payment of claims of participating

physicians; and

(ii) programs to familiarize beneficiaries with the

participating physician program and to assist such

beneficiaries in locating participating physicians;

(I) will submit annual reports to the Secretary describing the

steps taken to recover payments made under this part for items or

services for which payment has been or could be made under a

primary plan (as defined in section 1395y(b)(2)(A) of this

title); and

(J), (K) Repealed. Pub. L. 101-234, title II, Sec. 201(a), Dec.

13, 1989, 103 Stat. 1981;

(L) will monitor and profile physicians' billing patterns

within each area or locality and provide comparative data to

physicians whose utilization patterns vary significantly from

other physicians in the same payment area or locality;

and shall contain such other terms and conditions not inconsistent

with this section as the Secretary may find necessary or

appropriate. In determining the reasonable charge for services for

purposes of this paragraph, there shall be taken into consideration

the customary charges for similar services generally made by the

physician or other person furnishing such services, as well as the

prevailing charges in the locality for similar services. No charge

may be determined to be reasonable in the case of bills submitted

or requests for payment made under this part after December 31,

1970, if it exceeds the higher of (i) the prevailing charge

recognized by the carrier and found acceptable by the Secretary for

similar services in the same locality in administering this part on

December 31, 1970, or (ii) the prevailing charge level that, on the

basis of statistical data and methodology acceptable to the

Secretary, would cover 75 percent of the customary charges made for

similar services in the same locality during the 12-month period

ending on the June 30 last preceding the start of the calendar year

in which the service is rendered. In the case of physicians'

services the prevailing charge level determined for purposes of

clause (ii) of the preceding sentence for any twelve-month period

(beginning after June 30, 1973) specified in clause (ii) of such

sentence may not exceed (in the aggregate) the level determined

under such clause for the fiscal year ending June 30, 1973, or

(with respect to physicians' services furnished in a year after

1987) the level determined under this sentence (or under any other

provision of law affecting the prevailing charge level) for the

previous year except to the extent that the Secretary finds, on the

basis of appropriate economic index data, that such higher level is

justified by year-to-year economic changes. With respect to

power-operated wheelchairs for which payment may be made in

accordance with section 1395x(s)(6) of this title, charges

determined to be reasonable may not exceed the lowest charge at

which power-operated wheelchairs are available in the locality. In

the case of medical services, supplies, and equipment (including

equipment servicing) that, in the judgment of the Secretary, do not

generally vary significantly in quality from one supplier to

another, the charges incurred after December 31, 1972, determined

to be reasonable may not exceed the lowest charge levels at which

such services, supplies, and equipment are widely and consistently

available in a locality except to the extent and under the

circumstances specified by the Secretary. The requirement in

subparagraph (B) that a bill be submitted or request for payment be

made by the close of the following calendar year shall not apply if

(I) failure to submit the bill or request the payment by the close

of such year is due to the error or misrepresentation of an

officer, employee, fiscal intermediary, carrier, or agent of the

Department of Health and Human Services performing functions under

this subchapter and acting within the scope of his or its

authority, and (II) the bill is submitted or the payment is

requested promptly after such error or misrepresentation is

eliminated or corrected. Notwithstanding the provisions of the

third and fourth sentences preceding this sentence, the prevailing

charge level in the case of a physician service in a particular

locality determined pursuant to such third and fourth sentences for

any calendar year after 1974 shall, if lower than the prevailing

charge level for the fiscal year ending June 30, 1975, in the case

of a similar physician service in the same locality by reason of

the application of economic index data, be raised to such

prevailing charge level for the fiscal year ending June 30, 1975,

and shall remain at such prevailing charge level until the

prevailing charge for a year (as adjusted by economic index data)

equals or exceeds such prevailing charge level. The amount of any

charges for outpatient services which shall be considered

reasonable shall be subject to the limitations established by

regulations issued by the Secretary pursuant to section

1395x(v)(1)(K) of this title, and in determining the reasonable

charge for such services, the Secretary may limit such reasonable

charge to a percentage of the amount of the prevailing charge for

similar services furnished in a physician's office, taking into

account the extent to which overhead costs associated with such

outpatient services have been included in the reasonable cost or

charge of the facility.

(4)(A)(i) In determining the prevailing charge levels under the

third and fourth sentences of paragraph (3) for physicians'

services furnished during the 15-month period beginning July 1,

1984, the Secretary shall not set any level higher than the same

level as was set for the 12-month period beginning July 1, 1983.

(ii)(I) In determining the prevailing charge levels under the

third and fourth sentences of paragraph (3) for physicians'

services furnished during the 8-month period beginning May 1, 1986,

by a physician who is not a participating physician (as defined in

subsection (h)(1) of this section) at the time of furnishing the

services, the Secretary shall not set any level higher than the

same level as was set for the 12-month period beginning July 1,

1983.

(II) In determining the prevailing charge levels under the fourth

sentence of paragraph (3) for physicians' services furnished during

the 8-month period beginning May 1, 1986, by a physician who is a

participating physician (as defined in subsection (h)(1) of this

section) at the time of furnishing the services, the Secretary

shall permit an additional one percentage point increase in the

increase otherwise permitted under that sentence.

(iii) In determining the maximum allowable prevailing charges

which may be recognized consistent with the index described in the

fourth sentence of paragraph (3) for physicians' services furnished

on or after January 1, 1987, by participating physicians, the

Secretary shall treat the maximum allowable prevailing charges

recognized as of December 31, 1986, under such sentence with

respect to participating physicians as having been justified by

economic changes.

(iv) The reasonable charge for physicians' services furnished on

or after January 1, 1987, and before January 1, 1992, by a

nonparticipating physician shall be no greater than the applicable

percent of the prevailing charge levels established under the third

and fourth sentences of paragraph (3) (or under any other

applicable provision of law affecting the prevailing charge level).

In the previous sentence, the term "applicable percent" means for

services furnished (I) on or after January 1, 1987, and before

April 1, 1988, 96 percent, (II) on or after April 1, 1988, and

before January 1, 1989, 95.5 percent, and (III) on or after January

1, 1989, 95 percent.

(v) In determining the prevailing charge levels under the third

and fourth sentences of paragraph (3) for physicians' services

furnished during the 3-month period beginning January 1, 1988, the

Secretary shall not set any level higher than the same level as was

set for the 12-month period beginning January 1, 1987.

(vi) Before each year (beginning with 1989), the Secretary shall

establish a prevailing charge floor for primary care services (as

defined in subsection (i)(4) of this section) equal to 60 percent

of the estimated average prevailing charge levels based on the best

available data (determined, under the third and fourth sentences of

paragraph (3) and under paragraph (4), without regard to this

clause and without regard to physician specialty) for such service

for all localities in the United States (weighted by the relative

frequency of the service in each locality) for the year.

(vii) Beginning with 1987, the percentage increase in the MEI (as

defined in subsection (i)(3) of this section) for each year shall

be the same for nonparticipating physicians as for participating

physicians.

(B)(i) In determining the reasonable charge under paragraph (3)

for physicians' services furnished during the 15-month period

beginning July 1, 1984, the customary charges shall be the same

customary charges as were recognized under this section for the

12-month period beginning July 1, 1983.

(ii) In determining the reasonable charge under paragraph (3) for

physicians' services furnished during the 8-month period beginning

May 1, 1986, by a physician who is not a participating physician

(as defined in subsection (h)(1) of this section) at the time of

furnishing the services -

(I) if the physician was not a participating physician at any

time during the 12-month period beginning on October 1, 1984, the

customary charges shall be the same customary charges as were

recognized under this section for the 12-month period beginning

July 1, 1983, and

(II) if the physician was a participating physician at any time

during the 12-month period beginning on October 1, 1984, the

physician's customary charges shall be determined based upon the

physician's actual charges billed during the 12-month period

ending on March 31, 1985.

(iii) In determining the reasonable charge under paragraph (3)

for physicians' services furnished during the 3-month period

beginning January 1, 1988, the customary charges shall be the same

customary charges as were recognized under this section for the

12-month period beginning January 1, 1987.

(iv) In determining the reasonable charge under paragraph (3) for

physicians' services (other than primary care services, as defined

in subsection (i)(4) of this section) furnished during 1991, the

customary charges shall be the same customary charges as were

recognized under this section for the 9-month period beginning

April 1, 1990. In a case in which subparagraph (F) applies

(relating to new physicians) so as to limit the customary charges

of a physician during 1990 to a percent of prevailing charges, the

previous sentence shall not prevent such limit on customary charges

under such subparagraph from increasing in 1991 to a higher percent

of such prevailing charges.

(C) In determining the prevailing charge levels under the third

and fourth sentences of paragraph (3) for physicians' services

furnished during periods beginning after September 30, 1985, the

Secretary shall treat the level as set under subparagraph (A)(i) as

having fully provided for the economic changes which would have

been taken into account but for the limitations contained in

subparagraph (A)(i).

(D)(i) In determining the customary charges for physicians'

services furnished during the 8-month period beginning May 1, 1986,

or the 12-month period beginning January 1, 1987, by a physician

who was not a participating physician (as defined in subsection

(h)(1) of this section) on September 30, 1985, the Secretary shall

not recognize increases in actual charges for services furnished

during the 15-month period beginning on July 1, 1984, above the

level of the physician's actual charges billed in the 3-month

period ending on June 30, 1984.

(ii) In determining the customary charges for physicians'

services furnished during the 12-month period beginning January 1,

1987, by a physician who is not a participating physician (as

defined in subsection (h)(1) of this section) on April 30, 1986,

the Secretary shall not recognize increases in actual charges for

services furnished during the 7-month period beginning on October

1, 1985, above the level of the physician's actual charges billed

during the 3-month period ending on June 30, 1984.

(iii) In determining the customary charges for physicians'

services furnished during the 12-month period beginning January 1,

1987, or January 1, 1988, by a physician who is not a participating

physician (as defined in subsection (h)(1) of this section) on

December 31, 1986, the Secretary shall not recognize increases in

actual charges for services furnished during the 8-month period

beginning on May 1, 1986, above the level of the physician's actual

charges billed during the 3-month period ending on June 30, 1984.

(iv) In determining the customary charges for a physicians'

service furnished on or after January 1, 1988, if a physician was a

nonparticipating physician in a previous year (beginning with

1987), the Secretary shall not recognize any amount of such actual

charges (for that service furnished during such previous year) that

exceeds the maximum allowable actual charge for such service

established under subsection (j)(1)(C) of this section.

(E)(i) For purposes of this part for physicians' services

furnished in 1987, the percentage increase in the MEI is 3.2

percent.

(ii) For purposes of this part for physicians' services furnished

in 1988, on or after April 1, the percentage increase in the MEI is

-

(I) 3.6 percent for primary care services (as defined in

subsection (i)(4) of this section), and

(II) 1 percent for other physicians' services.

(iii) For purposes of this part for physicians' services

furnished in 1989, the percentage increase in the MEI is -

(I) 3.0 percent for primary care services, and

(II) 1 percent for other physicians' services.

(iv) For purposes of this part for items and services furnished

in 1990, after March 31, 1990, the percentage increase in the MEI

is -

(I) 0 percent for radiology services, for anesthesia services,

and for other services specified in the list referred to in

paragraph (14)(C)(i),

(II) 2 percent for other services (other than primary care

services), and

(III) such percentage increase in the MEI (as defined in

subsection (i)(3) of this section) as would be otherwise

determined for primary care services (as defined in subsection

(i)(4) of this section).

(v) For purposes of this part for items and services furnished in

1991, the percentage increase in the MEI is -

(I) 0 percent for services (other than primary care services),

and

(II) 2 percent for primary care services (as defined in

subsection (i)(4) of this section).

(5) Each contract under this section shall be for a term of at

least one year, and may be made automatically renewable from term

to term in the absence of notice by either party of intention to

terminate at the end of the current term; except that the Secretary

may terminate any such contract at any time (after such reasonable

notice and opportunity for hearing to the carrier involved as he

may provide in regulations) if he finds that the carrier has failed

substantially to carry out the contract or is carrying out the

contract in a manner inconsistent with the efficient and effective

administration of the insurance program established by this part.

(6) No payment under this part for a service provided to any

individual shall (except as provided in section 1395gg of this

title) be made to anyone other than such individual or (pursuant to

an assignment described in subparagraph (B)(ii) of paragraph (3))

the physician or other person who provided the service, except that

(A) payment may be made (i) to the employer of such physician or

other person if such physician or other person is required as a

condition of his employment to turn over his fee for such service

to his employer, or (ii) (where the service was provided in a

hospital, critical access hospital, clinic, or other facility) to

the facility in which the service was provided if there is a

contractual arrangement between such physician or other person and

such facility under which such facility submits the bill for such

service, (B) payment may be made to an entity (i) which provides

coverage of the services under a health benefits plan, but only to

the extent that payment is not made under this part, (ii) which has

paid the person who provided the service an amount (including the

amount payable under this part) which that person has accepted as

payment in full for the service, and (iii) to which the individual

has agreed in writing that payment may be made under this part, (C)

in the case of services described in clause (i) of section

1395x(s)(2)(K) of this title, payment shall be made to either (i)

the employer of the physician assistant involved, or (ii) with

respect to a physician assistant who was the owner of a rural

health clinic (as described in section 1395x(aa)(2) of this title)

for a continuous period beginning prior to August 5, 1997, and

ending on the date that the Secretary determines such rural health

clinic no longer meets the requirements of section 1395x(aa)(2) of

this title, payment may be made directly to the physician

assistant, (D) payment may be made to a physician for physicians'

services (and services furnished incident to such services)

furnished by a second physician to patients of the first physician

if (i) the first physician is unavailable to provide the services;

(ii) the services are furnished pursuant to an arrangement between

the two physicians that (I) is informal and reciprocal, or (II)

involves per diem or other fee-for-time compensation for such

services; (iii) the services are not provided by the second

physician over a continuous period of more than 60 days; and (iv)

the claim form submitted to the carrier for such services includes

the second physician's unique identifier (provided under the system

established under subsection (r) of this section) and indicates

that the claim meets the requirements of this subparagraph for

payment to the first physician, (E) in the case of an item or

service (other than services described in section

1395yy(e)(2)(A)(ii) of this title) furnished by, or under

arrangements made by, a skilled nursing facility to an individual

who (at the time the item or service is furnished) is a resident of

a skilled nursing facility, payment shall be made to the facility,

(F) in the case of home health services (including medical supplies

described in section 1395x(m)(5) of this title, but excluding

durable medical equipment to the extent provided for in such

section) furnished to an individual who (at the time the item or

service is furnished) is under a plan of care of a home health

agency, payment shall be made to the agency (without regard to

whether or not the item or service was furnished by the agency, by

others under arrangement with them made by the agency, or when any

other contracting or consulting arrangement, or otherwise), and (G)

in the case of services in a hospital or clinic to which section

1395qq(e) of this title applies, payment shall be made to such

hospital or clinic. No payment which under the preceding sentence

may be made directly to the physician or other person providing the

service involved (pursuant to an assignment described in

subparagraph (B)(ii) of paragraph (3)) shall be made to anyone else

under a reassignment or power of attorney (except to an employer or

facility as described in clause (A) of such sentence); but nothing

in this subsection shall be construed (i) to prevent the making of

such a payment in accordance with an assignment from the individual

to whom the service was provided or a reassignment from the

physician or other person providing such service if such assignment

or reassignment is made to a governmental agency or entity or is

established by or pursuant to the order of a court of competent

jurisdiction, or (ii) to preclude an agent of the physician or

other person providing the service from receiving any such payment

if (but only if) such agent does so pursuant to an agency agreement

under which the compensation to be paid to the agent for his

services for or in connection with the billing or collection of

payments due such physician or other person under this subchapter

is unrelated (directly or indirectly) to the amount of such

payments or the billings therefor, and is not dependent upon the

actual collection of any such payment. For purposes of subparagraph

(C) of the first sentence of this paragraph, an employment

relationship may include any independent contractor arrangement,

and employer status shall be determined in accordance with the law

of the State in which the services described in such clause are

performed.

(7)(A) In the case of physicians' services furnished to a patient

in a hospital with a teaching program approved as specified in

section 1395x(b)(6) of this title but which does not meet the

conditions described in section 1395x(b)(7) of this title, the

carrier shall not provide (except on the basis described in

subparagraph (C)) for payment for such services under this part -

(i) unless -

(I) the physician renders sufficient personal and

identifiable physicians' services to the patient to exercise

full, personal control over the management of the portion of

the case for which the payment is sought,

(II) the services are of the same character as the services

the physician furnishes to patients not entitled to benefits

under this subchapter, and

(III) at least 25 percent of the hospital's patients (during

a representative past period, as determined by the Secretary)

who were not entitled to benefits under this subchapter and who

were furnished services described in subclauses (I) and (II)

paid all or a substantial part of charges (other than nominal

charges) imposed for such services; and

(ii) to the extent that the payment is based upon a reasonable

charge for the services in excess of the customary charge as

determined in accordance with subparagraph (B).

(B) The customary charge for such services in a hospital shall be

determined in accordance with regulations issued by the Secretary

and taking into account the following factors:

(i) In the case of a physician who is not a teaching physician

(as defined by the Secretary), the carrier shall take into

account the amounts the physician charges for similar services in

the physician's practice outside the teaching setting.

(ii) In the case of a teaching physician, if the hospital, its

physicians, or other appropriate billing entity has established

one or more schedules of charges which are collected for medical

and surgical services, the carrier shall base payment under this

subchapter on the greatest of -

(I) the charges (other than nominal charges) which are most

frequently collected in full or substantial part with respect

to patients who were not entitled to benefits under this

subchapter and who were furnished services described in

subclauses (I) and (II) of subparagraph (A)(i),

(II) the mean of the charges (other than nominal charges)

which were collected in full or substantial part with respect

to such patients, or

(III) 85 percent of the prevailing charges paid for similar

services in the same locality.

(iii) If all the teaching physicians in a hospital agree to

have payment made for all of their physicians' services under

this part furnished to patients in such hospital on an

assignment-related basis, the customary charge for such services

shall be equal to 90 percent of the prevailing charges paid for

similar services in the same locality.

(C) In the case of physicians' services furnished to a patient in

a hospital with a teaching program approved as specified in section

1395x(b)(6) of this title but which does not meet the conditions

described in section 1395x(b)(7) of this title, if the conditions

described in subclauses (I) and (II) of subparagraph (A)(i) are met

and if the physician elects payment to be determined under this

subparagraph, the carrier shall provide for payment for such

services under this part on the basis of regulations of the

Secretary governing reimbursement for the services of

hospital-based physicians (and not on any other basis).

(D)(i) In the case of physicians' services furnished to a patient

in a hospital with a teaching program approved as specified in

section 1395x(b)(6) of this title but which does not meet the

conditions described in section 1395x(b)(7) of this title, no

payment shall be made under this part for services of assistants at

surgery with respect to a surgical procedure if such hospital has a

training program relating to the medical specialty required for

such surgical procedure and a qualified individual on the staff of

the hospital is available to provide such services; except that

payment may be made under this part for such services, to the

extent that such payment is otherwise allowed under this paragraph,

if such services, as determined under regulations of the Secretary

-

(I) are required due to exceptional medical circumstances,

(II) are performed by team physicians needed to perform complex

medical procedures, or

(III) constitute concurrent medical care relating to a medical

condition which requires the presence of, and active care by, a

physician of another specialty during surgery,

and under such other circumstances as the Secretary determines by

regulation to be appropriate.

(ii) For purposes of this subparagraph, the term "assistant at

surgery" means a physician who actively assists the physician in

charge of a case in performing a surgical procedure.

(iii) The Secretary shall determine appropriate methods of

reimbursement of assistants at surgery where such services are

reimbursable under this part.

(8)(A)(i) The Secretary shall by regulation -

(I) describe the factors to be used in determining the cases

(of particular items or services) in which the application of

this subchapter to payment under this part (other than to

physicians' services paid under section 1395w-4 of this title)

results in the determination of an amount that, because of its

being grossly excessive or grossly deficient, is not inherently

reasonable, and

(II) provide in those cases for the factors to be considered in

determining an amount that is realistic and equitable.

(ii) Notwithstanding the determination made in clause (i), the

Secretary may not apply factors that would increase or decrease the

payment under this part during any year for any particular item or

service by more than 15 percent from such payment during the

preceding year except as provided in subparagraph (B).

(B) The Secretary may make a determination under this

subparagraph that would result in an increase or decrease under

subparagraph (A) of more than 15 percent of the payment amount for

a year, but only if -

(i) the Secretary's determination takes into account the

factors described in subparagraph (C) and any additional factors

the Secretary determines appropriate,

(ii) the Secretary's determination takes into account the

potential impacts described in subparagraph (D), and

(iii) the Secretary complies with the procedural requirements

of paragraph (9).

(C) The factors described in this subparagraph are as follows:

(i) The programs established under this subchapter and

subchapter XIX of this chapter are the sole or primary sources of

payment for an item or service.

(ii) The payment amount does not reflect changing technology,

increased facility with that technology, or reductions in

acquisition or production costs.

(iii) The payment amount for an item or service under this part

is substantially higher or lower than the payment made for the

item or service by other purchasers.

(D) The potential impacts of a determination under subparagraph

(B) on quality, access, and beneficiary liability, including the

likely effects on assignment rates and participation rates.

(9)(A) The Secretary shall consult with representatives of

suppliers or other individuals who furnish an item or service

before making a determination under paragraph (8)(B) with regard to

that item or service.

(B) The Secretary shall publish notice of a proposed

determination under paragraph (8)(B) in the Federal Register -

(i) specifying the payment amount proposed to be established

with respect to an item or service,

(ii) explaining the factors and data that the Secretary took

into account in determining the payment amount so specified, and

(iii) explaining the potential impacts described in paragraph

(8)(D).

(C) After publication of the notice required by subparagraph (B),

the Secretary shall allow not less than 60 days for public comment

on the proposed determination.

(D)(i) Taking into consideration the comments made by the public,

the Secretary shall publish in the Federal Register a final

determination under paragraph (8)(B) with respect to the payment

amount to be established with respect to the item or service.

(ii) A final determination published pursuant to clause (i) shall

explain the factors and data that the Secretary took into

consideration in making the final determination.

(10)(A)(i) In determining the reasonable charge for procedures

described in subparagraph (B) and performed during the 9-month

period beginning on April 1, 1988, the prevailing charge for such

procedure shall be the prevailing charge otherwise recognized for

such procedure for 1987 -

(I) subject to clause (iii), reduced by 2.0 percent, and

(II) further reduced by the applicable percentage specified in

clause (ii).

(ii) For purposes of clause (i), the applicable percentage

specified in this clause is -

(I) 15 percent, in the case of a prevailing charge otherwise

recognized (without regard to this paragraph and determined

without regard to physician specialty) that is at least 150

percent of the weighted national average (as determined by the

Secretary) of such prevailing charges for such procedure for all

localities in the United States for 1987;

(II) 0 percent, in the case of a prevailing charge that does

not exceed 85 percent of such weighted national average; and

(III) in the case of any other prevailing charge, a percent

determined on the basis of a straight-line sliding scale, equal

to 3/13 of a percentage point for each percent by which the

prevailing charge exceeds 85 percent of such weighted national

average.

(iii) In no case shall the reduction under clause (i) for a

procedure result in a prevailing charge in a locality for 1988

which is less than 85 percent of the Secretary's estimate of the

weighted national average of such prevailing charges for such

procedure for all localities in the United States for 1987 (based

upon the best available data and determined without regard to

physician specialty) after making the reduction described in clause

(i)(I).

(B) The procedures described in this subparagraph are as follows:

bronchoscopy, carpal tunnel repair, cataract surgery (including

subsequent insertion of an intraocular lens), coronary artery

bypass surgery, diagnostic and/or therapeutic dilation and

curettage, knee arthroscopy, knee arthroplasty, pacemaker

implantation surgery, total hip replacement, suprapubic

prostatectomy, transurethral resection of the prostate, and upper

gastrointestinal endoscopy.

(C) In the case of a reduction in the reasonable charge for a

physicians' service under subparagraph (A), if a nonparticipating

physician furnishes the service to an individual entitled to

benefits under this part, after the effective date of such

reduction, the physician's actual charge is subject to a limit

under subsection (j)(1)(D) of this section.

(D) There shall be no administrative or judicial review under

section 1395ff of this title or otherwise of any determination

under subparagraph (A) or under paragraph (11)(B)(ii).

(11)(A) In providing payment for cataract eyeglasses and cataract

contact lenses, and professional services relating to them, under

this part, each carrier shall -

(i) provide for separate determinations of the payment amount

for the eyeglasses and lenses and of the payment amount for the

professional services of a physician (as defined in section

1395x(r) of this title), and

(ii) not recognize as reasonable for such eyeglasses and lenses

more than such amount as the Secretary establishes in guidelines

relating to the inherent reasonableness of charges for such

eyeglasses and lenses.

(B)(i) In determining the reasonable charge under paragraph (3)

for a cataract surgical procedure, subject to clause (ii), the

prevailing charge for such procedure otherwise recognized for

participating and nonparticipating physicians shall be reduced by

10 percent with respect to procedures performed in 1987.

(ii) In no case shall the reduction under clause (i) for a

surgical procedure result in a prevailing charge in a locality for

a year which is less than 75 percent of the weighted national

average of such prevailing charges for such procedure for all the

localities in the United States for 1986.

(C)(i) The prevailing charge level determined with respect to

A-mode ophthalmic ultrasound procedures may not exceed 5 percent of

the prevailing charge level established with respect to

extracapsular cataract removal with lens insertion.

(ii) The reasonable charge for an intraocular lens inserted

during or subsequent to cataract surgery in a physician's office

may not exceed the actual acquisition cost for the lens (taking

into account any discount) plus a handling fee (not to exceed 5

percent of such actual acquisition cost).

(D) In the case of a reduction in the reasonable charge for a

physicians' service or item under subparagraph (B) or (C), if a

nonparticipating physician furnishes the service or item to an

individual entitled to benefits under this part after the effective

date of such reduction, the physician's actual charge is subject to

a limit under subsection (j)(1)(D) of this section.

(12) Repealed. Pub. L. 105-33, title IV, Sec. 4512(b)(2), Aug. 5,

1997, 111 Stat. 444.

(13)(A) In determining payments under section 1395l(l) of this

title and section 1395w-4 of this title for anesthesia services

furnished on or after January 1, 1994, the methodology for

determining the base and time units used shall be the same for

services furnished by physicians, for medical direction by

physicians of two, three, or four certified registered nurse

anesthetists, or for services furnished by a certified registered

nurse anesthetist (whether or not medically directed) and shall be

based on the methodology in effect, for anesthesia services

furnished by physicians, as of August 10, 1993.

(B) The Secretary shall require claims for physicians' services

for medical direction of nurse anesthetists during the periods in

which the provisions of subparagraph (A) apply to indicate the

number of such anesthetists being medically directed concurrently

at any time during the procedure, the name of each nurse

anesthetist being directed, and the type of procedure for which the

services are provided.

(14)(A)(i) In determining the reasonable charge for a physicians'

service specified in subparagraph (C)(i) and furnished during the

9-month period beginning on April 1, 1990, the prevailing charge

for such service shall be the prevailing charge otherwise

recognized for such service for 1989 reduced by 15 percent or, if

less, 1/3 of the percent (if any) by which the prevailing charge

otherwise applied in the locality in 1989 exceeds the

locally-adjusted reduced prevailing amount (as determined under

subparagraph (B)(i)) for the service.

(ii) In determining the reasonable charge for a physicians'

service specified in subparagraph (C)(i) and furnished during 1991,

the prevailing charge for such service shall be the prevailing

charge otherwise recognized for such service for the period during

1990 beginning on April 1, reduced by the same amount as the amount

of the reduction effected under this paragraph (as amended by the

Omnibus Budget Reconciliation Act of 1990) for such service during

such period.

(B) For purposes of this paragraph:

(i) The "locally-adjusted reduced prevailing amount" for a

locality for a physicians' service is equal to the product of -

(I) the reduced national weighted average prevailing charge

for the service (specified under clause (ii)), and

(II) the adjustment factor (specified under clause (iii)) for

the locality.

(ii) The "reduced national weighted average prevailing charge"

for a physicians' service is equal to the national weighted

average prevailing charge for the service (specified in

subparagraph (C)(ii)) reduced by the percentage change (specified

in subparagraph (C)(iii)) for the service.

(iii) The "adjustment factor", for a physicians' service for a

locality, is the sum of -

(I) the practice expense component (percent), divided by 100,

specified in appendix A (pages 187 through 194) of the Report

of the Medicare and Medicaid Health Budget Reconciliation

Amendments of 1989, prepared by the Subcommittee on Health and

the Environment of the Committee on Energy and Commerce, House

of Representatives, (Committee Print 101-M, 101st Congress, 1st

Session) for the service, multiplied by the geographic practice

cost index value (specified in subparagraph (C)(iv)) for the

locality, and

(II) 1 minus the practice expense component (percent),

divided by 100.

(C) For purposes of this paragraph:

(i) The physicians' services specified in this clause are the

procedures specified (by code and description) in the Overvalued

Procedures List for Finance Committee, Revised September 20,

1989, prepared by the Physician Payment Review Commission which

specification is of physicians' services that have been

identified as overvalued by at least 10 percent based on a

comparison of payments for such services under a resource-based

relative value scale and of the national average prevailing

charges under this part.

(ii) The "national weighted average prevailing charge"

specified in this clause, for a physicians' service specified in

clause (i), is the national weighted average prevailing charge

for the service in 1989 as determined by the Secretary using the

best data available.

(iii) The "percentage change" specified in this clause, for a

physicians' service specified in clause (i), is the percent

difference (but expressed as a positive number) specified for the

service in the list referred to in clause (i).

(iv) The geographic practice cost index value specified in this

clause for a locality is the Geographic Overhead Costs Index

specified for the locality in table 1 of the September 1989

Supplement to the Geographic Medicare Economic Index: Alternative

Approaches (prepared by the Urban Institute and the Center for

Health Economics Research).

(D) In the case of a reduction in the prevailing charge for a

physicians' service under subparagraph (A), if a nonparticipating

physician furnishes the service to an individual entitled to

benefits under this part, after the effective date of such

reduction, the physician's actual charge is subject to a limit

under subsection (j)(1)(D) of this section.

(15)(A) In determining the reasonable charge for surgery,

radiology, and diagnostic physicians' services which the Secretary

shall designate (based on their high volume of expenditures under

this part) and for which the prevailing charge (but for this

paragraph) differs by physician specialty, the prevailing charge

for such a service may not exceed the prevailing charge or fee

schedule amount for that specialty of physicians that furnish the

service most frequently nationally.

(B) In the case of a reduction in the prevailing charge for a

physician's service under subparagraph (A), if 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 subsection (j)(1)(D) of this section.

(16)(A) In determining the reasonable charge for all physicians'

services other than physicians' services specified in subparagraph

(B) furnished during 1991, the prevailing charge for a locality

shall be 6.5 percent below the prevailing charges used in the

locality under this part in 1990 after March 31.

(B) For purposes of subparagraph (A), the physicians' services

specified in this subparagraph are as follows:

(i) Radiology, anesthesia and physician pathology services, the

technical components of diagnostic tests specified in paragraph

(17) and physicians' services specified in paragraph (14)(C)(i).

(ii) Primary care services specified in subsection (i)(4) of

this section, hospital inpatient medical services, consultations,

other visits, preventive medicine visits, psychiatric services,

emergency care facility services, and critical care services.

(iii) Partial mastectomy; tendon sheath injections and small

joint arthrocentesis; femoral fracture and trochanteric fracture

treatments; endotracheal intubation; thoracentesis; thoracostomy;

aneurysm repair; cystourethroscopy; transurethral fulguration and

resection; tympanoplasty with mastoidectomy; and ophthalmoscopy.

(17) With respect to payment under this part for the technical

(as distinct from professional) component of diagnostic tests

(other than clinical diagnostic laboratory tests, tests specified

in paragraph (14)(C)(i), and radiology services, including portable

x-ray services) which the Secretary shall designate (based on their

high volume of expenditures under this part), the reasonable charge

for such technical component (including the applicable portion of a

global service) may not exceed the national median of such charges

for all localities, as estimated by the Secretary using the best

available data.

(18)(A) Payment for any service furnished by a practitioner

described in subparagraph (C) and for which payment may be made

under this part on a reasonable charge or fee schedule basis may

only be made under this part on an assignment-related basis.

(B) A practitioner described in subparagraph (C) or other person

may not bill (or collect any amount from) the individual or another

person for any service described in subparagraph (A), except for

deductible and coinsurance amounts applicable under this part. No

person is liable for payment of any amounts billed for such a

service in violation of the previous sentence. If a practitioner or

other person knowingly and willfully bills (or collects an amount)

for such a service in violation of such sentence, the Secretary may

apply sanctions against the practitioner or other person in the

same manner as the Secretary may apply sanctions against a

physician in accordance with subsection (j)(2) of this section in

the same manner as such section applies with respect to a

physician. Paragraph (4) of subsection (j) of this section shall

apply in this subparagraph in the same manner as such paragraph

applies to such section.

(C) A practitioner described in this subparagraph is any of the

following:

(i) A physician assistant, nurse practitioner, or clinical

nurse specialist (as defined in section 1395x(aa)(5) of this

title).

(ii) A certified registered nurse anesthetist (as defined in

section 1395x(bb)(2) of this title).

(iii) A certified nurse-midwife (as defined in section

1395x(gg)(2) of this title).

(iv) A clinical social worker (as defined in section

1395x(hh)(1) of this title).

(v) A clinical psychologist (as defined by the Secretary for

purposes of section 1395x(ii) of this title).

(vi) A registered dietitian or nutrition professional.

(D) For purposes of this paragraph, a service furnished by a

practitioner described in subparagraph (C) includes any services

and supplies furnished as incident to the service as would

otherwise be covered under this part if furnished by a physician or

as incident to a physician's service.

(19) For purposes of section 1395l(a)(1) of this title, the

reasonable charge for ambulance services (as described in section

1395x(s)(7) of this title) provided during calendar year 1998 and

calendar year 1999 may not exceed the reasonable charge for such

services provided during the previous calendar year (after

application of this paragraph), 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 reduced by 1.0

percentage point.

(c) Advances of funds to carrier; prompt payment of claims

(1) Any contract entered into with a carrier under this section

shall provide for advances of funds to the carrier for the making

of payments by it under this part, and shall provide for payment of

the cost of administration of the carrier, as determined by the

Secretary to be necessary and proper for carrying out the functions

covered by the contract. The Secretary shall provide that in

determining a carrier's necessary and proper cost of

administration, the Secretary shall, with respect to each contract,

take into account the amount that is reasonable and adequate to

meet the costs which must be incurred by an efficiently and

economically operated carrier in carrying out the terms of its

contract. The Secretary shall cause to have published in the

Federal Register, by not later than September 1 before each fiscal

year, data, standards, and methodology to be used to establish

budgets for carriers under this section for that fiscal year, and

shall cause to be published in the Federal Register for public

comment, at least 90 days before such data, standards, and

methodology are published, the data, standards, and methodology

proposed to be used.

(2)(A) Each contract under this section which provides for the

disbursement of funds, as described in subsection (a)(1)(B) of this

section, shall provide that payment shall be issued, mailed, or

otherwise transmitted with respect to not less than 95 percent of

all claims submitted under this part -

(i) which are clean claims, and

(ii) for which payment is not made on a periodic interim

payment basis,

within the applicable number of calendar days after the date on

which the claim is received.

(B) In this paragraph:

(i) The term "clean claim" means a claim that has no defect or

impropriety (including any lack of any required substantiating

documentation) or particular circumstance requiring special

treatment that prevents timely payment from being made on the

claim under this part.

(ii) The term "applicable number of calendar days" means -

(I) with respect to claims received in the 12-month period

beginning October 1, 1986, 30 calendar days,

(II) with respect to claims received in the 12-month period

beginning October 1, 1987, 26 calendar days (or 19 calendar

days with respect to claims submitted by participating

physicians),

(III) with respect to claims received in the 12-month period

beginning October 1, 1988, 25 calendar days (or 18 calendar

days with respect to claims submitted by participating

physicians), and (!2)

(IV) with respect to claims received in the 12-month period

beginning October 1, 1989, and claims received in any

succeeding 12-month period ending on or before September 30,

1993, 24 calendar days (or 17 calendar days with respect to

claims submitted by participating physicians).(!3)

(V) with respect to claims received in the 12-month period

beginning October 1, 1993, and claims received in any

succeeding 12-month period, 30 calendar days.

(C) If payment is not issued, mailed, or otherwise transmitted

within the applicable number of calendar days (as defined in clause

(ii) of subparagraph (B)) after a clean claim (as defined in clause

(i) of such subparagraph) is received, interest shall be paid at

the rate used for purposes of section 3902(a) of title 31 (relating

to interest penalties for failure to make prompt payments) for the

period beginning on the day after the required payment date and

ending on the date on which payment is made.

(3)(A) Each contract under this section which provides for the

disbursement of funds, as described in subsection (a)(1)(B) of this

section, shall provide that no payment shall be issued, mailed, or

otherwise transmitted with respect to any claim submitted under

this subchapter within the applicable number of calendar days after

the date on which the claim is received.

(B) In this paragraph, the term "applicable number of calendar

days" means -

(i) with respect to claims submitted electronically as

prescribed by the Secretary, 13 days, and

(ii) with respect to claims submitted otherwise, 26 days.

(4) Neither a carrier nor the Secretary may impose a fee under

this subchapter -

(A) for the filing of claims related to physicians' services,

(B) for an error in filing a claim relating to physicians'

services or for such a claim which is denied,

(C) for any appeal under this subchapter with respect to

physicians' services,

(D) for applying for (or obtaining) a unique identifier under

subsection (r) of this section, or

(E) for responding to inquiries respecting physicians' services

or for providing information with respect to medical review of

such services.

(5) Each contract under this section which provides for the

disbursement of funds, as described in subsection (a)(1)(B) of this

section, shall require the carrier to meet criteria developed by

the Secretary to measure the timeliness of carrier responses to

requests for payment of items described in section 1395m(a)(15)(C)

of this title.

(6) No carrier may carry out (or receive payment for carrying

out) any activity pursuant to a contract under this subsection to

the extent that the activity is carried out pursuant to a contract

under the Medicare Integrity Program under section 1395ddd of this

title. The previous sentence shall not apply with respect to the

activity described in section 1395ddd(b)(5) of this title (relating

to prior authorization of certain items of durable medical

equipment under section 1395m(a)(15) of this title).

(d) Surety bonds

Any contract with a carrier under this section may require such

carrier or any of its officers or employees certifying payments or

disbursing funds pursuant to the contract, or otherwise

participating in carrying out the contract, to give surety bond to

the United States in such amount as the Secretary may deem

appropriate.

(e) Liability of certifying or disbursing officers or carriers

(1) No individual designated pursuant to a contract under this

section as a certifying officer shall, in the absence of gross

negligence or intent to defraud the United States, be liable with

respect to any payments certified by him under this section.

(2) No disbursing officer shall, in the absence of gross

negligence or intent to defraud the United States, be liable with

respect to any payment by him under this section if it was based

upon a voucher signed by a certifying officer designated as

provided in paragraph (1) of this subsection.

(3) No such carrier shall be liable to the United States for any

payments referred to in paragraph (1) or (2).

(f) "Carrier" defined

For purposes of this part, the term "carrier" means -

(1) with respect to providers of services and other persons, a

voluntary association, corporation, partnership, or other

nongovernmental organization which is lawfully engaged in

providing, paying for, or reimbursing the cost of, health

services under group insurance policies or contracts, medical or

hospital service agreements, membership or subscription

contracts, or similar group arrangements, in consideration of

premiums or other periodic charges payable to the carrier,

including a health benefits plan duly sponsored or underwritten

by an employee organization; and

(2) with respect to providers of services only, any agency or

organization (not described in paragraph (1)) with which an

agreement is in effect under section 1395h of this title.

(g) Authority of Railroad Retirement Board to enter into contracts

with carriers

The Railroad Retirement Board shall, in accordance with such

regulations as the Secretary may prescribe, contract with a carrier

or carriers to perform the functions set out in this section with

respect to individuals entitled to benefits as qualified railroad

retirement beneficiaries pursuant to section 426(a) of this title

and section 231f(d) of title 45.

(h) Participating physician or supplier; agreement with Secretary;

publication of directories; availability; inclusion of program in

explanation of benefits; payment of claims on assignment-related

basis

(1) Any physician or supplier may voluntarily enter into an

agreement with the Secretary to become a participating physician or

supplier. For purposes of this section, the term "participating

physician or supplier" means a physician or supplier (excluding any

provider of services) who, before the beginning of any year

beginning with 1984, enters into an agreement with the Secretary

which provides that such physician or supplier will accept payment

under this part on an assignment-related basis for all items and

services furnished to individuals enrolled under this part during

such year. In the case of a newly licensed physician or a physician

who begins a practice in a new area, or in the case of a new

supplier who begins a new business, or in such similar cases as the

Secretary may specify, such physician or supplier may enter into

such an agreement after the beginning of a year, for items and

services furnished during the remainder of the year.

(2) Each carrier having an agreement with the Secretary under

subsection (a) of this section shall maintain a toll-free telephone

number or numbers at which individuals enrolled under this part may

obtain the names, addresses, specialty, and telephone numbers of

participating physicians and suppliers and may request a copy of an

appropriate directory published under paragraph (4). Each such

carrier shall, without charge, mail a copy of such directory upon

such a request.

(3)(A) In any case in which a carrier having an agreement with

the Secretary under subsection (a) of this section is able to

develop a system for the electronic transmission to such carrier of

bills for services, such carrier shall establish direct lines for

the electronic receipt of claims from participating physicians and

suppliers.

(B) The Secretary shall establish a procedure whereby an

individual enrolled under this part may assign, in an appropriate

manner on the form claiming a benefit under this part for an item

or service furnished by a participating physician or supplier, the

individual's rights of payment under a medicare supplemental policy

(described in section 1395ss(g)(1) of this title) in which the

individual is enrolled. In the case such an assignment is properly

executed and a payment determination is made by a carrier with a

contract under this section, the carrier shall transmit to the

private entity issuing the medicare supplemental policy notice of

such fact and shall include an explanation of benefits and any

additional information that the Secretary may determine to be

appropriate in order to enable the entity to decide whether (and

the amount of) any payment is due under the policy. The Secretary

may enter into agreements for the transmittal of such information

to entities electronically. The Secretary shall impose user fees

for the transmittal of information under this subparagraph by a

carrier, whether electronically or otherwise, and such user fees

shall be collected and retained by the carrier.

(4) At the beginning of each year the Secretary shall publish

directories (for appropriate local geographic areas) containing the

name, address, and specialty of all participating physicians and

suppliers (as defined in paragraph (1)) for that area for that

year. Each directory shall be organized to make the most useful

presentation of the information (as determined by the Secretary)

for individuals enrolled under this part. Each participating

physician directory for an area shall provide an alphabetical

listing of all participating physicians practicing in the area and

an alphabetical listing by locality and specialty of such

physicians.

(5)(A) The Secretary shall promptly notify individuals enrolled

under this part through an annual mailing of the participation

program under this subsection and the publication and availability

of the directories and shall make the appropriate area directory or

directories available in each district and branch office of the

Social Security Administration, in the offices of carriers, and to

senior citizen organizations.

(B) The annual notice provided under subparagraph (A) shall

include -

(i) a description of the participation program,

(ii) an explanation of the advantages to beneficiaries of

obtaining covered services through a participating physician or

supplier,

(iii) an explanation of the assistance offered by carriers in

obtaining the names of participating physicians and suppliers,

and

(iv) the toll-free telephone number under paragraph (2)(A) for

inquiries concerning the program and for requests for free copies

of appropriate directories.

(6) The Secretary shall provide that the directories shall be

available for purchase by the public. The Secretary shall provide

that each appropriate area directory is sent to each participating

physician located in that area and that an appropriate number of

copies of each such directory is sent to hospitals located in the

area. Such copies shall be sent free of charge.

(7) The Secretary shall provide that each explanation of benefits

provided under this part for services furnished in the United

States, in conjunction with the payment of claims under section

1395l(a)(1) of this title (made other than on an assignment-related

basis), shall include -

(A) a prominent reminder of the participating physician and

supplier program established under this subsection (including the

limitation on charges that may be imposed by such physicians and

suppliers and a clear statement of any amounts charged for the

particular items or services on the claim involved above the

amount recognized under this part),

(B) the toll-free telephone number or numbers, maintained under

paragraph (2), at which an individual enrolled under this part

may obtain information on participating physicians and suppliers,

(C)(i) an offer of assistance to such an individual in

obtaining the names of participating physicians of appropriate

specialty and (ii) an offer to provide a free copy of the

appropriate participating physician directory; and

(D) in the case of services for which the billed amount exceeds

the limiting charge imposed under section 1395w-4(g) of this

title, information regarding such applicable limiting charge

(including information concerning the right to a refund under

section 1395w-4(g)(1)(A)(iv) of this title).

(8) The Secretary may refuse to enter into an agreement with a

physician or supplier under this subsection, or may terminate or

refuse to renew such agreement, in the event that such physician or

supplier has been convicted of a felony under Federal or State law

for an offense which the Secretary determines is detrimental to the

best interests of the program or program beneficiaries.

(i) Definitions

For purposes of this subchapter:

(1) A claim is considered to be paid on an "assignment-related

basis" if the claim is paid on the basis of an assignment

described in subsection (b)(3)(B)(ii) of this section, in

accordance with subsection (b)(6)(B) of this section, or under

the procedure described in section 1395gg(f)(1) of this title.

(2) The term "participating physician" refers, with respect to

the furnishing of services, to a physician who at the time of

furnishing the services is a participating physician (under

subsection (h)(1) of this section); the term "nonparticipating

physician" refers, with respect to the furnishing of services, a

(!4) physician who at the time of furnishing the services is not

a participating physician; and the term "nonparticipating

supplier or other person" means a supplier or other person

(excluding a provider of services) that is not a participating

physician or supplier (as defined in subsection (h)(1) of this

section).

(3) The term "percentage increase in the MEI" means, with

respect to physicians' services furnished in a year, the

percentage increase in the medicare economic index (referred to

in the fourth sentence of subsection (b)(3) of this section)

applicable to such services furnished as of the first day of that

year.

(4) The term "primary care services" means physicians' services

which constitute office medical services, emergency department

services, home medical services, skilled nursing, intermediate

care, and long-term care medical services, or nursing home,

boarding home, domiciliary, or custodial care medical services.

(j) Monitoring of charges of nonparticipating physicians;

sanctions; restitution

(1)(A) In the case of a physician who is not a participating

physician for items and services furnished during a portion of the

30-month period beginning July 1, 1984, the Secretary shall monitor

the physician's actual charges to individuals enrolled under this

part for physicians' services during that portion of that period.

If such physician knowingly and willfully bills individuals

enrolled under this part for actual charges in excess of such

physician's actual charges for the calendar quarter beginning on

April 1, 1984, the Secretary may apply sanctions against such

physician in accordance with paragraph (2).

(B)(i) During any period (on or after January 1, 1987, and before

the date specified in clause (ii)), during which a physician is a

nonparticipating physician, the Secretary shall monitor the actual

charges of each such physician for physicians' services furnished

to individuals enrolled under this part. If such physician

knowingly and willfully bills on a repeated basis for such a

service an actual charge in excess of the maximum allowable actual

charge determined under subparagraph (C) for that service, the

Secretary may apply sanctions against such physician in accordance

with paragraph (2).

(ii) Clause (i) shall not apply to services furnished after

December 31, 1990.

(C)(i) For a particular physicians' service furnished by a

nonparticipating physician to individuals enrolled under this part

during a year, for purposes of subparagraph (B), the maximum

allowable actual charge is determined as follows: If the

physician's maximum allowable actual charge for that service in the

previous year was -

(I) less than 115 percent of the applicable percent (as defined

in subsection (b)(4)(A)(iv) of this section) of the prevailing

charge for the year and service involved, the maximum allowable

actual charge for the year involved is the greater of the maximum

allowable actual charge described in subclause (II) or the charge

described in clause (ii), or

(II) equal to, or greater than, 115 percent of the applicable

percent (as defined in subsection (b)(4)(A)(iv) of this section)

of the prevailing charge for the year and service involved, the

maximum allowable actual charge is 101 percent of the physician's

maximum allowable actual charge for the service for the previous

year.

(ii) For purposes of clause (i)(I), the charge described in this

clause for a particular physicians' service furnished in a year is

the maximum allowable actual charge for the service of the

physician for the previous year plus the product of (I) the

applicable fraction (as defined in clause (iii)) and (II) the

amount by which 115 percent of the prevailing charge for the year

involved for such service furnished by nonparticipating physicians,

exceeds the physician's maximum allowable actual charge for the

service for the previous year.

(iii) In clause (ii), the "applicable fraction" is -

(I) for 1987, 1/4 ,

(II) for 1988, 1/3 ,

(III) for 1989, 1/2 , and

(IV) for any subsequent year, 1.

(iv) For purposes of determining the maximum allowable actual

charge under clauses (i) and (ii) for 1987, in the case of a

physicians' service for which the physician has actual charges for

the calendar quarter beginning on April 1, 1984, the "maximum

allowable actual charge" for 1986 is the physician's actual charge

for such service furnished during such quarter.

(v) For purposes of determining the maximum allowable actual

charge under clauses (i) and (ii) for a year after 1986, in the

case of a physicians' service for which the physician has no actual

charges for the calendar quarter beginning on April 1, 1984, and

for which a maximum allowable actual charge has not been previously

established under this clause, the "maximum allowable actual

charge" for the previous year shall be the 50th percentile of the

customary charges for the service (weighted by frequency of the

service) performed by nonparticipating physicians in the locality

during the 12-month period ending June 30 of that previous year.

(vi) For purposes of this subparagraph, a "physician's actual

charge" for a physicians' service furnished in a year or other

period is the weighted average (or, at the option of the Secretary

for a service furnished in the calendar quarter beginning April 1,

1984, the median) of the physician's charges for such service

furnished in the year or other period.

(vii) In the case of a nonparticipating physician who was a

participating physician during a previous period, for the purpose

of computing the physician's maximum allowable actual charge during

the physician's period of nonparticipation, the physician shall be

deemed to have had a maximum allowable actual charge during the

period of participation, and such deemed maximum allowable actual

charge shall be determined according to clauses (i) through (vi).

(viii) Notwithstanding any other provision of this subparagraph,

the maximum allowable actual charge for a particular physician's

service furnished by a nonparticipating physician to individuals

enrolled under this part during the 3-month period beginning on

January 1, 1988, shall be the amount determined under this

subparagraph for 1987. The maximum allowable actual charge for any

such service otherwise determined under this subparagraph for 1988

shall take effect on April 1, 1988.

(ix) If there is a reduction under subsection (b)(13) of this

section in the reasonable charge for medical direction furnished by

a nonparticipating physician, the maximum allowable actual charge

otherwise permitted under this subsection for such services shall

be reduced in the same manner and in the same percentage as the

reduction in such reasonable charge.

(D)(i) If an action described in clause (ii) results in a

reduction in a reasonable charge for a physicians' service or item

and a nonparticipating physician furnishes the service or item to

an individual entitled to benefits under this part after the

effective date of such action, the physician may not charge the

individual more than 125 percent of the reduced payment allowance

(as defined in clause (iii)) plus (for services or items furnished

during the 12-month period (or 9-month period in the case of an

action described in clause (ii)(II)) beginning on the effective

date of the action) 1/2 of the amount by which the physician's

maximum allowable actual charge for the service or item for the

previous 12-month period exceeds such 125 percent level.

(ii) The first sentence of clause (i) shall apply to -

(I) an adjustment under subsection (b)(8)(B) of this section

(relating to inherent reasonableness),

(II) a reduction under subsection (b)(10)(A) or (b)(14)(A) of

this section (relating to certain overpriced procedures),

(III) a reduction under subsection (b)(11)(B) of this section

(relating to certain cataract procedures),

(IV) a prevailing charge limit established under subsection

(b)(11)(C)(i) or (b)(15)(A) of this section,

(V) a reasonable charge limit established under subsection

(b)(11)(C)(ii) of this section, and

(VI) an adjustment under section 1395l(l)(3)(B) of this title

(relating to physician supervision of certified registered nurse

anesthetists).

(iii) In clause (i), the term "reduced payment allowance" means,

with respect to an action -

(I) under subsection (b)(8)(B) of this section, the inherently

reasonable charge established under subsection (b)(8) of this

section;

(II) under subsection (b)(10)(A), (b)(11)(B), (b)(11)(C)(i),

(b)(14)(A), or (b)(15)(A) of this section or under section

1395l(l)(3)(B) of this title, the prevailing charge for the

service after the action; or

(III) under subsection (b)(11)(C)(ii) of this section, the

payment allowance established under such subsection.

(iv) If a physician knowingly and willfully bills in violation of

clause (i) (whether or not such charge violates subparagraph (B)),

the Secretary may apply sanctions against such physician in

accordance with paragraph (2).

(v) Clause (i) shall not apply to items and services furnished

after December 31, 1990.

(2) Subject to paragraph (3), the sanctions which the Secretary

may apply under this paragraph are -

(A) excluding a physician 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, or

(B) civil monetary penalties and assessments, in the same

manner as such penalties and assessments are authorized under

section 1320a-7a(a) of this title,

or both. The provisions of section 1320a-7a of this title (other

than the first 2 sentences of subsection (a) and other than

subsection (b)) shall apply to a civil money penalty and assessment

under subparagraph (B) in the same manner as such provisions apply

to a penalty, assessment, or proceeding under section 1320a-7a(a)

of this title, except to the extent such provisions are

inconsistent with subparagraph (A) or paragraph (3).

(3)(A) The Secretary may not exclude a physician pursuant to

paragraph (2)(A) if such physician is a sole community physician or

sole source of essential specialized services in a community.

(B) The Secretary shall take into account access of beneficiaries

to physicians' services for which payment may be made under this

part in determining whether to bar a physician from participation

under paragraph (2)(A).

(4) The Secretary may, out of any civil monetary penalty or

assessment collected from a physician pursuant to this subsection,

make a payment to a beneficiary enrolled under this part in the

nature of restitution for amounts paid by such beneficiary to such

physician which was determined to be an excess charge under

paragraph (1).

(k) Sanctions for billing for services of assistant at cataract

operations

(1) If a physician knowingly and willfully presents or causes to

be presented a claim or bills an individual enrolled under this

part for charges for services as an assistant at surgery for which

payment may not be made by reason of section 1395y(a)(15) of this

title, the Secretary may apply sanctions against such physician in

accordance with subsection (j)(2) of this section in the case of

surgery performed on or after March 1, 1987.

(2) If a physician knowingly and willfully presents or causes to

be presented a claim or bills an individual enrolled under this

part for charges that includes a charge for an assistant at surgery

for which payment may not be made by reason of section 1395y(a)(15)

of this title, the Secretary may apply sanctions against such

physician in accordance with subsection (j)(2) of this section in

the case of surgery performed on or after March 1, 1987.

(l) Prohibition of unassigned billing of services determined to be

medically unnecessary by carrier

(1)(A) Subject to subparagraph (C), if -

(i) a nonparticipating physician furnishes services to an

individual enrolled for benefits under this part,

(ii) payment for such services is not accepted on an

assignment-related basis,

(iii)(I) a carrier determines under this part or a peer review

organization determines under part B of subchapter XI of this

chapter that payment may not be made by reason of section

1395y(a)(1) of this title because a service otherwise covered

under this subchapter is not reasonable and necessary under the

standards described in that section or (II) payment under this

subchapter for such services is denied under section

1320c-3(a)(2) of this title by reason of a determination under

section 1320c-3(a)(1)(B) of this title, and

(iv) the physician has collected any amounts for such services,

the physician shall refund on a timely basis to the individual (and

shall be liable to the individual for) any amounts so collected.

(B) A refund under subparagraph (A) is considered to be on a

timely basis only if -

(i) in the case of a physician who does not request

reconsideration or seek appeal on a timely basis, the refund is

made within 30 days after the date the physician receives a

denial notice under paragraph (2), 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

physician receives notice of an adverse determination on

reconsideration or appeal.

(C) Subparagraph (A) shall not apply to the furnishing of a

service by a physician to an individual in the case described in

subparagraph (A)(iii)(I) if -

(i) the physician establishes that the physician did not know

and could not reasonably have been expected to know that payment

may not be made for the service by reason of section 1395y(a)(1)

of this title, or

(ii) before the service was provided, the individual was

informed that payment under this part may not be made for the

specific service and the individual has agreed to pay for that

service.

(2) Each carrier with a contract in effect under this section

with respect to physicians and each peer review organization with a

contract under part B of subchapter XI of this chapter shall send

any notice of denial of payment for physicians' services based on

section 1395y(a)(1) of this title and for which payment is not

requested on an assignment-related basis to the physician and the

individual involved.

(3) If a physician knowingly and willfully fails to make refunds

in violation of paragraph (1)(A), the Secretary may apply sanctions

against such physician in accordance with subsection (j)(2) of this

section.

(m) Disclosure of information of unassigned claims for certain

physicians' services

(1) In the case of a nonparticipating physician who -

(A) performs an elective surgical procedure for an individual

enrolled for benefits under this part and for which the

physician's actual charge is at least $500, and

(B) does not accept payment for such procedure on an

assignment-related basis,

the physician must disclose to the individual, in writing and in a

form approved by the Secretary, the physician's estimated actual

charge for the procedure, the estimated approved charge under this

part for the procedure, the excess of the physician's actual charge

over the approved charge, and the coinsurance amount applicable to

the procedure. The written estimate may not be used as the basis

for, or evidence in, a civil suit.

(2) A physician who fails to make a disclosure required under

paragraph (1) with respect to a procedure shall refund on a timely

basis to the individual (and shall be liable to the individual for)

any amounts collected for the procedure in excess of the charges

recognized and approved under this part.

(3) If a physician knowingly and willfully fails to comply with

paragraph (2), the Secretary may apply sanctions against such

physician in accordance with subsection (j)(2) of this section.

(4) The Secretary shall provide for such monitoring of requests

for payment for physicians' services to which paragraph (1) applies

as is necessary to assure compliance with paragraph (2).

(n) Elimination of markup for certain purchased services

(1) If a physician's bill or a request for payment for services

billed by a physician includes a charge for a diagnostic test

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

clinical diagnostic laboratory test) for which the bill or request

for payment does not indicate that the billing physician personally

performed or supervised the performance of the test or that another

physician with whom the physician who shares a practice personally

performed or supervised the performance of the test, the amount

payable with respect to the test shall be determined as follows:

(A) If the bill or request for payment indicates that the test

was performed by a supplier, identifies the supplier, and

indicates the amount the supplier charged the billing physician,

payment for the test (less the applicable deductible and

coinsurance amounts) shall be the actual acquisition costs (net

of any discounts) or, if lower, the supplier's reasonable charge

(or other applicable limit) for the test.

(B) If the bill or request for payment (i) does not indicate

who performed the test, or (ii) indicates that the test was

performed by a supplier but does not identify the supplier or

include the amount charged by the supplier, no payment shall be

made under this part.

(2) A physician may not bill an individual enrolled under this

part -

(A) any amount other than the payment amount specified in

paragraph (1)(A) and any applicable deductible and coinsurance

for a diagnostic test for which payment is made pursuant to

paragraph (1)(A), or

(B) any amount for a diagnostic test for which payment may not

be made pursuant to paragraph (1)(B).

(3) If a physician knowingly and willfully in repeated cases

bills one or more individuals in violation of paragraph (2), the

Secretary may apply sanctions against such physician in accordance

with subsection (j)(2) of this section.

(o) Reimbursement for drugs and biologicals

(1) If a physician's, supplier's, or any other person's bill or

request for payment for services includes a charge for a drug or

biological for which payment may be made under this part and the

drug or biological is not paid on a cost or prospective payment

basis as otherwise provided in this part, the amount payable for

the drug or biological is equal to 95 percent of the average

wholesale price.

(2) If payment for a drug or biological is made to a licensed

pharmacy approved to dispense drugs or biologicals under this part,

the Secretary may pay a dispensing fee (less the applicable

deductible and coinsurance amounts) to the pharmacy.

(3)(A) Payment for a charge for any drug or biological for which

payment may be made under this part may be made only on an

assignment-related basis.

(B) The provisions of subsection (b)(18)(B) of this section shall

apply to charges for such drugs or biologicals in the same manner

as they apply to services furnished by a practitioner described in

subsection (b)(18)(C) of this section.

(p) Requiring submission of diagnostic information

(1) Each request for payment, or bill submitted, for an item or

service furnished by a physician or practitioner specified in

subsection (b)(18)(C) of this section for which payment may be made

under this part shall include the appropriate diagnosis code (or

codes) as established by the Secretary for such item or service.

(2) In the case of a request for payment for an item or service

furnished by a physician or practitioner specified in subsection

(b)(18)(C) of this section on an assignment-related basis which

does not include the code (or codes) required under paragraph (1),

payment may be denied under this part.

(3) In the case of a request for payment for an item or service

furnished by a physician not submitted on an assignment-related

basis and which does not include the code (or codes) required under

paragraph (1) -

(A) if the physician knowingly and willfully fails to provide

the code (or codes) promptly upon request of the Secretary or a

carrier, the physician may be subject to a civil money penalty in

an amount not to exceed $2,000, and

(B) if the physician knowingly, willfully, and in repeated

cases fails, after being notified by the Secretary of the

obligations and requirements of this subsection, to include the

code (or codes) required under paragraph (1), the physician may

be subject to the sanction described in subsection (j)(2)(A) of

this section.

The provisions of section 1320a-7a of this title (other than

subsections (a) and (b)) shall apply to civil money penalties under

subparagraph (A) in the same manner as they apply to a penalty or

proceeding under section 1320a-7a(a) of this title.

(4) In the case of an item or service defined in paragraph (3),

(6), (8), or (9) of subsection 1395x(s) of this title ordered by a

physician or a practitioner specified in subsection (b)(18)(C) of

this section, but furnished by another entity, if the Secretary (or

fiscal agent of the Secretary) requires the entity furnishing the

item or service to provide diagnostic or other medical information

in order for payment to be made to the entity, the physician or

practitioner shall provide that information to the entity at the

time that the item or service is ordered by the physician or

practitioner.

(q) Anesthesia services; counting actual time units

(1)(A) The Secretary, in consultation with groups representing

physicians who furnish anesthesia services, shall establish by

regulation a relative value guide for use in all carrier localities

in making payment for physician anesthesia services furnished under

this part. Such guide shall be designed so as to result in

expenditures under this subchapter for such services in an amount

that would not exceed the amount of such expenditures which would

otherwise occur.

(B) For physician anesthesia services furnished under this part

during 1991, the prevailing charge conversion factor used in a

locality under this subsection shall, subject to clause (iv), be

reduced to the adjusted prevailing charge conversion factor for the

locality determined as follows:

(i) The Secretary shall estimate the national weighted average

of the prevailing charge conversion factors used under this

subsection for services furnished during 1990 after March 31,

using the best available data.

(ii) The national weighted average estimated under clause (i)

shall be reduced by 7 percent.

(iii) The adjusted prevailing charge conversion factor for a

locality is the sum of -

(I) the product of (a) the portion of the reduced national

weighted average prevailing charge 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 prevailing charge conversion factor

computed under clause (ii) and (b) the geographic practice cost

index value specified in subsection (b)(14)(C)(iv) of this

section for the locality.

In applying this clause, 70 percent of the prevailing charge

conversion factor shall be considered to be attributable to

physician work.

(iv) The prevailing charge conversion factor to be applied to a

locality under this subparagraph shall not be reduced by more

than 15 percent below the prevailing charge conversion factor

applied in the locality for the period during 1990 after March

31, but in no case shall the prevailing charge conversion factor

be less than 60 percent of the national weighted average of the

prevailing charge conversion factors (computed under clause (i)).

(2) For purposes of payment for anesthesia services (whether

furnished by physicians or by certified registered nurse

anesthetists) under this part, the time units shall be counted

based on actual time rather than rounded to full time units.

(r) Establishment of physician identification system

The Secretary shall establish a system which provides for a

unique identifier for each physician who furnishes services for

which payment may be made under this subchapter. Under such system,

the Secretary may impose appropriate fees on such physicians to

cover the costs of investigation and recertification activities

with respect to the issuance of the identifiers.

(s) Application of fee schedule

(1) The Secretary may implement a statewide or other areawide fee

schedule to be used for payment of any item or service described in

paragraph (2) which is paid on a reasonable charge basis. Any fee

schedule established under this paragraph for such item or service

shall be updated each year by 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 preceding

year, except that in no event shall a fee schedule for an item

described in paragraph (2)(D) be updated before 2003.

(2) The items and services described in this paragraph are as

follows:

(A) Medical supplies.

(B) Home dialysis supplies and equipment (as defined in section

1395rr(b)(8) of this title).

(C) Therapeutic shoes.

(D) Parenteral and enteral nutrients, equipment, and supplies.

(E) Electromyogram devices.

(F) Salivation devices.

(G) Blood products.

(H) Transfusion medicine.

(t) Facility provider number required on claims

Each request for payment, or bill submitted, for an item or

service furnished to an individual who is a resident of a skilled

nursing facility for which payment may be made under this part

shall include the facility's medicare provider number.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1842, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 309; amended

Pub. L. 90-248, title I, Secs. 125(a), 154(d), Jan. 2, 1968, 81

Stat. 845, 863; Pub. L. 92-603, title II, Secs. 211(c)(3), 224(a),

227(e)(3), 236(a), 258(a), 262(a), 263(d)(5), 281(d), Oct. 30,

1972, 86 Stat. 1384, 1395, 1407, 1414, 1447-1449, 1455; Pub. L.

93-445, title III, Sec. 307, Oct. 16, 1974, 88 Stat. 1358; Pub. L.

94-182, title I, Sec. 101(a), Dec. 31, 1975, 89 Stat. 1051; Pub. L.

94-368, Secs. 2, 3(a), (b), July 16, 1976, 90 Stat. 997; Pub. L.

95-142, Sec. 2(a)(1), Oct. 25, 1977, 91 Stat. 1175; Pub. L. 95-216,

title V, Sec. 501(b), Dec. 20, 1977, 91 Stat. 1565; Pub. L. 96-499,

title IX, Secs. 918(a)(1), 946(a), (b), 948(b), Dec. 5, 1980, 94

Stat. 2625, 2642, 2643; Pub. L. 97-35, title XXI, Sec. 2142(b),

Aug. 13, 1981, 95 Stat. 798; Pub. L. 97-248, title I, Secs. 104(a),

113(a), 128(d)(1), Sept. 3, 1982, 96 Stat. 336, 340, 367; Pub. L.

98-369, div. B, title III, Secs. 2303(e), 2306(a), (b)(1), (c),

2307(a)(1), (2), 2326(c)(2), (d)(2), 2339, 2354(b)(13), (14), title

VI, 2663(j)(2)(F)(iv), July 18, 1984, 98 Stat. 1066, 1070, 1071,

1073, 1087, 1088, 1093, 1101, 1170; Pub. L. 98-617, Sec. 3(a)(1),

(b)(5), (6), Nov. 8, 1984, 98 Stat. 3295, 3296; Pub. L. 99-272,

title IX, Secs. 9219(b)(1)(A), (2)(A), 9301(b)(1), (2), (c)(2)-(4),

(d)(1)-(3), 9304(a), 9306(a), 9307(c), Apr. 7, 1986, 100 Stat.

182-188, 190, 193, 194; Pub. L. 99-509, title IX, Secs.

9307(c)(2)(A), 9311(c), 9320(e)(3), 9331(a)(1)-(3), (b)(1)-(3),

(c)(3)(A), 9332(a)(1), (b)(1), (2), (c)(1), (d)(1), 9333(a), (b),

9334(a), 9338(b), (c), 9341(a)(2), Oct. 21, 1986, 100 Stat. 1995,

1998, 2015, 2018-2026, 2028, 2035, 2038; Pub. L. 99-514, title

XVIII, Sec. 1895(b)(14)(A), (15), (16)(A), Oct. 22, 1986, 100 Stat.

2934; Pub. L. 100-93, Sec. 8(c)(2), Aug. 18, 1987, 101 Stat. 692;

Pub. L. 100-203, title IV, Secs. 4031(a)(2), 4035(a)(2),

4041(a)(1), (3)(A), 4042(a), (b)(1), (2)(A), (c), 4044(a), 4045(a),

(c)(1), (2)(B), (D), 4046(a), 4047(a), 4048(a), (e), 4051(a),

4053(a), formerly 4052(a), 4054(a), formerly 4053(a), 4063(a),

4081(a), 4082(c), 4085(g)(1), (i)(5)-(7), (22)(C), (24)-(27),

4096(a)(1), Dec. 22, 1987, 101 Stat. 1330-76, 1330-78, 1330-83 to

1330-89, 1330-93, 1330-97, 1330-109, 1330-126, 1330-128, 1330-131,

1330-132, 1330-139, as amended Pub. L. 100-360, title IV, Sec.

411(f)(1)(A), (2)(C), (D), (F), (3)(A), (4)(B), (7)(B), (11)(A),

(14), (g)(2)(C), (i)(2), (4)(C)(vi), (j)(4)(A), July 1, 1988, 102

Stat. 776-779, 781, 783, 788, 789, 791; Pub. L. 100-360, title II,

Secs. 201(c), 202(c)(1), (e)(1)-(3)(A), (C), (4)(A), (5), (g),

223(b), (c), title IV, Sec. 411(a)(3)(A), (C)(i), (f)(1)(B),

(2)(A), (B), (E), (3)(B), (4)(A), (C), (5), (6)(B), (7)(A), (9),

(g)(2)(A), (B), (i)(1)(A), July 1, 1988, 102 Stat. 702, 713,

716-718, 747, 768, 776-780, 783, 787; Pub. L. 100-485, title VI,

Sec. 608(d)(5)(A)-(D), (F)-(H), (17), (21)(A), (B), (D), (24)(B),

Oct. 13, 1988, 102 Stat. 2414, 2418, 2420, 2421; Pub. L. 101-234,

title II, Sec. 201(a), title III, Sec. 301(b)(2), (6), (c)(2),

(d)(3), Dec. 13, 1989, 103 Stat. 1981, 1985, 1986; Pub. L. 101-239,

title VI, Secs. 6003(g)(3)(D)(ix), 6102(b), (e)(2)-(4), (9), 6104,

6106(a), 6107(b), 6108(a)(1), (b)(1), (2), 6114(b), (c),

6202(d)(2), Dec. 19, 1989, 103 Stat. 2153, 2184, 2187, 2188, 2208,

2210, 2212, 2213, 2218, 2234; Pub. L. 101-508, title IV, Secs.

4101(a), (b)(1), 4103, 4105(a)(1), (2), (b)(1), 4106(a)(1), (b)(2),

4108(a), 4110(a), 4118(a)(1), (2), (f)(2)(A)-(C), (i)(1), (j)(2),

4155(c), Nov. 5, 1990, 104 Stat. 1388-54, 1388-58 to 1388-63,

1388-66, 1388-67, 1388-69 to 1388-71, 1388-87; Pub. L. 101-597,

title IV, Sec. 401(c)(2), Nov. 16, 1990, 104 Stat. 3035; Pub. L.

103-66, title XIII, Secs. 13515(a)(2), 13516(a)(2), 13517(b),

13568(a), (b), Aug. 10, 1993, 107 Stat. 583-585, 608; Pub. L.

103-432, title I, Secs. 123(b)(1), (2)(B), (c), 125(a), (b)(1),

126(a)(1), (c), (e), (g)(9), (h)(2), 135(b)(2), 151(b)(1)(B),

(2)(B), Oct. 31, 1994, 108 Stat. 4411-4416, 4423, 4434; Pub. L.

104-191, title II, Secs. 202(b)(2), 221(b), Aug. 21, 1996, 110

Stat. 1998, 2011; Pub. L. 105-33, title IV, Secs. 4201(c)(1),

4205(d)(3)(B), 4302(b), 4315(a), 4316(a), 4317(a), (b), 4432(b)(2),

(4), 4512(b)(2), (c), 4531(a)(2), 4556(a), 4603(c)(2)(B)(i),

4611(d), Aug. 5, 1997, 111 Stat. 373, 377, 382, 390, 392, 421, 444,

450, 462, 471, 473; Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title

II, Sec. 223(c), title III, Secs. 305(a), 321(k)(4)], Nov. 29,

1999, 113 Stat. 1536, 1501A-353, 1501A-361, 1501A-366; Pub. L.

106-554, Sec. 1(a)(6) [title I, Secs. 105(d), 114(a), title II,

Sec. 222(a), title III, Sec. 313(b)(1), (2), title IV, Sec.

432(b)(2)], Dec. 21, 2000, 114 Stat. 2763, 2763A-472, 2763A-473,

2763A-487, 2763A-499, 2763A-526.)

-REFTEXT-

REFERENCES IN TEXT

Part A of this subchapter, referred to in subsecs. (a) and

(b)(2)(E), is classified to section 1395c et seq. of this title.

Section 1395w-1 of this title, referred to in subsec. (b)(2)(A),

was repealed by Pub. L. 105-33, title IV, Sec. 4022(b)(2)(A), Aug.

5, 1997, 111 Stat. 354.

Section 4611 of the Balanced Budget Act of 1997, referred to in

subsec. (b)(2)(E), is section 4611 of Pub. L. 105-33, which amended

this section and sections 1395d, 1395x and 1395ff of this title.

The Omnibus Budget Reconciliation Act of 1990, referred to in

subsec. (b)(14)(A)(ii), is Pub. L. 101-508, Nov. 5, 1990, 104 Stat.

1388. For complete classification of this Act to the Code, see

Tables.

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

(l)(1)(A)(iii), (2), is classified to section 1320c et seq. of this

title.

-MISC1-

AMENDMENTS

2000 - Subsec. (b)(6)(C). Pub. L. 106-554, Sec. 1(a)(6) [title

II, Sec. 222(a)], struck out "for such services provided before

January 1, 2003," before "payment may be made" and substituted

comma for semicolon at end.

Subsec. (b)(6)(E). Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec.

313(b)(1)], inserted "by, or under arrangements made by, a skilled

nursing facility" before "to an individual who" and struck out "or

of a part of a facility that includes a skilled nursing facility

(as determined under regulations)" before ", payment shall be made"

and "(without regard to whether or not the item or service was

furnished by the facility, by others under arrangement with them

made by the facility, under any other contracting or consulting

arrangement, or otherwise)" after "to the facility".

Subsec. (b)(6)(G). Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec.

432(b)(2)], added subpar. (G).

Subsec. (b)(18)(C)(vi). Pub. L. 106-554, Sec. 1(a)(6) [title I,

Sec. 105(d)], added cl. (vi).

Subsec. (o)(3). Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec.

114(a)], added par. (3).

Subsec. (t). Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec.

313(b)(2)], struck out "by a physician" before "to an individual"

and "or of a part of a facility that includes a skilled nursing

facility (as determined under regulations)," before "for which

payment may be made".

1999 - Subsec. (b)(6)(F). Pub. L. 106-113, Sec. 1000(a)(6) [title

III, Sec. 305(a)], inserted "(including medical supplies described

in section 1395x(m)(5) of this title, but excluding durable medical

equipment to the extent provided for in such section)" after "home

health services".

Subsec. (b)(8)(A)(i)(I). Pub. L. 106-113, Sec. 1000(a)(6) [title

II, Sec. 223(c)], substituted "the application of this subchapter

to payment under this part" for "the application of this part".

Subsec. (s)(2)(E). Pub. L. 106-113, Sec. 1000(a)(6) [title III,

Sec. 321(k)(4)], inserted period at end.

1997 - Subsec. (b)(2)(E). Pub. L. 105-33, Sec. 4611(d), added

subpar. (E).

Subsec. (b)(6). Pub. L. 105-33, Sec. 4512(c), inserted at end

"For purposes of subparagraph (C) of the first sentence of this

paragraph, an employment relationship may include any independent

contractor arrangement, and employer status shall be determined in

accordance with the law of the State in which the services

described in such clause are performed."

Subsec. (b)(6)(A)(ii). Pub. L. 105-33, Sec. 4201(c)(1),

substituted "critical access" for "rural primary care".

Subsec. (b)(6)(C). Pub. L. 105-33, Sec. 4205(d)(3)(B), amended

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

follows: "in the case of services described in clauses (i), (ii),

or (iv) of section 1395x(s)(2)(K) of this title payment shall be

made to the employer of the physician assistant or nurse

practitioner involved, and".

Subsec. (b)(6)(E). Pub. L. 105-33, Sec. 4432(b)(2), added subpar.

(E).

Subsec. (b)(6)(F). Pub. L. 105-33, Sec. 4603(c)(2)(B)(i), added

subpar. (F).

Subsec. (b)(8), (9). Pub. L. 105-33, Sec. 4316(a), amended pars.

(8) and (9) generally. Prior to amendment, par. (8) related to

determination of reasonable charges for physician services,

including factors to be considered, provision for increase or

decrease of charge, consideration of resource costs, accounting for

regional differences in prevailing charges, and impact of changes

in reasonable charges, and par. (9) related to notice of proposed

reasonable charges to be published in Federal Register, provision

for comments on proposed changes, and publication of final

determinations with respect to change in reasonable charges.

Subsec. (b)(12). Pub. L. 105-33, Sec. 4512(b)(2), struck out par.

(12) which read as follows:

"(12)(A) With respect to services described in clauses (i), (ii),

or (iv) of section 1395x(s)(2)(K) of this title (relating to a

physician assistants and nurse practitioners) -

"(i) payment under this part may only be made on an

assignment-related basis; and

"(ii) the prevailing charges determined under paragraph (3)

shall not exceed -

"(I) in the case of services performed as an assistant at

surgery, 65 percent of the amount that would otherwise be

recognized if performed by a physician who is serving as an

assistant at surgery, or

"(II) in other cases, the applicable percentage (as defined

in subparagraph (B)) of the prevailing charge rate determined

for such services (or, for services furnished on or after

January 1, 1992, the fee schedule amount specified in section

1395w-4 of this title) performed by physicians who are not

specialists.

"(B) In subparagraph (A)(ii)(II), the term 'applicable

percentage' means -

"(i) 75 percent in the case of services performed (other than

as an assistant at surgery) in a hospital, and

"(ii) 85 percent in the case of other services."

Subsec. (b)(19). Pub. L. 105-33, Sec. 4531(a)(2), added par.

(19).

Subsec. (h)(8). Pub. L. 105-33, Sec. 4302(b), added par. (8).

Subsec. (o). Pub. L. 105-33, Sec. 4556(a), added subsec. (o).

Subsec. (p)(1), (2). Pub. L. 105-33, Sec. 4317(a), inserted "or

practitioner specified in subsection (b)(18)(C) of this section"

after "by a physician".

Subsec. (p)(4). Pub. L. 105-33, Sec. 4317(b), added par. (4).

Subsec. (s). Pub. L. 105-33, Sec. 4315(a), added subsec. (s).

Subsec. (t). Pub. L. 105-33, Sec. 4432(b)(4), added subsec. (t).

1996 - Subsec. (c)(6). Pub. L. 104-191, Sec. 202(b)(2), added

par. (6).

Subsec. (r). Pub. L. 104-191, Sec. 221(b), inserted at end "Under

such system, the Secretary may impose appropriate fees on such

physicians to cover the costs of investigation and recertification

activities with respect to the issuance of the identifiers."

1994 - Subsec. (b)(2)(A). Pub. L. 103-432, Sec. 126(g)(9), made

technical amendment to directory language of Pub. L. 101-508, Sec.

4118(j)(2). See 1990 Amendment note below.

Subsec. (b)(2)(D). Pub. L. 103-432, Sec. 151(b)(2)(B), added

subpar. (D).

Subsec. (b)(3)(G). Pub. L. 103-432, Sec. 151(b)(1)(B)(i), which

directed striking out "and" at end of subpar. (G), could not be

executed because "and" did not appear at end of subpar. (G)

subsequent to amendment by Pub. L. 103-432, Sec. 123(c)(2). See

below.

Pub. L. 103-432, Sec. 123(c)(2), amended subpar. (G) generally.

Prior to amendment, subpar. (G) read as follows: "will provide to

each nonparticipating physician, at the beginning of each year, a

list of the physician's limiting charges established under section

1395w-4(g)(2) of this title for the year for the physicians'

services mostly commonly furnished by that physician; and".

Subsec. (b)(3)(H). Pub. L. 103-432, Sec. 151(b)(1)(B)(ii), which

directed striking out "and" at end of subpar. (H), could not be

executed because "and" does not appear at end.

Subsec. (b)(3)(I). Pub. L. 103-432, Sec. 151(b)(1)(B)(iii), added

subpar. (I).

Subsec. (b)(6)(D). Pub. L. 103-432, Sec. 125(b)(1), amended

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

follows: "payment may be made to a physician who arranges for visit

services (including emergency visits and related services) to be

provided to an individual by a second physician on an occasional,

reciprocal basis if (i) the first physician is unavailable to

provide the visit services, (ii) the individual has arranged or

seeks to receive the visit services from the first physician, (iii)

the claim form submitted to the carrier includes the second

physician's unique identifier (provided under the system

established under subsection (r) of this section) and indicates

that the claim is for such a 'covered visit service (and related

services)', and (iv) the visit services are not provided by the

second physician over a continuous period of longer than 60 days."

Subsec. (b)(12)(C). Pub. L. 103-432, Sec. 123(b)(2)(B), struck

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

"Except for deductible and coinsurance amounts applicable under

section 1395l of this title, 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 clauses (i), (ii), or (iv) of section 1395x(s)(2)(K)

of this title in violation of subparagraph (A)(i) 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. (b)(16)(B)(iii). Pub. L. 103-432, Sec. 126(a)(1), struck

out ", simple and subcutaneous" after "Partial", substituted

"injections and small joint" for "injections; small joint" and

"femoral fracture and" for "femoral fracture treatments;", struck

out "lobectomy;" after "thoracostomy;" and "enterectomy; colectomy;

cholecystectomy;" after "aneurysm repair;", substituted

"fulguration and resection" for "fulguration; transurerethral

resection", and struck out "sacral laminectomy;" before

"tympanoplasty".

Subsec. (b)(17). Pub. L. 103-432, Sec. 126(e), redesignated par.

(18), relating to payment for technical component of diagnostic

tests, as (17) and inserted ", tests specified in paragraph

(14)(C)(i)," after "diagnostic laboratory tests".

Subsec. (b)(18). Pub. L. 103-432, Sec. 126(e), redesignated par.

(18), relating to payment for technical component of diagnostic

tests, as (17).

Pub. L. 103-432, Sec. 123(b)(1), added par. (18), relating to

payment for service furnished by a practitioner described in

subpar. (C).

Subsec. (c)(1). Pub. L. 103-432, Sec. 126(h)(2), struck out

subpar. (A) designation before "Any contract entered" and struck

out subpar. (B) which read as follows: "Of the amounts appropriated

for administrative activities to carry out this part, the Secretary

shall provide payments, totaling 1 percent of the total payments to

carriers for claims processing in any fiscal year, to carriers

under this section, to reward carriers for their success in

increasing the proportion of physicians in the carrier's service

area who are participating physicians or in increasing the

proportion of total payments for physicians' services which are

payments for such services rendered by participating physicians."

Subsec. (c)(4). Pub. L. 103-432, Sec. 125(a), added par. (4).

Subsec. (c)(5). Pub. L. 103-432, Sec. 135(b)(2), added par. (5).

Subsec. (h)(7)(C). Pub. L. 103-432, Sec. 123(c)(1)(B), struck out

"shall include" before cl. (i).

Subsec. (h)(7)(D). Pub. L. 103-432, Sec. 123(c)(1)(A), (C), (D),

added subpar. (D).

Subsec. (q)(1). Pub. L. 103-432, Sec. 126(c)(1), made technical

amendment to Pub. L. 101-508, Sec. 4103(a). See 1990 Amendment note

below.

Subsec. (q)(1)(B). Pub. L. 103-432, Sec. 126(c)(2)(A),

substituted "shall, subject to clause (iv), be reduced to the

adjusted prevailing charge conversion factor for the locality

determined as follows:" for "shall be determined as follows:" in

introductory provisions.

Subsec. (q)(1)(B)(iii). Pub. L. 103-432, Sec. 126(c)(2)(B),

substituted "The adjusted prevailing charge conversion factor for"

for "Subject to clause (iv), the prevailing charge conversion

factor to be applied in".

1993 - Subsec. (b)(4)(F). Pub. L. 103-66, Sec. 13515(a)(2),

struck out subpar. (F) which related to prevailing charge or fee

schedule amount in case of professional services of health care

practitioner (other than primary care services and other than

services furnished in rural area designated as health professional

shortage area) furnished during practitioner's first through fourth

years of practice.

Subsec. (b)(13)(A). Pub. L. 103-66, Sec. 13516(a)(2)(A), added

subpar. (A) and struck out former subpar. (A) which read as

follows: "In determining the reasonable charge under paragraph (3)

of a physician for medical direction of two or more nurse

anesthetists performing, on or after April 1, 1988, and before

January 1, 1996, anesthesia services in whole or in part

concurrently, the number of base units which may be recognized with

respect to such medical direction for each concurrent procedure

(other than cataract surgery or an iridectomy) shall be reduced by

-

"(i) 10 percent, in the case of medical direction of 2 nurse

anesthetists concurrently,

"(ii) 25 percent, in the case of medical direction of 3 nurse

anesthetists concurrently, and

"(iii) 40 percent, in the case of medical direction of 4 nurse

anesthetists concurrently."

Subsec. (b)(13)(B), (C). Pub. L. 103-66, Sec. 13516(a)(2),

redesignated subpar. (C) as (B), substituted "subparagraph (A)" for

"subparagraph (A) or (B)", and struck out former subpar. (B) which

read as follows: "In determining the reasonable charge under

paragraph (3) of a physician for medical direction of two or more

nurse anesthetists performing, on or after January 1, 1989, and

before January 1, 1996, anesthesia services in whole or in part

concurrently, the number of base units which may be recognized with

respect to such medical direction for each concurrent cataract

surgery or iridectomy procedure shall be reduced by 10 percent."

Subsec. (c)(2)(B)(ii). Pub. L. 103-66, Sec. 13568(b), substituted

"period ending on or before September 30, 1993" for "period" in

subcl. (IV) and added subcl. (V).

Subsec. (c)(3)(B). Pub. L. 103-66, Sec. 13568(a), added cls. (i)

and (ii) and struck out former cls. (i) and (ii) which read as

follows:

"(i) with respect to claims received in the 3-month period

beginning July 1, 1988, 10 days, and

"(ii) with respect to claims received in the 12-month period

beginning October 1, 1988, 14 days."

Subsec. (i)(2). Pub. L. 103-66, Sec. 13517(b), substituted "; the

term" for ", and the term" and inserted before period at end "; and

the term 'nonparticipating supplier or other person' means a

supplier or other person (excluding a provider of services) that is

not a participating physician or supplier (as defined in subsection

(h)(1) of this section)".

1990 - Subsec. (b)(2)(A). Pub. L. 101-508, Sec. 4118(j)(2), as

amended by Pub. L. 103-432, Sec. 126(g)(9), substituted "section

1395w-1(e)(2)" for "section 1395w-1(f)(2)".

Subsec. (b)(3)(G). Pub. L. 101-508, Sec. 4118(f)(2)(B),

substituted "section 1395w-4(g)(2) of this title" for "subsection

(j)(1)(C) of this section".

Subsec. (b)(4)(A)(vi). Pub. L. 101-508, Sec. 4105(b)(1),

substituted "60 percent" for "50 percent".

Subsec. (b)(4)(B)(iv). Pub. L. 101-508, Sec. 4105(a)(2), added

cl. (iv).

Subsec. (b)(4)(E)(iv)(I). Pub. L. 101-508, Sec. 4118(a)(2),

substituted "the list referred to in paragraph (14)(C)(i)" for

"Table #2 in the Joint Explanatory Statement of the Committee of

Conference submitted with the Conference Report to accompany H.R.

3299 (the 'Omnibus Budget Reconciliation Act of 1989'), 101st

Congress".

Subsec. (b)(4)(E)(v). Pub. L. 101-508, Sec. 4105(a)(1), added cl.

(v).

Subsec. (b)(4)(F). Pub. L. 101-508, Sec. 4106(a)(1), amended

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

follows: "In determining the customary charges for physicians'

services furnished during a calendar year (other than primary care

services and other than services furnished in a rural area (as

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

designated, under section 254e(a)(1)(A) of this title, as a health

manpower shortage area) for which adequate actual charge data are

not available because a physician has not yet been in practice for

a sufficient period of time, the Secretary shall set a customary

charge at a level no higher than 80 percent of the prevailing

charge for a service. For the first calendar year during which the

preceding sentence no longer applies, the Secretary shall set the

customary charge at a level no higher than 85 percent of the

prevailing charge for the service."

Subsec. (b)(4)(F)(i). Pub. L. 101-597 substituted "health

professional shortage area" for "health manpower shortage area".

Pub. L. 101-508, Sec. 4106(b)(2)(A), (B), substituted

"professional services" for "physicians' services and professional

services" and "practitioner's first" for "physician's or

practitioner's first".

Subsec. (b)(4)(F)(ii)(II). Pub. L. 101-508, Sec. 4106(b)(2)(C),

substituted "practitioner" for "physician or practitioner" in two

places.

Subsec. (b)(6)(C). Pub. L. 101-508, Sec. 4155(c), substituted

"clauses (i), (ii), or (iv) of section 1395x(s)(2)(K)" for "section

1395x(s)(2)(K)".

Subsec. (b)(6)(D). Pub. L. 101-508, Sec. 4110(a), added subpar.

(D).

Subsec. (b)(12)(A). Pub. L. 101-508, Sec. 4155(c), substituted

"clauses (i), (ii), or (iv) of section 1395x(s)(2)(K)" for "section

1395x(s)(2)(K)" in introductory provisions.

Subsec. (b)(12)(A)(ii)(II). Pub. L. 101-508, Sec. 4118(f)(2)(C),

struck out ", as the case may be" after "section 1395w-4 of this

title".

Pub. L. 101-508, Sec. 4118(f)(2)(A), made technical correction to

Pub. L. 101-239, Sec. 6102(e)(4). See 1989 Amendment note below.

Subsec. (b)(12)(C). Pub. L. 101-508, Sec. 4155(c), substituted

"clauses (i), (ii), or (iv) of section 1395x(s)(2)(K)" for "section

1395x(s)(2)(K)".

Subsec. (b)(13)(A), (B). Pub. L. 101-508, Sec. 4103(b),

substituted "1996" for "1991".

Subsec. (b)(14)(A). Pub. L. 101-508, Sec. 4101(a), designated

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

Subsec. (b)(14)(B)(iii)(I). Pub. L. 101-508, Sec. 4118(a)(1)(A),

which directed amendment of subcl. (I) by substituting "practice

expense component (percent), divided by 100, specified in appendix

A (pages 187 through 194) of the Report of the Medicare and

Medicaid Health Budget Reconciliation Amendments of 1989, prepared

by the Subcommittee on Health and the Environment of the Committee

on Energy and Commerce, House of Representatives, (Committee Print

101-M, 101st Congress, 1st Session) for the service" for "practice

expense ratio for the service (specified in table #1 in the Joint

Explanatory Statement referred to in subparagraph (C)(i))", was

executed by making the substitution for "practice expense ratio for

the service (specified in Table #1 in the Joint Explanatory

Statement referred to in subparagraph (C)(i))" to reflect the

probable intent of Congress.

Subsec. (b)(14)(B)(iii)(II). Pub. L. 101-508, Sec. 4118(a)(1)(B),

substituted "practice expense component (percent), divided by 100"

for "practice expense ratio".

Subsec. (b)(14)(C)(i). Pub. L. 101-508, Sec. 4118(a)(1)(C),

substituted "procedures specified (by code and description) in the

Overvalued Procedures List for Finance Committee, Revised September

20, 1989, prepared by the Physician Payment Review Commission" for

"physicians' services specified in Table #2 in the Joint

Explanatory Statement of the Committee of Conference submitted with

the Conference Report to accompany H.R. 3299 (the 'Omnibus Budget

Reconciliation Act of 1989'), 101st Congress,".

Subsec. (b)(14)(C)(iii). Pub. L. 101-508, Sec. 4118(a)(1)(D),

which directed amendment of cl. (iii) by substituting "The

'percentage change' specified in this clause, for a physicians'

service specified in clause (i), is the percent difference (but

expressed as a positive number) specified for the service in the

list" for "The 'percent change' specified in this clause, for a

physicians' service specified in clause (i), is the percent change

specified for the service in table #2 in the Joint Explanatory

Statement", was executed by making the substitution for "The

'percent change' specified in this clause, for a physicians'

service specified in clause (i), is the percent change specified

for the service in Table #2 in the Joint Explanatory Statement" to

reflect the probable intent of Congress.

Subsec. (b)(14)(C)(iv). Pub. L. 101-508, Sec. 4118(a)(1)(E),

which directed amendment of cl. (iv) by substituting "the

Geographic Overhead Costs Index specified for the locality in table

1 of the September 1989 Supplement to the Geographic Medicare

Economic Index: Alternative Approaches (prepared by the Urban

Institute and the Center for Health Economics Research)" for "such

value specified for the locality in table #3 in the Joint

Explanatory Statement referred to in clause (i)", was executed by

making the substitution for "such value specified for the locality

in Table #3 in the Joint Explanatory Statement referred to in

clause (i)" to reflect the probable intent of Congress.

Subsec. (b)(16). Pub. L. 101-508, Sec. 4101(b), added par. (16).

Subsec. (b)(18). Pub. L. 101-508, Sec. 4108(a), added par. (18).

Subsec. (q)(1). Pub. L. 101-508, Sec. 4103(a), as amended by Pub.

L. 103-432, Sec. 126(c)(1), designated existing provisions as

subpar. (A) and added subpar. (B).

Subsec. (r). Pub. L. 101-508, Sec. 4118(i)(1), added subsec. (r).

1989 - Subsec. (b)(2)(A). Pub. L. 101-239, Sec. 6202(d)(2),

inserted at end "The Secretary may not require, as a condition of

entering into or renewing a contract under this section or under

section 1395hh of this title, that a carrier match data obtained

other than in its activities under this part with data used in the

administration of this part for purposes of identifying situations

in which section 1395y(b) of this title may apply."

Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, Sec.

202(e)(3)(C), and provided that the provisions of law amended or

repealed by such section are restored or revived as if such section

had not been enacted, see 1988 Amendment note below.

Subsec. (b)(2)(C). Pub. L. 101-239, Sec. 6114(c)(2), added

subpar. (C).

Subsec. (b)(3)(G). Pub. L. 101-239, Sec. 6102(e)(2), substituted

"limiting charges established under subsection (j)(1)(C) of this

section" for "maximum allowable actual charges (established under

subsection (j)(1)(C) of this section)".

Subsec. (b)(3)(I) to (K). Pub. L. 101-234, Sec. 201(a), repealed

Pub. L. 100-360, Secs. 201(c), 202(e)(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. (b)(3)(L). Pub. L. 101-239, Sec. 6102(b), added subpar.

(L).

Subsec. (b)(4)(A)(iv). Pub. L. 101-239, Sec. 6102(e)(3), inserted

"and before January 1, 1992," after "January 1, 1987,".

Subsec. (b)(4)(E)(iv). Pub. L. 101-239, Sec. 6107(b), added cl.

(iv).

Subsec. (b)(4)(F). Pub. L. 101-239, Sec. 6108(a)(1), inserted

"furnished during a calendar year" after "physicians' services" and

inserted at end "For the first calendar year during which the

preceding sentence no longer applies, the Secretary shall set the

customary charge at a level no higher than 85 percent of the

prevailing charge for the service."

Subsec. (b)(6)(A)(ii). Pub. L. 101-239, Sec. 6003(g)(3)(D)(ix),

inserted "rural primary care hospital," after "hospital,".

Subsec. (b)(6)(C). Pub. L. 101-239, Sec. 6114(c)(1), inserted "or

nurse practitioner" after "physician assistant".

Subsec. (b)(12)(A). Pub. L. 101-239, Sec. 6114(b), substituted

"physician assistants and nurse practitioners" for "physician

assistant acting under the supervision of a physician" in

introductory provisions.

Subsec. (b)(12)(A)(ii)(II). Pub. L. 101-239, Sec. 6102(e)(4), as

amended by Pub. L. 101-508, Sec. 4118(f)(2)(A), inserted "(or, for

services furnished on or after January 1, 1992, the fee schedule

amount specified in section 1395w-4 of this title, as the case may

be)" after "prevailing charge rate determined for such services".

Subsec. (b)(14). Pub. L. 101-239, Sec. 6104(a), added par. (14).

Subsec. (b)(15). Pub. L. 101-239, Sec. 6108(b)(1), added par.

(15).

Subsecs. (c)(1)(A), (2)(A), (3)(A), (4), (f)(3), (h)(1), (2),

(4). Pub. L. 101-234, Sec. 201(a), repealed Pub. L. 100-360, Sec.

202(c)(1)(A), (B), (e)(1), (3)(A), (4)(A), (5), 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. (j)(1)(B)(ii). Pub. L. 101-239, Sec. 6102(e)(9),

substituted "December 31, 1990." for "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. (j)(1)(C)(vii). Pub. L. 101-234, Sec. 301(b)(2), (c)(2),

amended cl. (vii) identically, substituting "according" for

"accordingly".

Subsec. (j)(1)(D)(ii)(II). Pub. L. 101-239, Sec. 6104(b)(1),

inserted "or (b)(14)(A)" after "(b)(10)(A)".

Subsec. (j)(1)(D)(ii)(IV). Pub. L. 101-239, Sec. 6108(b)(2)(A),

inserted "or (b)(15)(A)" after "subsection (b)(11)(C)(i)".

Subsec. (j)(1)(D)(iii)(II). Pub. L. 101-239, Sec. 6108(b)(2)(B),

substituted "(b)(14)(A), or (b)(15)(A)" for "or (b)(14)(A)".

Pub. L. 101-239, Sec. 6104(b)(2), substituted "(b)(11)(C)(i), or

(b)(14)(A)" for "or (b)(11)(C)(i)".

Subsec. (j)(1)(D)(v). Pub. L. 101-239, Sec. 6102(e)(9),

substituted "December 31, 1990." for "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. (j)(2). Pub. L. 101-234, Sec. 301(b)(6), (d)(3), which

directed identical amendments to subsec. (j)(2) by substituting

"subsections" for "paragraphs" in subpar. (B) as amended by section

8(c)(2)(A) of the Medicare and Medicaid Fraud and Abuse Patient

Protection Act of 1987 [probably meaning section 8(c)(2)(A) of Pub.

L. 100-93, the Medicare and Medicaid Patient and Program Protection

Act of 1987, which amended subpar. (A) of subsec. (j)(2),

generally] could not be executed because the word "paragraphs" did

not appear.

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

100-360, Sec. 202(c)(1)(C), and provided that the provisions of law

amended or repealed by such section are restored or revived as if

such section had not been enacted, see 1988 Amendment note below.

Subsec. (q). Pub. L. 101-239, Sec. 6106(a), added subsec. (q).

1988 - Subsec. (b)(2). Pub. L. 100-360, Sec. 411(i)(2), amended

Pub. L. 100-203, Sec. 4082(c), see 1987 Amendment note below.

Subsec. (b)(2)(A). Pub. L. 100-485, Sec. 608(d)(5)(G), inserted

", including claims processing functions" after "and related

functions" in last sentence.

Pub. L. 100-360, Sec. 411(f)(1)(B), inserted reference to section

1395w-1(f)(2) of this title in third sentence.

Pub. L. 100-360, Sec. 202(e)(3)(C), as amended by Pub. L.

100-485, Sec. 608(d)(5)(F), inserted at end "With respect to

activities relating to implementation and operation (and related

functions) of the electronic system established under subsection

(o)(4) of this section, the Secretary may enter into contracts with

carriers under this section to perform such activities on a

regional basis."

Subsec. (b)(3). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), added

Pub. L. 100-203, Sec. 4085(i)(24), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(f)(4)(B)(ii), added Pub. L. 100-203,

Sec. 4045(c)(2)(D), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(f)(11)(A), (14), renumbered and amended

Pub. L. 100-203, Sec. 4053(a), see 1987 Amendment note below.

Subsec. (b)(3)(B)(ii). Pub. L. 100-360, Sec. 411(j)(4)(A), made

technical correction to directory language of Pub. L. 100-203, Sec.

4096(a)(1)(A), see 1987 Amendment note below.

Subsec. (b)(3)(I). Pub. L. 100-360, Sec. 201(c), added subpar.

(I) requiring notice that an individual has reached the part B

catastrophic limit on out-of-pocket cost sharing for the year.

Subsec. (b)(3)(J). Pub. L. 100-360, Sec. 202(e)(2), added subpar.

(J) relating to requirements for determinations or payments with

respect to covered outpatient drugs, to receive information and

respond to requests by participating pharmacies.

Subsec. (b)(3)(K). Pub. L. 100-485, Sec. 608(d)(5)(C), inserted

", including claims processing functions," after "and for related

functions".

Pub. L. 100-360, Sec. 202(e)(2), added subpar. (K) requiring

contracts with organizations described in subsection (f)(3) of this

section to implement and operate the electronic system established

under subsection (o)(4) of this section for covered outpatient

drugs.

Subsec. (b)(4)(A)(iv). Pub. L. 100-360, Sec. 411(f)(2)(F)(i), as

amended by Pub. L. 100-485, Sec. 608(d)(21)(B), redesignated and

amended Pub. L. 100-203, Sec. 4042(c)(1), see 1987 Amendment note

below.

Subsec. (b)(4)(A)(iv)(II). Pub. L. 100-360, Sec. 411(f)(2)(E),

substituted "before January 1, 1989" for "before January 1, 1988".

Subsec. (b)(4)(A)(vi). Pub. L. 100-360, Sec. 411(f)(3)(A), made

technical amendment to directory language of Pub. L. 100-203, Sec.

4044(a), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(f)(3)(B), substituted "subsection

(i)(4) of this section" for "subparagraph (E)(iii)" and "the

estimated average prevailing charge levels based on the best

available data" for "the average of the prevailing charge levels"

and struck out "for participating physicians" before "under the

third".

Subsec. (b)(4)(A)(vii). Pub. L. 100-360, Sec. 411(f)(2)(D), added

Pub. L. 100-203, Sec. 4042(b)(2)(A), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(f)(3)(A), made technical amendment to

directory language of Pub. L. 100-203, Sec. 4044(a), see 1987

Amendment note below.

Subsec. (b)(4)(E). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub.

L. 100-203, Sec. 4042(b)(1)(C), (D), see 1987 Amendment notes

below.

Subsec. (b)(4)(F). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub.

L. 100-203, Sec. 4042(b)(1)(D), see 1987 Amendment note below.

Subsec. (b)(4)(F)(ii)(I). Pub. L. 100-360, Sec. 411(f)(2)(B),

substituted "subsection (i)(4) of this section" for "subparagraph

(E)(iii)".

Subsec. (b)(4)(F)(iii). Pub. L. 100-360, Sec. 411(f)(2)(A),

substituted "services," for "services;" in subcl. (I) and

"physicians' " for "physician's" in subcl. (II).

Subsec. (b)(4)(G). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub.

L. 100-203, Sec. 4042(b)(1)(D), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 411(f)(6)(B), substituted "other than

primary care services" for "other primary care services" and struck

out "(as determined under the third and fourth sentences of

paragraph (3) and under paragraph (4))" after "the prevailing

charge".

Subsec. (b)(7)(B)(iii). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi),

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

below.

Subsec. (b)(10)(A)(i). Pub. L. 100-360, Sec. 411(f)(4)(A)(i),

struck out "under paragraph (3)" after "reasonable charge",

substituted "subparagraph (B)" for "subparagraph (C)", and struck

out "for participating and nonparticipating physicians" after

"charge for such procedure".

Subsec. (b)(10)(A)(iii). Pub. L. 100-360, Sec. 411(f)(4)(A)(ii),

substituted "clause (i)(I)" for "clause (i)(II)".

Subsec. (b)(10)(B). Pub. L. 100-360, Sec. 411(f)(4)(A)(iii),

inserted "(including subsequent insertion of an intraocular lens)"

after "cataract surgery".

Subsec. (b)(10)(D). Pub. L. 100-360, Sec. 411(f)(4)(A)(iv),

substituted "under section 1395ff" for "section 1395ff".

Subsec. (b)(11)(B)(i). Pub. L. 100-360, Sec. 411(f)(4)(B)(i),

amended Pub. L. 100-203, Sec. 4045(c)(2)(B), see 1987 Amendment

note below.

Subsec. (b)(11)(C)(i). Pub. L. 100-360, Sec. 411(f)(5)(A),

substituted "insertion" for "implantation".

Subsec. (b)(11)(C)(ii). Pub. L. 100-360, Sec. 411(g)(2)(A),

substituted "inserted during or subsequent to" for "implanted

during".

Subsec. (b)(12)(C). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), added

Pub. L. 100-203, Sec. 4085(i)(25), see 1987 Amendment note below.

Subsec. (b)(13), (14). Pub. L. 100-360, Sec. 411(f)(7)(A),

redesignated par. (14) as (13).

Subsec. (c)(1)(A). Pub. L. 100-360, Sec. 202(e)(3)(A), designated

existing provisions as cl. (i), inserted ", except as provided in

clause (ii)," after "under this part, and" and added cl. (ii)

relating to payment for implementation and operation of the

electronic system for covered outpatient drugs.

Subsec. (c)(1)(A)(ii). Pub. L. 100-485, Sec. 608(d)(5)(D),

inserted ", including claims processing functions" after "and

related functions".

Subsec. (c)(2)(A), (3)(A). Pub. L. 100-360, Sec. 202(e)(5)(A), as

amended by Pub. L. 100-485, Sec. 608(d)(5)(H), substituted "Except

as provided in paragraph (4), each" for "Each".

Subsec. (c)(4). Pub. L. 100-360, Sec. 202(e)(5)(B), added par.

(4) requiring contracts for the disbursement of funds with respect

to claims for payment for covered outpatient drugs to provide for a

payment cycle, and requiring interest if such requirements are not

met.

Subsec. (f)(3). Pub. L. 100-485, Sec. 608(d)(5)(B), inserted ",

including claims processing functions" after "and related

functions".

Pub. L. 100-360, Sec. 202(e)(1), added par. (3) which read as

follows: "with respect to implementation and operation (and related

functions) of the electronic system established under subsection

(o)(4) of this section, a voluntary association, corporation,

partnership, or other nongovernmental organization, which the

Secretary determines to be qualified to conduct such activities."

Subsec. (h)(1). Pub. L. 100-360, Sec. 202(c)(1)(A), inserted ",

except that, with respect to a supplier of covered outpatient

drugs, the term 'participating supplier' means a participating

pharmacy (as defined in subsection (o)(1) of this section)" after

"part during such year".

Subsec. (h)(2). Pub. L. 100-360, Sec. 202(e)(4)(A), inserted

"(other than a carrier described in subsection (f)(3) of this

section)" after "Each carrier".

Subsec. (h)(3)(B). Pub. L. 100-360, Sec. 411(i)(1)(A),

substituted "payment determination" for "claims determination",

"shall include an explanation of benefits and any additional

information that the Secretary may determine to be appropriate in

order" for "including such information as the Secretary determines

is generally provided", "enter into agreements" for "enter into

arrangements", and "under this subparagraph by a carrier" for

"under this subparagraph" and inserted ", and such user fees shall

be collected and retained by the carrier".

Subsec. (h)(4). Pub. L. 100-360, Sec. 202(c)(1)(B), inserted at

end "In publishing directories under this paragraph, the Secretary

shall provide for separate directories (wherever appropriate) for

participating pharmacies."

Subsec. (h)(5). Pub. L. 100-360, Sec. 223(b), designated existing

provisions as subpar. (A), inserted "through an annual mailing",

struck out at end "The Secretary shall include such notice in the

mailing of appropriate benefit checks provided under subchapter II

of this chapter.", and added subpar. (B).

Subsec. (h)(7). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L.

100-203, Sec. 4042(b)(1)(A), see 1987 Amendment note below.

Pub. L. 100-360, Sec. 223(c), in subpar. (A) inserted "prominent"

before "reminder" and substituted "and a clear statement of any

amounts charged for the particular items or services on the claim

involved above the amount recognized under this part)," for "7E),

and" and added subpar. (C).

Subsec. (h)(8). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L.

100-203, Sec. 4042(b)(1)(B), see 1987 Amendment note below.

Subsec. (i). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L.

100-203, Sec. 4042(b)(1)(B), see 1987 Amendment note below.

Subsec. (i)(2), (3). Pub. L. 100-360, Sec. 411(f)(2)(C), added

Pub. L. 100-203, Sec. 4042(b)(1)(C), see 1987 Amendment note below.

Subsec. (i)(3). Pub. L. 100-485, Sec. 608(d)(21)(A), substituted

"subsection (b)(3) of this section" for "paragraph (3)".

Subsec. (i)(4). Pub. L. 100-360, Sec. 411(f)(2)(C), added Pub. L.

100-203, Sec. 4042(b)(1)(E), see 1987 Amendment note below.

Subsec. (j)(1)(C)(i). Pub. L. 100-360, Sec. 411(f)(2)(F)(ii),

added Pub. L. 100-203, Sec. 4042(c)(2), see 1987 Amendment note

below.

Subsec. (j)(1)(C)(viii). Pub. L. 100-360, Sec. 411(f)(1)(A),

amended Pub. L. 100-203, Sec. 4041(a)(1)(B), see 1987 Amendment

note below.

Subsec. (j)(1)(C)(ix). Pub. L. 100-360, Sec. 411(f)(7)(B), added

Pub. L. 100-203, Sec. 4048(e), see 1987 Amendment note below.

Subsec. (j)(1)(D)(ii)(IV). Pub. L. 100-360, Sec. 411(f)(5)(B),

struck out "is" after "limit".

Subsec. (j)(1)(D)(ii)(V). Pub. L. 100-360, Sec. 411(g)(2)(B),

redesignated subcl. (IV) as (V) and struck out "is" after "limit".

Subsec. (j)(1)(D)(iii). Pub. L. 100-360, Sec. 411(g)(2)(C),

amended Pub. L. 100-203, Sec. 4063(a)(2)(B), see 1987 Amendment

note below.

Subsec. (j)(1)(D)(iv). Pub. L. 100-360, Sec. 411(f)(4)(C),

substituted "bills" for "imposes a charge".

Subsec. (j)(2). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), as

amended by Pub. L. 100-485, Sec. 608(d)(24)(B), added Pub. L.

100-203, Sec. 4085(i)(26), see 1987 Amendment note below.

Subsec. (l)(1)(C)(i). Pub. L. 100-360, Sec. 411(i)(4)(C)(vi),

added Pub. L. 100-203, Sec. 4085(i)(27), see 1987 Amendment note

below.

Subsec. (n)(1). Pub. L. 100-360, Sec. 411(f)(9)(A), in

introductory provisions, struck out "to a patient" after "includes

a charge", inserted "the bill or request for" after "for which",

and substituted "shares a practice" for "shares his practice" and

"supervised the performance of the test, the" for "supervised the

test, the".

Subsec. (n)(1)(A). Pub. L. 100-485, Sec. 608(d)(17), substituted

"the supplier's" for "the the supplier's".

Pub. L. 100-360, Sec. 411(f)(9)(B), as amended by Pub. L.

100-485, Sec. 608(d)(21)(D), substituted "(or other applicable

limit)" for "to individuals enrolled under this part".

Pub. L. 100-360, Sec. 411(a)(3)(A), (C)(i), clarified that

illegible matter after "or, if lower, the" was "the supplier's

reasonable charge to individuals enrolled under this part for the

test".

Subsec. (n)(2)(A). Pub. L. 100-360, Sec. 411(f)(9)(C), inserted

"the payment amount specified in paragraph (1)(A) and" after "other

than".

Subsec. (n)(3). Pub. L. 100-360, Sec. 411(f)(9)(D), struck out

"or supplier" after "such physician".

Subsec. (o). Pub. L. 100-360, Sec. 202(c)(1)(C), added subsec.

(o) relating to "participating pharmacies" as entities authorized

under State law to dispense covered outpatient drugs which had

entered into agreements with Secretary to participate in

catastrophic coverage program.

Subsec. (o)(1)(A)(i). Pub. L. 100-485, Sec. 608(d)(5)(A)(i),

substituted "paragraph (4)" for "subparagraph (D)(i)".

Subsec. (o)(1)(B)(ii). Pub. L. 100-485, Sec. 608(d)(5)(A)(ii),

substituted "an eligible organization" for "eligible organization".

Subsec. (p). Pub. L. 100-360, Sec. 202(g), added subsec. (p).

1987 - Subsec. (b)(2). Pub. L. 100-203, Sec. 4082(c), as amended

by Pub. L. 100-360, Sec. 411(i)(2), designated existing provisions

as subpar. (A) and added subpar. (B).

Pub. L. 100-203, Sec. 4041(a)(3)(A)(i), inserted at end "In

establishing such standards and criteria, the Secretary shall

provide a system to measure a carrier's performance of

responsibilities described in paragraph (3)(H) and subsection (h)

of this section."

Subsec. (b)(3). Pub. L. 100-203, Sec. 4085(i)(24), as added by

Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), substituted "In the case of

physicians' services" for "In the case of physician services" and

"(with respect to physicians' services" for "(with respect to

physicians services" in fourth sentence.

Pub. L. 100-203, Sec. 4045(c)(2)(D), as added by Pub. L. 100-360,

Sec. 411(f)(4)(B)(ii), inserted "(or under any other provision of

law affecting the prevailing charge level)" in fourth sentence.

Pub. L. 100-203, Sec. 4053(a), formerly Sec. 4052(a), as

renumbered and amended by Pub. L. 100-360, Sec. 411(f)(11)(A),

(14), inserted ", and shall remain at such prevailing charge level

until the prevailing charge for a year (as adjusted by economic

index data) equals or exceeds such prevailing charge level" before

period at end of penultimate sentence.

Subsec. (b)(3)(B)(ii). Pub. L. 100-203, Sec. 4096(a)(1)(A), as

amended by Pub. L. 100-360, Sec. 411(j)(4)(A), added subcl. (II),

redesignated former subcl. (II) as (III), and inserted "(and to

refund amounts already collected)".

Subsec. (b)(3)(C). Pub. L. 100-203, Sec. 4085(i)(5), substituted

"less than $500" for "not more than $500".

Subsec. (b)(4)(A)(iv). Pub. L. 100-203, Sec. 4042(c)(1), formerly

Sec. 4042(c), as redesignated and amended by Pub. L. 100-360, Sec.

411(f)(2)(F)(i), and by Pub. L. 100-485, Sec. 608(d)(21)(B),

amended cl. (iv) generally. Prior to amendment, cl. (iv) read as

follows: "In determining the prevailing charge level under the

third and fourth sentences of paragraph (3) for a physicians'

service furnished on or after January 1, 1987, by a

nonparticipating physician, the Secretary shall set the level at 96

percent of the prevailing charge levels established under such

sentences with respect to such service furnished by participating

physicians."

Subsec. (b)(4)(A)(v). Pub. L. 100-203, Sec. 4041(a)(1)(A)(i),

added cl. (v). Former cl. (v) redesignated (vi).

Subsec. (b)(4)(A)(vi). Pub. L. 100-203, Sec. 4044(a), as amended

by Pub. L. 100-360, Sec. 411(f)(3)(A), added cl. (vi). Former cl.

(vi) redesignated (vii).

Pub. L. 100-203, Sec. 4041(a)(1)(A)(i), redesignated former cl.

(v) as (vi).

Subsec. (b)(4)(A)(vii). Pub. L. 100-203, Sec. 4042(b)(2)(A), as

added by Pub. L. 100-360, Sec. 411(f)(2)(D), substituted

"subsection (i)(3) of this section" for "subparagraph (E)(ii)".

Pub. L. 100-203, Sec. 4044(a), as amended by Pub. L. 100-360,

Sec. 411(f)(3)(A), redesignated former cl. (vi) as (vii).

Subsec. (b)(4)(B)(iii). Pub. L. 100-203, Sec. 4041(a)(1)(A)(ii),

added cl. (iii).

Subsec. (b)(4)(E). Pub. L. 100-203, Sec. 4042(b)(1)(D), as added

by Pub. L. 100-360, Sec. 411(f)(2)(C), redesignated subpar. (F) as

(E). Former subpar. (E) transferred to subsec. (i).

Pub. L. 100-203, Sec. 4042(b)(1)(C), as added by Pub. L. 100-360,

Sec. 411(f)(2)(C), struck out "(E) In this section:" before cl.

(i), redesignated cls. (i) and (ii) as pars. (2) and (3),

respectively, and transferred those pars. to subsec. (i).

Subsec. (b)(4)(F). Pub. L. 100-203, Sec. 4042(b)(1)(D), as added

by Pub. L. 100-360, Sec. 411(f)(2)(C), redesignated subpar. (G) as

(F). Former subpar. (F) redesignated (E).

Pub. L. 100-203, Sec. 4042(a), added subpar. (F).

Subsec. (b)(4)(G). Pub. L. 100-203, Sec. 4042(b)(1)(D), as added

by Pub. L. 100-360, Sec. 411(f)(2)(C), redesignated subpar. (G) as

(F).

Pub. L. 100-203, Sec. 4047(a), added subpar. (G).

Subsec. (b)(7)(B)(iii). Pub. L. 100-203, Sec. 4085(i)(22)(C), as

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

assignment-related basis" for "the basis of an assignment described

in paragraph (3)(B)(ii) or under the procedure described in section

1395gg(f)(1) of this title".

Subsec. (b)(10). Pub. L. 100-203, Sec. 4045(a), amended par. (10)

generally, revising and restating as subpars. (A) to (D) provisions

of former subpars. (A) to (C).

Subsec. (b)(11)(B)(i). Pub. L. 100-203, Sec. 4045(c)(2)(B), as

amended by Pub. L. 100-360, Sec. 411(f)(4)(B)(i), struck out "and

shall be further reduced by 2 percent with respect to procedures

performed in 1988" after "in 1987" and struck out second sentence

which read as follows: "A reduced prevailing charge under this

subparagraph shall become the prevailing charge level for

subsequent years for purposes of applying the economic index under

the fourth sentence of paragraph (3)."

Subsec. (b)(11)(C). Pub. L. 100-203, Sec. 4063(a)(1)(A),

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

Pub. L. 100-203, Sec. 4046(a)(1)(B), (C), added subpar. (C) and

redesignated former subpar. (C) as (D).

Pub. L. 100-203, Sec. 4045(c)(1)(A), struck out former cl. (i)

designation before "In the case of" and substituted ", the

physician's actual charge is subject to a limit under subsection

(j)(1)(D) of this section." for "(subject to clause (iv)), the

physician may not charge the individual more than the limiting

charge (as defined in clause (ii)) 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.", and struck out former cls. (ii) to (iv)

which read as follows:

"(ii) In clause (i), 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 clause (i).

"(iii) If a physician knowingly and willfully imposes charges in

violation of clause (i), the Secretary may apply sanctions against

such physician in accordance with subsection (j)(2) of this

section.

"(iv) This subparagraph 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. (b)(11)(D). Pub. L. 100-203, Sec. 4063(a)(1)(B), which

directed that subpar. (D) be amended by inserting "or item" after

"service" or "services" each place either appears, was executed by

inserting "or item" after "service" wherever appearing. The word

"services" does not appear because of a prior amendment by section

4045(c)(1)(A) of Pub. L. 100-203 to subpar. (D), formerly (C), see

above.

Pub. L. 100-203, Sec. 4046(a)(1)(A), (B), redesignated former

subpar. (C) as (D) and substituted "subparagraph (B) or (C)" for

"subparagraph (B)".

Subsec. (b)(12)(C). Pub. L. 100-203, Sec. 4085(i)(25), 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. (b)(14). Pub. L. 100-203, Sec. 4048(a), added par. (14).

Subsec. (c)(1). Pub. L. 100-203, Sec. 4041(a)(3)(A)(ii),

designated existing provisions as subpar. (A) and added subpar.

(B).

Pub. L. 100-203, Sec. 4035(a)(2), inserted at end "The Secretary

shall cause to have published in the Federal Register, by not later

than September 1 before each fiscal year, data, standards, and

methodology to be used to establish budgets for carriers under this

section for that fiscal year, and shall cause to be published in

the Federal Register for public comment, at least 90 days before

such data, standards, and methodology are published, the data,

standards, and methodology proposed to be used."

Subsec. (c)(3). Pub. L. 100-203, Sec. 4031(a)(2), added par. (3).

Subsec. (h)(3). Pub. L. 100-203, Sec. 4081(a), designated

existing provisions as subpar. (A) and added subpar. (B).

Subsec. (h)(5). Pub. L. 100-203, Sec. 4085(i)(6), substituted

"the participation program" for "the the participation program".

Subsec. (h)(7). Pub. L. 100-203, Sec. 4042(b)(1)(A), as added by

Pub. L. 100-360, Sec. 411(f)(2)(C), struck out ", described in

paragraph (8)" after "assignment-related basis" in introductory

provisions.

Subsec. (h)(8). Pub. L. 100-203, Sec. 4042(b)(1)(B), as added by

Pub. L. 100-360, Sec. 411(f)(2)(C), substituted "(1) A" for "(8)

For purposes of this subchapter, a", indented such par. 2 ems, and

inserted subsec. (i) designation and "For purposes of this

subchapter:", effectively transferring former subsec. (h)(8) to

subsec. (i).

Subsec. (i). Pub. L. 100-203, Sec. 4042(b)(1)(B), as added by

Pub. L. 100-360, Sec. 411(f)(2)(C), transferred introductory

provisions and par. (1) from former subsec. (h)(8).

Subsec. (i)(2), (3). Pub. L. 100-203, Sec. 4042(b)(1)(C), as

added by Pub. L. 100-360, Sec. 411(f)(2)(C), transferred pars. (2)

and (3) from subsec. (b)(4)(E).

Subsec. (i)(4). Pub. L. 100-203, Sec. 4042(b)(1)(E), as added by

Pub. L. 100-360, Sec. 411(f)(2)(C), added par. (4).

Subsec. (j)(1)(B)(i). Pub. L. 100-203, Sec. 4054(a)(1), (2),

formerly Sec. 4053(a)(1), (2), as renumbered by Pub. L. 100-360,

Sec. 411(f)(14), substituted "the actual charges of each such

physician" for "each such physician's actual charges" and "on a

repeated basis for such a service an actual charge" for "for such a

service a physician's actual charge (as defined in subparagraph

(C)(vi)".

Subsec. (j)(1)(C)(i). Pub. L. 100-203, Sec. 4085(i)(7)(A),

inserted "maximum allowable" after "If the physician's".

Pub. L. 100-203, Sec. 4042(c)(2), as added by Pub. L. 100-360,

Sec. 411(f)(2)(F)(ii), substituted "applicable percent (as defined

in subsection (b)(4)(A)(iv) of this section) of the prevailing

charge for the year and service involved" for "prevailing charge

for the year involved for such service furnished by

nonparticipating physicians" in subcls. (I) and (II).

Subsec. (j)(1)(C)(v). Pub. L. 100-203, Sec. 4085(i)(7)(B),

substituted "1986" for "1987".

Subsec. (j)(1)(C)(vi). Pub. L. 100-203, Sec. 4054(a)(3), formerly

Sec. 4053(a)(3), as renumbered by Pub. L. 100-360, Sec. 411(f)(14),

struck out "and subparagraph (B)" after "purposes of this

subparagraph".

Subsec. (j)(1)(C)(vii). Pub. L. 100-203, Sec. 4085(i)(7)(C),

added cl. (vii).

Subsec. (j)(1)(C)(viii). Pub. L. 100-203, Sec. 4041(a)(1)(B), as

amended by Pub. L. 100-360, Sec. 411(f)(1)(A), added cl. (viii).

Subsec. (j)(1)(C)(ix). Pub. L. 100-203, Sec. 4048(e), as added by

Pub. L. 100-360, Sec. 411(f)(7)(B), added cl. (ix).

Subsec. (j)(1)(D). Pub. L. 100-203, Sec. 4045(c)(1)(B), added

subpar. (D).

Subsec. (j)(1)(D)(ii)(IV). Pub. L. 100-203, Sec. 4063(a)(2)(A),

added subcl. (IV) relating to establishment of reasonable charge

limit under subsec. (b)(11)(C)(ii) of this section.

Pub. L. 100-203, Sec. 4046(a)(2)(A), added subcl. (IV) relating

to establishment of prevailing charge limit under subsec.

(b)(11)(C)(i) of this section. Former subcl. (IV) redesignated (V).

Subsec. (j)(1)(D)(ii)(V), (VI). Pub. L. 100-203, Sec.

4063(a)(2)(A), redesignated former subcl. (V) as (VI).

Pub. L. 100-203, Sec. 4046(a)(2)(A), redesignated former subcl.

(IV) as (V).

Subsec. (j)(1)(D)(iii). Pub. L. 100-203, Sec. 4063(a)(2)(B), as

amended by Pub. L. 100-360, Sec. 411(g)(2)(C), struck out "or" at

end of subcl. (I), substituted "; or" for period at end of subcl.

(II), and added subcl. (III).

Pub. L. 100-203, Sec. 4046(a)(2)(B), substituted ", (b)(11)(B),

or (b)(11)(C)(i)" for "or (b)(11)(B)" in subcl. (II).

Subsec. (j)(2). Pub. L. 100-203, Sec. 4085(i)(26), as added by

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

100-485, Sec. 608(d)(24)(B), substituted "chapter" for "subchapter"

in subpar. (A), struck out "the imposition of" before "civil

monetary penalties" and inserted "and assessments" in subpar. (B),

substituted "chapter" for "subchapter" in two places in last

sentence, and amended last sentence generally. Prior to amendment,

last sentence read as follows: "No payment may be made under this

chapter with respect to any item or service furnished by a

physician during the period when he is excluded from participation

in the programs under this chapter pursuant to this subsection."

Pub. L. 100-93, Sec. 8(c)(2)(A), amended subpar. (A) generally

and substituted "excluded from participation in the programs" for

"barred from participation in the program" in last sentence. Prior

to amendment, subpar. (A) read as follows: "barring a physician

from participation under the program under this subchapter for a

period not to exceed 5 years, in accordance with the procedures of

paragraphs (2) and (3) of section 1395y(d) of this title, or".

Subsec. (j)(3)(A). Pub. L. 100-93, Sec. 8(c)(2)(B), substituted

"exclude" for "bar".

Subsec. (k)(1), (2). Pub. L. 100-203, Sec. 4085(g)(1),

substituted "subsection (j)(2) of this section in the case of

surgery performed on or after March 1, 1987" for "subsection (j)(2)

of this section".

Subsec. (l)(1)(A)(iii). Pub. L. 100-203, Sec. 4096(a)(1)(B),

designated existing provisions as subcl. (I) and added subcl. (II).

Subsec. (l)(1)(C). Pub. L. 100-203, Sec. 4096(a)(1)(C), inserted

"in the case described in subparagraph (A)(iii)(I)" after "to an

individual" in introductory provisions.

Subsec. (l)(1)(C)(i). Pub. L. 100-203, Sec. 4085(i)(27), as added

by Pub. L. 100-360, Sec. 411(i)(4)(C)(vi), inserted "the physician

establishes that" after "(i)".

Subsec. (n). Pub. L. 100-203, Sec. 4051(a), added subsec. (n).

1986 - Subsec. (b)(3). Pub. L. 99-509, Sec. 9331(c)(3)(A),

inserted "or (with respect to physicians services furnished in a

year after 1987) the level determined under this sentence for the

previous year" after "ending June 30, 1973," and "year-to-year"

before "economic changes" in fourth sentence.

Pub. L. 99-272, Sec. 9301(d)(1)(B), (C), substituted "June 30

last preceding the start of the calendar year" for "March 31 last

preceding the start of the twelve-month period (beginning October 1

of each year)" in third sentence, and struck out "the twelve-month

period beginning on October 1 in" before "any calendar year after

1974" in eighth sentence.

Subsec. (b)(3)(C). Pub. L. 99-509, Sec. 9341(a)(2), substituted

"at least $100, but not more than $500" for "$100 or more".

Subsec. (b)(3)(F). Pub. L. 99-272, Sec. 9301(d)(1)(A), struck out

"(ending on September 30)" after "before the year".

Subsec. (b)(3)(G). Pub. L. 99-509, Sec. 9331(b)(2), added subpar.

(G).

Subsec. (b)(3)(H). Pub. L. 99-509, Sec. 9332(a)(1), added subpar.

(H).

Subsec. (b)(4)(A)(i), (ii). Pub. L. 99-272, Sec. 9301(b)(1)(A),

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

Subsec. (b)(4)(A)(iii). Pub. L. 99-509, Sec. 9331(a)(1), added

cl. (iii) and struck out former cl. (iii) which read as follows:

"In determining the prevailing charge levels under the third and

fourth sentences of paragraph (3) for physicians' services

furnished during a 12-month period beginning on or after January 1,

1987, by a physician who is not a participating physician (as

defined in subsection (h)(1) of this section) at the time of

furnishing the services, the Secretary shall not set any level

higher than the same level as was set for services furnished during

the previous calendar year (without regard to clause (ii)(II)) for

physicians who were participating physicians during that year."

Pub. L. 99-272, Sec. 9301(b)(1)(A)(ii), added cl. (iii).

Subsec. (b)(4)(A)(iv), (v). Pub. L. 99-509, Sec. 9331(a)(1),

added cls. (iv) and (v).

Subsec. (b)(4)(B). Pub. L. 99-272, Sec. 9301(b)(1)(B), designated

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

Subsec. (b)(4)(C). Pub. L. 99-509, Sec. 9331(a)(2), directed

amendment of subpar. (C) by striking out "(i)" after "(C)" and

striking out cl. (ii), applicable to services furnished on or after

Jan. 1, 1987, which is identical to amendment by Pub. L. 99-514,

Sec. 1895(b)(14)(A), as amended, effective as if included in

enactment of Pub. L. 99-272.

Pub. L. 99-514, Sec. 1895(b)(14)(A), as amended by Pub. L.

99-509, Sec. 9307(c)(2)(A), struck out cl. (i) designation, and

struck out cl. (ii) which read as follows: "In determining the

prevailing charge levels under the third and fourth sentences of

paragraph (3) for physicians' services furnished during the periods

beginning after December 31, 1986, by a physician who was not a

participating physician on that date, the Secretary shall treat the

level as set under subparagraph (A)(ii) as having fully provided

for the economic changes which would have been taken into account

but for the limitations contained in subparagraph (A)(ii)."

Pub. L. 99-272, Sec. 9301(b)(1)(C), designated existing

provisions as cl. (i), substituted "subparagraph (A)(i)" for

"subparagraph (A)" wherever appearing, and added cl. (ii).

Subsec. (b)(4)(D)(i) to (iii). Pub. L. 99-272, Sec.

9301(b)(1)(D), designated existing provisions as cl. (i),

substituted "In determining the customary charges for physicians'

services furnished during the 8-month period beginning May 1, 1986,

or the 12-month period beginning January 1, 1987, by a physician

who was not a participating physician (as defined in subsection

(h)(1) of this section) on September 30, 1985" for "In determining

the customary charges for physicians' services furnished during the

12-month period beginning October 1, 1985, or October 1, 1986, by a

physician who at no time for any services furnished during the

12-month period beginning October 1, 1984, was a participating

physician (as defined in subsection (h)(1) of this section)", and

added cls. (ii) and (iii).

Subsec. (b)(4)(D)(iv). Pub. L. 99-509, Sec. 9331(b)(3), added cl.

(iv).

Subsec. (b)(4)(E). Pub. L. 99-509, Sec. 9331(a)(3), added subpar.

(E).

Subsec. (b)(6). Pub. L. 99-509, Sec. 9338(c), substituted "except

that (A) payment may be made (i)" for "except that payment may be

made (A)(i)", substituted "(B) payment may be made" for "or (B)",

and inserted before the period at end ", and (C) in the case of

services described in section 1395x(s)(2)(K) of this title payment

shall be made to the employer of the physician assistant involved".

Subsec. (b)(7)(B)(ii)(III). Pub. L. 99-272, Sec. 9219(b)(1)(A),

realigned margin of subcl. (III).

Subsec. (b)(7)(B)(iii). Pub. L. 99-272, Sec. 9219(b)(2)(A),

realigned margin of cl. (iii).

Subsec. (b)(8). Pub. L. 99-509, Sec. 9333(a), designated existing

provisions as subpar. (A), redesignated former subpars. (A) and (B)

as cls. (i) and (ii), respectively, and added subpars. (B) and (C).

Pub. L. 99-272, Sec. 9304(a), added par. (8).

Subsec. (b)(9). Pub. L. 99-509, Sec. 9333(b), added par. (9).

Former par. (9) redesignated (11).

Pub. L. 99-272, Sec. 9306(a), added par. (9).

Subsec. (b)(10). Pub. L. 99-509, Sec. 9333(b), added par. (10).

Subsec. (b)(11). Pub. L. 99-509, Sec. 9334(a), designated

existing provisions as subpar. (A), redesignated former subpars.

(A) and (B) as cls. (i) and (ii), respectively, and added subpars.

(B) and (C).

Pub. L. 99-509, Sec. 9333(b), redesignated former par. (9) as

(11).

Subsec. (b)(12). Pub. L. 99-509, Sec. 9338(b), added par. (12).

Subsec. (c). Pub. L. 99-509, Sec. 9311(c), designated existing

provisions as par. (1) and added par. (2).

Subsec. (h)(1). Pub. L. 99-272, Sec. 9301(d)(2), substituted

"before the beginning of any year beginning with 1984" for "before

October 1 of any year beginning with 1984", "on an

assignment-related basis" for "on the basis of an assignment

described in subsection (b)(3)(B)(ii) of this section, in

accordance with subsection (b)(6)(B) of this section, or under the

procedure described in section 1395gg(f)(1) of this title", "during

such year" for "during the 12-month period beginning on October 1

of such year", "after the beginning of a year" for "after October 1

of a year", and "during the remainder of the year" for "during the

remainder of the 12-month period beginning on such October 1".

Subsec. (h)(2). Pub. L. 99-509, Sec. 9332(b)(1)(A), struck out

period at end and substituted "and may request a copy of an

appropriate directory published under paragraph (4). Each such

carrier shall, without charge, mail a copy of such directory upon

such a request."

Subsec. (h)(4). Pub. L. 99-509, Sec. 9332(b)(2), inserted at end

"Each participating physician directory for an area shall provide

an alphabetical listing of all participating physicians practicing

in the area and an alphabetical listing by locality and specialty

of such physicians."

Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated par. (2) of

subsec. (i) as par. (4) of this subsection.

Subsec. (h)(5). Pub. L. 99-509, Sec. 9332(b)(1)(B), substituted

"the participation program under this subsection and the

publication and availability of the directories" for "publication

of the directories" and inserted at end "The Secretary shall

include such notice in the mailing of appropriate benefit checks

provided under subchapter II of this chapter."

Pub. L. 99-514, Sec. 1895(b)(15)(A), struck out "such" before

"the directories" and before "the appropriate area directory".

Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated par. (3) of

subsec. (i) as par. (5) of this subsection.

Subsec. (h)(6). Pub. L. 99-509, Sec. 9332(b)(1)(C), inserted

before period at end of second sentence "and that an appropriate

number of copies of each such directory is sent to hospitals

located in the area" and inserted at end "Such copies shall be sent

free of charge."

Pub. L. 99-514, Sec. 1895(b)(15)(B), substituted "the" for "the

the" before "directories".

Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated par. (4) of

subsec. (i) as par. (6) of this subsection.

Subsec. (h)(7), (8). Pub. L. 99-272, Sec. 9301(c)(4), added pars.

(7) and (8).

Subsec. (i)(1). Pub. L. 99-272, Sec. 9301(c)(3)(A), struck out

par. (1) which required the Secretary to publish a list containing

the name, address, specialty, and percent of claims submitted with

respect to each physician and supplier during preceding year that

were paid on the basis of an assignment described in subsec.

(b)(3)(B)(ii) of this section, in accordance with subsec. (b)(6)(B)

of this section, or under procedure described in section

1395gg(f)(1) of this title.

Subsec. (i)(2). Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated

par. (2) of this subsection as par. (4) of subsec. (h).

Pub. L. 99-272, Sec. 9301(d)(3), substituted "year" for "fiscal

year", wherever appearing.

Pub. L. 99-272, Sec. 9301(c)(2)(A), (B), (3)(B), substituted

"shall publish directories (for appropriate local geographic

areas)" for "shall publish a directory", inserted "for that area"

before "for that fiscal year", substituted "Each directory shall"

for "The directory shall", and substituted "paragraph (1)" for

"subsection (h)(1) of this section".

Subsec. (i)(3). Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated

par. (3) of this subsection as par. (5) of subsec. (h).

Pub. L. 99-272, Sec. 9301(c)(2)(C), (3)(C), struck out

"directory" first place it appeared and inserted in lieu "the

directories", struck out "directory" second place it appeared and

inserted in lieu "the appropriate area directory or directories",

and struck out "list and" wherever appearing.

Subsec. (i)(4). Pub. L. 99-272, Sec. 9301(c)(3)(D), redesignated

par. (4) of this subsection as par. (6) of subsec. (h).

Pub. L. 99-272, Sec. 9301(c)(2)(D), (3)(C), struck out "list and"

after "The Secretary shall provide that the" in first sentence,

substituted "the directories shall" for "directory shall", and

inserted provision requiring the Secretary to provide that each

appropriate area directory be sent to each participating physician

located in that area.

Subsec. (j)(1). Pub. L. 99-509, Sec. 9331(b)(1), designated

existing provisions as subpar. (A) and added subpars. (B) and (C).

Pub. L. 99-272, Sec. 9301(b)(2), amended first sentence

generally. Prior to amendment, first sentence read as follows: "In

the case of a physician who is not a participating physician, the

Secretary shall monitor each such physician's actual charges to

individuals enrolled under this part for physicians' services

furnished during the 15-month period beginning July 1, 1984."

Subsec. (j)(2). Pub. L. 99-509, Sec. 9320(e)(3), substituted

"this paragraph" for "paragraph (1) or subsection (k) of this

section" in introductory text.

Pub. L. 99-272, Sec. 9307(c)(1), inserted reference to subsec.

(k) of this section in introductory text.

Subsec. (k). Pub. L. 99-514, Sec. 1895(b)(16)(A), inserted

"presents or causes to be presented a claim or" in pars. (1) and

(2).

Pub. L. 99-272, Sec. 9307(c)(2), added subsec. (k).

Subsec. (l). Pub. L. 99-509, Sec. 9332(c)(1), added subsec. (l).

Subsec. (m). Pub. L. 99-509, Sec. 9332(d)(1), added subsec. (m).

1984 - Subsec. (b)(2). Pub. L. 98-369, Sec. 2326(c)(2), inserted

at end provision that the Secretary publish in the Federal Register

standards and criteria for efficient and effective performance of

contract obligations under this section and provide an opportunity

for public comment prior to implementation.

Subsec. (b)(3). Pub. L. 98-369, Sec. 2306(b)(1)(B), (C),

substituted "during the 12-month period ending on the March 31 last

preceding" for "during the last preceding calendar year elapsing

prior to" in third sentence and substituted "October 1" for "July

1" wherever appearing in third and eighth sentences.

Pub. L. 98-369, Sec. 2354(b)(14), substituted "(I)" and "(II)"

for "(i)" and "(ii)", respectively in concluding provisions.

Pub. L. 98-369, Sec. 2663(j)(2)(F)(iv), substituted "Health and

Human Services" for "Health, Education, and Welfare" in concluding

provisions.

Subsec. (b)(3)(B)(ii)(II). Pub. L. 98-369, Sec. 2354(b)(13),

struck out the period after "subchapter".

Subsec. (b)(3)(F). Pub. L. 98-369, Sec. 2306(b)(1)(A),

substituted "September 30" for "June 30".

Subsec. (b)(4), (5). Pub. L. 98-369, Sec. 2306(a), added par. (4)

and redesignated former pars. (4) and (5) as (5) and (6),

respectively.

Subsec. (b)(6). Pub. L. 98-369, Sec. 2339, redesignated cl. (A)

as cl. (A)(i) and former cl. (B) as cl. (A)(ii), added a new cl.

(B), and in the provisions after cl. (B), substituted "clause (A)

of such sentence" for "clause (A) or (B) of such sentence".

Pub. L. 98-369, Sec. 2306(a), redesignated par. (5) as (6).

Former par. (6) redesignated (7).

Subsec. (b)(7). Pub. L. 98-369, Sec. 2306(a), redesignated par.

(6) as (7).

Subsec. (b)(7)(A). Pub. L. 98-617, Sec. 3(b)(5)(B), struck out at

end "If all the teaching physicians in a hospital agree to have

payment made for all of their physicians' services under this part

furnished patients in the hospital on the basis of an assignment

described in paragraph (3)(B)(ii) or under the procedure described

in section 1395gg(f)(1) of this title, notwithstanding clause (ii)

of this subparagraph, the carrier shall provide for payment in an

amount equal to 90 percent of the prevailing charges paid for

similar services in the same locality."

Pub. L. 98-369, Sec. 2307(a)(1), as amended by Pub. L. 98-617,

Sec. 3(a)(1), inserted "If all the teaching physicians in a

hospital agree to have payment made for all of their physicians'

services under this part furnished patients in the hospital on the

basis of an assignment described in paragraph (3)(B)(ii) or under

the procedure described in section 1395gg(f)(1) of this title,

notwithstanding clause (ii) of this subparagraph, the carrier shall

provide for payment in an amount equal to 90 percent of the

prevailing charges paid for similar services in the same locality."

at the end.

Subsec. (b)(7)(A)(ii). Pub. L. 98-617, Sec. 3(b)(5)(A),

substituted "the payment is based upon a reasonable charge for the

services in excess of the customary charge as determined in

accordance with subparagraph (B)" for "the amount of the payment

exceeds the reasonable charge for the services (with the customary

charge determined consistent with subparagraph (B))".

Subsec. (b)(7)(B)(i). Pub. L. 98-369, Sec. 2307(a)(2)(A), (B),

substituted "physician who is not a teaching physician (as defined

by the Secretary)" for "physician who has a substantial practice

outside the teaching setting" and "practice outside the teaching

setting" for "outside practice".

Subsec. (b)(7)(B)(ii). Pub. L. 98-369, Sec. 2307(a)(2)(C), (D),

substituted "In the case of a teaching physician" for "In the case

of a physician who does not have a practice described in clause

(i)" and "greatest" for "greater".

Subsec. (b)(7)(B)(ii)(III). Pub. L. 98-369, Sec.

2307(a)(2)(E)-(G), added subcl. (III).

Subsec. (b)(7)(B)(iii). Pub. L. 98-617, Sec. 3(b)(6), added cl.

(iii).

Subsec. (c). Pub. L. 98-369, Sec. 2326(d)(2), inserted provision

that the Secretary, in determining a carrier's necessary and proper

cost of administration with respect to each contract, take into

account the amount that is reasonable and adequate to meet the

costs which must be incurred by an efficiently and economically

operated carrier in carrying out the terms of its contract.

Subsec. (h). Pub. L. 98-369, Sec. 2306(c), added subsec. (h).

Pub. L. 98-369, Sec. 2303(e), struck out subsec. (h) providing

for payment for laboratory tests.

Subsecs. (i), (j). Pub. L. 98-369, Sec. 2306(c), added subsecs.

(i) and (j).

1982 - Subsec. (b)(3)(B)(ii)(II). Pub. L. 97-248, Sec. 128(d)(1),

substituted "section 1395y(a)" for "section 1395y".

Subsec. (b)(3). Pub. L. 97-248, Sec. 104(a), in provisions

following subpar. (F), inserted provisions that in determining the

reasonable charge for outpatient services, the Secretary may limit

such reasonable charge to a percentage of the amount of the

prevailing charge for similar services furnished in a physician's

office, taking into account the extent to which overhead costs

associated with such outpatient services have been included in the

reasonable cost or charge of the facility.

Subsec. (b)(6)(D). Pub. L. 97-248, Sec. 113(a), added subpar.

(D).

1981 - Subsec. (b)(3). Pub. L. 97-35 inserted provision that the

amount of any charges for outpatient services which shall be

considered reasonable shall be subject to the limitations

established by regulations issued by the Secretary pursuant to

section 1395x(v)(1)(K) of this title.

1980 - Subsec. (b)(3). Pub. L. 96-499, Sec. 946(a), in provisions

following subpar. (F), substituted "service is rendered" for "bill

is submitted or the request for payment is made".

Subsec. (b)(3)(F). Pub. L. 96-499, Sec. 946(b), added subpar.

(F).

Subsec. (b)(6). Pub. L. 96-499, Sec. 948(b), added par. (6).

Subsec. (h). Pub. L. 96-499, Sec. 918(a)(1), added subsec. (h).

1977 - Subsec. (b)(3). Pub. L. 95-216 provided that, with respect

to power-operated wheelchairs for which payment may be made in

accordance with section 1395x(s)(6) of this title, charges

determined to be reasonable may not exceed the lowest charge at

which power-operated wheelchairs are available in the locality.

Subsec. (b)(5). Pub. L. 95-142 inserted provisions relating to

payments under a reassignment or power of attorney in cases other

than direct payments to physicians or service providers.

1976 - Subsec. (b)(3). Pub. L. 94-368 substituted "for the

twelve-month period beginning on July 1 in any calendar year after

1974" for "for the fiscal year beginning July 1, 1975,", "prior to

the start of the twelve-month period (beginning July 1, of each

year) in which the bill is submitted or the request for payment is

made" for "prior to the start of the fiscal year in which the bill

is submitted or the request for payment is made", and "for any

twelve-month period (beginning after June 30, 1973) specified in

clause (ii) of such sentence" for "for any fiscal year beginning

after June 30, 1973,".

1975 - Subsec. (b)(3). Pub. L. 94-182 inserted provisions

relating to raising for fiscal year beginning July 1, 1975

inadequate prevailing charge levels for services of physicians in

certain localities.

1974 - Subsec. (g). Pub. L. 93-445 substituted "section 231f(d)

of title 45" for "section 228s-2(b) of title 45".

1972 - Subsec. (a). Pub. L. 92-603, Sec. 227(e)(3), substituted

"which involve payments for physicians' services on a reasonable

charge basis" for "which involve payments for physicians'

services".

Subsec. (b)(3). Pub. L. 92-603, Secs. 244(a), 258(a), inserted

provisions relating to determination of reasonableness of physician

charges, medical services, supplies, and equipment and for the

extension of time for filing claims for supplementary medical

insurance benefits where the delay is due to administrative error,

at end thereof.

Subsec. (b)(3)(B)(ii). Pub. L. 92-603, Secs. 211(c)(3), 281(d),

designated existing provisions as subcl. (I), added subcl. II,

inserted exception in the case of services furnished as described

in section 1395y(a)(4) of this title, other than for purposes of

section 1395gg(f) of this title.

Subsec. (b)(3)(C). Pub. L. 92-603, Sec. 262(a), inserted

provisions setting a $100 minimum amount on claims to establish

entitlement to a hearing.

Subsec. (b)(5). Pub. L. 92-603, Sec. 236(a), added par. (5).

Subsec. (g). Pub. L. 92-603, Sec. 263(d)(5), added subsec. (g).

1968 - Subsec. (b)(3)(B). Pub. L. 90-248 provided that payment be

made on the basis of an itemized bill instead of a receipted bill

as formerly required, and established a time limit within which

payment may be requested, and inserted "(except as otherwise

provided in section 1395gg(f) of this title)" after "payment will".

-CHANGE-

CHANGE OF NAME

Committee on Energy and Commerce of House of Representatives

treated as referring to Committee on Commerce of House of

Representatives by section 1(a) of Pub. L. 104-14, set out as a

note preceding section 21 of Title 2, The Congress. Committee on

Commerce of House of Representatives changed to Committee on Energy

and Commerce of House of Representatives, and jurisdiction over

matters relating to securities and exchanges and insurance

generally transferred to Committee on Financial Services of House

of Representatives by House Resolution No. 5, One Hundred Seventh

Congress, Jan. 3, 2001.

-MISC2-

EFFECTIVE DATE OF 2000 AMENDMENT

Amendment by section 1(a)(6) [title I, Sec. 105(d)] of Pub. L.

106-554 applicable to services furnished on or after Jan. 1, 2002,

see section 1(a)(6) [title I, Sec. 105(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 I, Sec. 114(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-474, provided that: "The amendment made

by subsection (a) [amending this section] shall apply to items

furnished on or after January 1, 2001."

Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 222(b)], Dec. 21,

2000, 114 Stat. 2763, 2763A-487, provided that: "The amendments

made by subsection (a) [amending this section] shall take effect on

the date of the enactment of this Act [Dec. 21, 2000]."

Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 313(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-499, provided that: "The amendments

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

1395y and 1395cc of this title] shall apply to services furnished

on or after January 1, 2001."

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 432(c)], Dec. 21,

2000, 114 Stat. 2763, 2763A-526, provided that: "The amendments

made by this section [amending this section and sections 1395y and

1395qq of this title] shall apply to services furnished on or after

July 1, 2001."

EFFECTIVE DATE OF 1999 AMENDMENT

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

305(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A-362, provided that:

"The amendments made by this section [amending this section and

section 1395y of this title] shall apply to payments for services

provided on or after the date of enactment of this Act [Nov. 29,

1999]."

Amendment by section 1000(a)(6) [title III, Sec. 321(k)(4)] 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.

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 4205(d)(3)(B) of Pub. L. 105-33 effective

Aug. 5, 1997, see section 4205(d)(4) of Pub. L. 105-33, set out as

a note under section 1395x of this title.

Section 4302(c) of Pub. L. 105-33 provided that: "The amendments

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

this title] shall take effect on the date of the enactment of this

Act [Aug. 5, 1997] and apply to the entry and renewal of contracts

on or after such date."

Amendment by section 4315(a) of Pub. L. 105-33, to the extent

such amendment substitutes fee schedules for reasonable charges,

applicable to particular services as of date specified by the

Secretary of Health and Human Services, see section 4315(c) of Pub.

L. 105-33, set out as a note under section 1395l of this title.

Amendment by section 4316(a) of Pub. L. 105-33 effective Aug. 5,

1997, see section 4316(c) of Pub. L. 105-33, set out as a note

under section 1395m of this title.

Section 4317(c) of Pub. L. 105-33 provided that: "The amendments

made by this section [amending this section] shall apply to items

and services furnished on or after January 1, 1998."

Amendment by section 4432(b)(2), (4) 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 4512(b)(2), (c) of Pub. L. 105-33 applicable

with respect to services furnished and supplies provided on and

after Jan. 1, 1998, see section 4512(d) of Pub. L. 105-33, set out

as a note under section 1395l of this title.

Amendment by section 4556(a) of Pub. L. 105-33 applicable to

drugs and biologicals furnished on or after Jan. 1, 1998, see

section 4556(d) of Pub. L. 105-33, set out as a note under section

1395l of this title.

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

Amendment by section 4611(d) of Pub. L. 105-33 applicable to

services furnished on or after Jan. 1, 1998, and for purposes of

applying such amendment, any home health spell of illness that

began, but did not end, before such date, to be considered to have

begun as of such date, see section 4611(f) of Pub. L. 105-33, set

out as a note under section 1395d of this title.

EFFECTIVE DATE OF 1994 AMENDMENT

Amendment by section 123(b)(1), (2)(B) of Pub. L. 103-432

applicable to services furnished on or after Jan. 1, 1995, see

section 123(f)(2) of Pub. L. 103-432, set out as a note under

section 1395l of this title.

Section 123(f)(3), (4) of Pub. L. 103-432 provided that:

"(3) EOMBs. - The amendments made by subsection (c)(1) [amending

this section] shall apply to explanations of benefits provided on

or after July 1, 1995.

"(4) Carrier determinations. - The amendments made by subsection

(c)(2) [amending this section] shall apply to contracts as of

January 1, 1995."

Section 125(b)(2) of Pub. L. 103-432 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to services furnished on or after the first day of the first month

beginning more than 60 days after the date of the enactment of this

Act [Oct. 31, 1994]."

Amendment by section 126(a)(1), (c), (e), (g)(9) of Pub. L.

103-432 effective as if included in the enactment of Pub. L.

101-508, see section 126(i) of Pub. L. 103-432, set out as a note

under section 1395m of this title.

Section 126(h)(2) of Pub. L. 103-432 provided that the amendment

made by that section is effective for payments for fiscal years

beginning with fiscal year 1994.

Section 135(b)(2) of Pub. L. 103-432 provided that the amendment

made by that section is effective for standards applied for

contract years beginning after Oct. 31, 1994.

Amendment by section 151(b)(1)(B), (2)(B) of Pub. L. 103-432

applicable to contracts with fiscal intermediaries and carriers

under this subchapter for contract years beginning with 1995, see

section 151(b)(4) of Pub. L. 103-432, set out as a note under

section 1395h of this title.

EFFECTIVE DATE OF 1993 AMENDMENT

Section 13515(d) of Pub. L. 103-66 provided that: "The amendments

made by subsection (a) [amending this section and section 1395w-4

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

January 1, 1994."

Amendment by section 13568(a), (b) of Pub. L. 103-66 applicable

to claims received on or after Oct. 1, 1993, see section 13568(c)

of Pub. L. 103-66, set out as a note under section 1395h of this

title.

EFFECTIVE DATE OF 1990 AMENDMENT

Section 4105(b)(3) of Pub. L. 101-508, as amended by Pub. L.

103-432, title I, Sec. 126(g)(2)(A)(ii), Oct. 31, 1994, 108 Stat.

4415, provided that: "The amendment made by paragraph (1) [amending

this section] shall apply to services furnished on or after January

1, 1991."

Section 4106(d) of Pub. L. 101-508 provided that:

"(1) The amendments made by subsection (a) [amending this section

and provisions set out below] apply to services furnished after

1990, except that -

"(A) the provisions concerning the third and fourth years of

practice apply only to physicians' services furnished after 1990

and 1991, respectively, and

"(B) the provisions concerning the second, third, and fourth

years of practice apply only to services of a health care

practitioner furnished after 1991, 1992, and 1993, respectively.

"(2) The amendments made by subsection (b) [amending this section

and section 1395w-4 of this title] shall apply to services

furnished after 1991."

Section 4108(b) of Pub. L. 101-508 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to tests

and services furnished on or after January 1, 1991."

Section 4110(b) of Pub. L. 101-508 provided that: "The amendment

made by subsection (a) [amending this section] shall apply to

services furnished on or after the first day of the first month

beginning more than 60 days after the date of the enactment of this

Act [Nov. 5, 1990]."

Section 4118(a)(3) of Pub. L. 101-508 provided that: "The

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

apply to services furnished after March 1990."

Section 4118(f)(2)(A) of Pub. L. 101-508 provided that the

amendment by that section is effective as if included in the

Omnibus Budget Reconciliation Act of 1989, Pub. L. 101-239.

Section 4118(f)(2)(B) of Pub. L. 101-508 provided that the

amendment by that section is effective Jan. 1, 1991.

Amendment by section 4155(c) 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.

EFFECTIVE DATE OF 1989 AMENDMENTS

Section 6102(e)(3) of Pub. L. 101-239 provided that the amendment

made by that section is effective for physicians' services

furnished on or after Jan. 1, 1992.

Section 6106(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 April 1, 1990."

Section 6108(a)(2) of Pub. L. 101-239, as amended by Pub. L.

101-508, title IV, Sec. 4106(a)(2), Nov. 5, 1990, 104 Stat.

1388-61, provided that:

"(A) Subject to subparagraph (B), the amendments made by

paragraph (1) [amending this section] apply to services furnished

in 1990 or 1991 which were subject to the first sentence of section

1842(b)(4)(F) of the Social Security Act [subsec. (b)(4)(F) of this

section] in 1989 or 1990.

"(B) The amendments made by paragraph (1) shall not apply to

services furnished in 1990 before April 1, 1990. With respect to

physicians' services furnished during 1990 on and after April 1,

such amendments shall be applied as though any reference, in the

matter inserted by such amendments, to the 'first calendar year

during which the preceding sentence no longer applies' were deemed

a reference to the remainder of 1990."

Section 6108(b)(3) of Pub. L. 101-239 provided that: "The

amendments made by this subsection [amending this section] apply to

procedures performed after March 31, 1990."

Section 6114(f) of Pub. L. 101-239 provided that: "The amendments

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

this title] shall apply to services furnished on or after April 1,

1990."

Amendment by section 6202(d)(2) of Pub. L. 101-239 applicable to

agreements and contracts entered into or renewed on or after Dec.

19, 1989, see section 6202(d)(3) of Pub. L. 101-239, set out as a

note under section 1395h 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.

Section 301(e) of Pub. L. 101-234 provided that: "The provisions

of this section [amending this section and sections 1395m, 1395cc,

1395ll, and 1395ww of this title, enacting provisions set out as

notes under section 1395m of this title, and repealing provisions

set out as notes under sections 1395b, 1395b-1, 1395b-2, and 1395h

of this title and section 8902 of Title 5, Government Organization

and Employees] (other than subsections (c) and (d) [amending this

section and sections 1395m, 1395cc, 1395ll, and 1395ww of this

title and enacting provisions set out as a note under section 1395m

of this title]) shall take effect January 1, 1990, except that -

"(1) the repeal of section 421 of MCCA [Pub. L. 100-360, set

out as a note under section 1395b of this title] shall not apply

to duplicative part A benefits for periods before January 1,

1990, and

"(2) the amendments made by subsection (b) [amending this

section and sections 1395m, 1395cc, 1395ll, and 1395ww of this

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

[Dec. 13, 1989]."

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.

Section 202(m) of Pub. L. 100-360, as amended by Pub. L. 101-234,

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

that:

"(1) [Repealed. Prior to repeal by Pub. L. 101-234, par. (1) read

as follows: 'In general. - Except as otherwise provided in this

subsection, the amendments made by this section [enacting section

1395w-3 of this title and amending this section and sections

1320a-7a, 1395l, 1395m, 1395x, 1395y, 1395cc, 1395mm, and 1396b of

this title] shall apply to items dispensed on or after January 1,

1990.']

"(2) [Repealed. Prior to repeal by Pub. L. 101-234, par. (2) read

as follows: 'Carriers. - The amendments made by subsection (e)

[amending this section] shall take effect on the date of the

enactment of this Act [July 1, 1988]; except that the amendments

made by subsection (e)(5) [amending this section] shall take effect

on January 1, 1991, but shall not be construed as requiring payment

before February 1, 1991.']

"(3) [Repealed. Prior to repeal by Pub. L. 101-234, par. (3) read

as follows: 'HMO/CMP enrollments. - The amendment made by

subsection (f) [amending section 1395mm of this title] shall apply

to enrollments effected on or after January 1, 1990.']

"(4) Diagnostic coding. - The amendment made by subsection (g)

[amending this section] shall apply to services furnished after

March 31, 1989.

"(5) [Repealed. Prior to repeal by Pub. L. 101-234, par. (5) read

as follows: 'Transition. - With respect to administrative expenses

(and costs of the Prescription Drug Payment Review Commission) for

periods before January 1, 1990, amounts otherwise payable from the

Federal Catastrophic Drug Insurance Trust Fund shall be payable

from the Federal Supplementary Medical Insurance Trust Fund and

shall also be treated as a debit to the Medicare Catastrophic

Coverage Account.']."

[Amendment of section 202(m) of Pub. L. 100-360, set out above,

effective Jan. 1, 1990, see section 201(c) of Pub. L. 101-234, set

out as an Effective Date of 1989 Amendment note under section

1320a-7a of this title.]

Section 223(d)(2), (3) of Pub. L. 100-360 provided that:

"(2) The amendments made by subsection (b) [amending this

section] shall apply to annual notices beginning with 1989.

"(3) The amendments made by subsection (c) [amending this

section] shall first apply to explanations of benefits provided for

items and services furnished on or after January 1, 1989."

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

100-360, amendment by section 411(a)(3)(A), (C)(i), (f)(1)(A), (B),

(2)-(4)(C), (5), (6)(B), (7), (9), (11)(A), (14), (g)(2)(A)-(C),

(i)(1)(A), (2), (4)(C)(vi), and (j)(4)(A) 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 AMENDMENTS

Amendment by section 4031(a)(2) of Pub. L. 100-203 applicable to

claims received on or after July 1, 1988, see section 4031(a)(3)(A)

of Pub. L. 100-203, set out as a note under section 1395h of this

title.

Amendment by section 4035(a)(2) of Pub. L. 100-203 effective Dec.

22, 1987, and applicable to budgets for fiscal years beginning with

fiscal year 1989, see section 4035(a)(3) of Pub. L. 100-203, set

out as a note under section 1395h of this title.

Section 4044(b) of Pub. L. 100-203 provided that: "The amendments

made by subsection (a) [amending this section] shall apply to

payment for physicians' services furnished on or after January 1,

1989."

Section 4045(d) of Pub. L. 100-203 provided that: "The amendments

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

1395w-1 of this title and amending provisions set out below] shall

apply to items and services furnished on or after April 1, 1988,

except the amendment made by subsection (c)(2)(B) [amending this

section] shall apply to services furnished on or after January 1,

1988."

Section 4046(b) of Pub. L. 100-203 provided that: "The amendments

made by subsection (a) [amending this section] shall apply to

services furnished on or after April 1, 1988."

Section 4047(b) of Pub. L. 100-203, as amended by Pub. L.

100-360, title IV, Sec. 411(f)(6)(C), July 1, 1988, 102 Stat. 779,

provided that: "The amendment made by subsection (a) [amending this

section] shall apply to physicians who first furnish services to

medicare beneficiaries on or after April 1, 1988."

Section 4051(c) of Pub. L. 100-203 provided that:

"(1) The amendment made by subsection (a) [amending this section]

shall apply to diagnostic tests performed on or after April 1,

1988.

"(2) The Secretary of Health and Human Services shall complete

the review and make an appropriate adjustment of prevailing charge

levels under subsection (b) [set out below] for items and services

furnished no later than January 1, 1989."

Section 4053(b), formerly Sec. 4052(b), of Pub. L. 100-203, as

renumbered and amended by Pub. L. 100-360, title IV, Sec.

411(f)(11)(B), (14), July 1, 1988, 102 Stat. 781, provided that:

"The amendment made by subsection (a) [amending this section] shall

apply to payment for services furnished on or after April 1, 1988."

Section 4054(c), formerly Sec. 4053(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 that: "The amendment made by

subsection (a) [amending this section] shall apply to charges

imposed for services furnished on or after April 1, 1988."

Amendment by section 4063(a) of Pub. L. 100-203 applicable to

items furnished on or after July 1, 1988, see section 4063(c) of

Pub. L. 100-203, set out as a note under section 1395(l) of this

title.

Section 4081(c)(1) of Pub. L. 100-203 provided that: "The

amendment made by subsection (a) [amending this section] shall

apply to contracts with carriers for claims for items and services

furnished by participating physicians and suppliers on or after

January 1, 1989."

Section 4082(e)(3) of Pub. L. 100-203 provided that: "The

amendments made by subsection (c) [amending this section] shall

apply to evaluation of performance of carriers under contracts

entered into or renewed on or after October 1, 1988."

Section 4085(g)(2) of Pub. L. 100-203 provided that: "The

amendment made by paragraph (1) [amending this section] shall be

effective as if included in section 9307(c) of the Consolidated

Omnibus Budget Reconciliation Act of 1985 [Pub. L. 99-272]."

Section 4085(i)(7) of Pub. L. 100-203 provided that the amendment

made by that section is effective as if included in the enactment

of Pub. L. 99-509.

Amendment by section 4096(a)(1) of Pub. L. 100-203 applicable to

services furnished on or after Jan. 1, 1988, see section 4096(d) of

Pub. L. 100-203, set out as a note under section 1320c-3 of this

title.

Amendment by Pub. L. 100-93 effective at end of fourteen-day

period beginning Aug. 18, 1987, and inapplicable to administrative

proceedings commenced before end of such period, see section 15(a)

of Pub. L. 100-93, set out as a note under section 1320a-7 of this

title.

EFFECTIVE DATE OF 1986 AMENDMENTS

Section 1895(b)(16)(B) of Pub. L. 99-514 provided that: "The

amendment made by subparagraph (A) [amending this section] shall

apply to claims presented after the date of the enactment of this

Act [Oct. 22, 1986]."

Amendment by section 1895(b)(14)(A), (15) of Pub. L. 99-514

effective, except as otherwise provided, as if included in

enactment of the Consolidated Omnibus Budget Reconciliation Act of

1985, Pub. L. 99-272, see section 1895(e) of Pub. L. 99-514, set

out as a note under section 162 of Title 26, Internal Revenue Code.

Section 9307(c)(2) of Pub. L. 99-509 provided that the amendment

made by section 9307(c)(2)(A) of Pub. L. 99-509 [amending directory

language of section 1895(b)(14)(A)(ii) of Pub. L. 99-514 which

amended this section] is effective as if included in the enactment

of the Tax Reform Act of 1986, Pub. L. 99-514.

Amendment by section 9311(c) of Pub. L. 99-509 applicable to

claims received on or after Nov. 1, 1986, with subsec. (c)(2)(C) of

this section applicable to claims received on or after Apr. 1,

1987, see section 9311(d) of Pub. L. 99-509, set out as a note

under section 1395h of this title.

Amendment by section 9320(e)(3) 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.

Section 9331(a)(4) of Pub. L. 99-509 provided that: "The

amendments made by this subsection [amending this section] shall

apply to services furnished on or after January 1, 1987."

Section 9331(b)(4) of Pub. L. 99-509 provided that: "The

amendments made by this subsection [amending this section] shall

apply to services furnished on or after January 1, 1987."

Section 9331(c)(3)(B) of Pub. L. 99-509 provided that: "The

amendments made by subparagraph (A) [amending this section] shall

apply to physicians' services furnished on or after January 1,

1988."

Section 9332(a)(4)(A) of Pub. L. 99-509 provided that: "The

amendment made by paragraph (1) [amending this section] shall be

effective for contracts under section 1842 of the Social Security

Act [this section] as of October 1, 1987."

Section 9332(b)(3) of Pub. L. 99-509 provided that: "The

amendments made by this paragraph [probably means 'this subsection'

which amended this section] shall first apply to directories for

1987."

Section 9332(c)(2) of Pub. L. 99-509 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to services furnished on or after October 1, 1987."

Section 9332(d)(2) of Pub. L. 99-509 provided that: "The

amendment made by paragraph (1) [amending this section] shall apply

to surgical procedures performed on or after October 1, 1987."

Section 9333(d) of Pub. L. 99-509 provided that: "The amendments

made by this section [amending this section] shall take effect on

the date of the enactment of this Act [Oct. 21, 1986]."

Section 9334(c) of Pub. L. 99-509 provided that: "The amendments

made by this section [amending this section] shall apply to

services furnished on or after January 1, 1987."

Amendment by section 9338(b), (c) of Pub. L. 99-509 applicable to

services furnished on or after Jan. 1, 1987, see section 9338(f) of

Pub. L. 99-509 set out as a note under section 1395x of this title.

Amendment by section 9341(a)(2) of Pub. L. 99-509 applicable to

items and services furnished on or after Jan. 1, 1987, see section

9341(b) of Pub. L. 99-509, set out as a note under section 1395ff

of this title.

Section 9219(b)(1)(D) of Pub. L. 99-272 provided that: "The

amendments made by this paragraph [amending this section and

sections 1395x and 1395yy of this title] shall be effective as if

they had been originally included in the Deficit Reduction Act of

1984 [Pub. L. 98-369]."

Section 9219(b)(2)(B) of Pub. L. 99-272 provided that: "The

amendment made by subparagraph (A) [amending this section] shall be

effective as if it had been originally included in Public Law

98-617."

Section 9301(b)(4) of Pub. L. 99-272 provided that: "The

amendments made by this subsection [amending this section and

enacting provisions set out as a note under this section] shall

apply to services furnished on or after May 1, 1986."

Section 9301(c)(5) of Pub. L. 99-272, as amended by Pub. L.

99-514, title XVIII, Sec. 1895(b)(14)(B), Oct. 22, 1986, 100 Stat.

2934, provided that: "Section 1842(h)(7) of the Social Security Act

[subsec. (h)(7) of this section], as added by paragraph (4) of this

subsection, shall apply to explanations of benefits provided on or

after such date (not later than October 1, 1986) as the Secretary

of Health and Human Services shall specify."

Section 9301(d)(4) of Pub. L. 99-272 provided that: "The

amendments made by this subsection [amending this section and

enacting provisions set out as a note under this section] shall

apply to items and services furnished on or after October 1, 1986."

Section 9306(b) of Pub. L. 99-272 provided that: "The amendments

made by this section [amending this section] shall apply to items

and services furnished on or after April 1, 1986."

Amendment by section 9307(c) of Pub. L. 99-272 applicable to

services performed on or after April 1, 1986, see section 9307(e)

of Pub. L. 99-272, set out as a note under section 1320c-3 of this

title.

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.

Amendment by section 2303(e) of Pub. L. 98-369 applicable to

clinical diagnostic laboratory tests furnished on or after July 1,

1984, but not applicable to clinical diagnostic laboratory tests

furnished to inpatients of a provider operating under a waiver

granted pursuant to section 602(k) of Pub. L. 98-21, set out as a

note under section 1395y of this title, see section 2303(j)(1), (3)

of Pub. L. 98-369, set out as a note under section 1395l of this

title.

Section 2306(b)(2) of Pub. L. 98-369 provided that: "The

amendments made by paragraph (1) [amending this section] shall

apply to items and services furnished on or after October 1, 1985."

Section 2307(a)(3) of Pub. L. 98-369 provided that: "The

amendments made by this subsection [amending this section] shall

apply to services furnished on or after July 1, 1984."

Amendment by section 2326(d)(2) of Pub. L. 98-369 applicable to

agreements and contracts entered into or renewed after Sept. 30,

1984, see section 2326(d)(3) of Pub. L. 98-369, set out as a note

under section 1395h of this title.

Amendment by section 2354(b)(13), (14) of Pub. L. 98-369

effective July 18, 1984, but not to be construed as changing or

affecting any right, liability, status, or interpretation which

existed (under the provisions of law involved) before that date,

see section 2354(e)(1) of Pub. L. 98-369, set out as a note under

section 1320a-1 of this title.

Amendment by section 2663(j)(2)(F)(iv) of Pub. L. 98-369

effective July 18, 1984, but not to be construed as changing or

affecting any right, liability, status, or interpretation which

existed (under the provisions of law involved) before that date,

see section 2664(b) of Pub. L. 98-369, set out as a note under

section 401 of this title.

EFFECTIVE DATE OF 1982 AMENDMENT

Section 104(b) of Pub. L. 97-248, as amended by Pub. L. 97-448,

title III, Sec. 309(a)(2), Jan. 12, 1983, 96 Stat. 2408, provided

that: "The amendment made by subsection (a) [amending this section]

shall be effective with respect to services furnished on or after

October 1, 1982."

Section 113(b)(1) of Pub. L. 97-248 provided that: "The amendment

made by subsection (a) [amending this section] is effective with

respect to services performed on or after October 1, 1982."

Amendment by section 128(d)(1) of Pub. L. 97-248 effective Sept.

3, 1982, see section 128(e)(3) of Pub. L. 97-248, set out as a note

under section 1395x of this title.

EFFECTIVE DATE OF 1980 AMENDMENT

Section 918(a)(2) of Pub. L. 96-499 provided that: "The amendment

made by paragraph (1) [amending this section] shall apply to bills

submitted and requests for payment made on or after such date (not

later than April 1, 1981) as the Secretary of Health and Human

Services prescribes by a notice published in the Federal Register."

Section 946(c) of Pub. L. 96-499 provided that: "The amendments

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

become effective with respect to bills submitted or requests for

payment made on or after July 1, 1981."

Section 948(c)(2) of Pub. L. 96-499 provided that: "The amendment

made by subsection (b) [amending this section] shall apply with

respect to cost accounting periods beginning on or after January 1,

1981."

EFFECTIVE DATE OF 1977 AMENDMENTS

Amendment by Pub. L. 95-216 effective in the case of items and

services furnished after Dec. 20, 1977, see section 501(c) of Pub.

L. 95-216, set out as a note under section 1395x of this title.

Amendment by Pub. L. 95-142 applicable with respect to care and

services furnished on or after Oct. 25, 1977, see section 2(a)(4)

of Pub. L. 95-142, set out as a note under section 1395g of this

title.

EFFECTIVE DATE OF 1976 AMENDMENT

Section 4 of Pub. L. 94-368 provided that: "The amendments made

by sections 2 and 3 of this Act [amending this section and

provisions set out as a note under section 390e of Title 7,

Agriculture] shall be effective with respect to periods beginning

after June 30, 1976; except that, for the twelve-month period

beginning July 1, 1976, the amendments made by section 3 [amending

this section and provisions set out as a note under section 390e of

Title 7, Agriculture] shall be applicable with respect to claims

filed under part B of title XVIII of the Social Security Act [this

part] (after June 30, 1976, and before July 1, 1977) with a carrier

designated pursuant to section 1842 of such Act [this section], and

processed by such carrier after the appropriate changes were made

pursuant to such section 3 in the prevailing charge levels for such

twelve-month period under the third and fourth sentences of section

1842(b)(3) of the Social Security Act [subsec. (b)(3) of this

section]."

EFFECTIVE DATE OF 1974 AMENDMENT

Amendment by Pub. L. 93-445 effective Jan. 1, 1975, see section

603 of Pub. L. 93-445, set out as a note under section 402 of this

title.

EFFECTIVE DATE OF 1972 AMENDMENT

Amendment by section 211(c)(3) 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 227(e)(3) of Pub. L. 92-603 applicable with

respect to accounting periods beginning after June 30, 1973, see

section 227(g) of Pub. L. 92-603, set out as a note under section

1395x of this title.

Section 236(c) of Pub. L. 92-603 provided that: "The amendment

made by subsection (a) [amending this section] shall apply with

respect to bills submitted and requests for payments made after the

date of the enactment of this Act [Oct. 30, 1972]. The amendments

made by subsection (b) [amending section 1396a of this title] shall

be effective January 1, 1973 (or earlier if the State plan so

provides)."

Section 258(b) of Pub. L. 92-603 provided that: "The amendment

made by subsection (a) [amending this section] shall apply with

respect to bills submitted and requests for payment made after

March 1968."

Section 262(b) of Pub. L. 92-603 provided that: "The amendment

made by subsection (a) [amending this section] shall apply with

respect to hearings requested (under the procedures established

under section 1842(b)(3)(C) of the Social Security Act [subsec.

(b)(3)(C) of this section]) after the date of the enactment of this

Act [Oct. 30, 1972]."

Amendment by section 263(d)(5) of Pub. L. 92-603 with respect to

collection of premiums applicable to premiums becoming due and

payable after the fourth month following the month of enactment of

Pub. L. 92-603 which was approved on Oct. 30, 1972, see section

263(f) of Pub. L. 92-603, set out as a note under section 1395s of

this title.

Amendment by section 281(d) of Pub. L. 92-603 to apply in the

case of notices sent to individuals after 1968, see section 281(g)

of Pub. L. 92-603, set out as a note under section 1395gg of this

title.

EFFECTIVE DATE OF 1968 AMENDMENT

Section 125(b) of Pub. L. 90-248 provided that: "The amendments

made by subsection (a) [amending this section] shall apply with

respect to claims on which a final determination has not been made

on or before the date of enactment of this Act [Jan. 2, 1968]."

-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.

-MISC3-

REVISED PART B PAYMENT FOR DRUGS AND BIOLOGICALS AND RELATED

SERVICES

Pub. L. 106-554, Sec. 1(a)(6) [title IV, Sec. 429], Dec. 21,

2000, 114 Stat. 2763, 2763A-522, provided that:

"(a) Recommendations for Revised Payment Methodology for Drugs

and Biologicals. -

"(1) Study. -

"(A) In general. - The Comptroller General of the United

States shall conduct a study on the reimbursement for drugs and

biologicals under the current medicare payment methodology

(provided under section 1842(o) of the Social Security Act (42

U.S.C. 1395u(o))) and for related services under part B of

title XVIII of such Act [this part]. In the study, the

Comptroller General shall -

"(i) identify the average prices at which such drugs and

biologicals are acquired by physicians and other suppliers;

"(ii) quantify the difference between such average prices

and the reimbursement amount under such section; and

"(iii) determine the extent to which (if any) payment under

such part is adequate to compensate physicians, providers of

services, or other suppliers of such drugs and biologicals

for costs incurred in the administration, handling, or

storage of such drugs or biologicals.

"(B) Consultation. - In conducting the study under

subparagraph (A), the Comptroller General shall consult with

physicians, providers of services, and suppliers of drugs and

biologicals under the medicare program under title XVIII of

such Act [this subchapter], as well as other organizations

involved in the distribution of such drugs and biologicals to

such physicians, providers of services, and suppliers.

"(2) Report. - Not later than 9 months after the date of the

enactment of this Act [Dec. 21, 2000], the Comptroller General

shall submit to Congress and to the Secretary of Health and Human

Services a report on the study conducted under this subsection,

and shall include in such report recommendations for revised

payment methodologies described in paragraph (3).

"(3) Recommendations for revised payment methodologies. -

"(A) In general. - The Comptroller General shall provide

specific recommendations for revised payment methodologies for

reimbursement for drugs and biologicals and for related

services under the medicare program. The Comptroller General

may include in the recommendations -

"(i) proposals to make adjustments under subsection (c) of

section 1848 of the Social Security Act (42 U.S.C. 1395w-4)

for the practice expense component of the physician fee

schedule under such section for the costs incurred in the

administration, handling, or storage of certain categories of

such drugs and biologicals, if appropriate; and

"(ii) proposals for new payments to providers of services

or suppliers for such costs, if appropriate.

"(B) Ensuring patient access to care. - In making

recommendations under this paragraph, the Comptroller General

shall ensure that any proposed revised payment methodology is

designed to ensure that medicare beneficiaries continue to have

appropriate access to health care services under the medicare

program.

"(C) Matters considered. - In making recommendations under

this paragraph, the Comptroller General shall consider -

"(i) the method and amount of reimbursement for similar

drugs and biologicals made by large group health plans;

"(ii) as a result of any revised payment methodology, the

potential for patients to receive inpatient or outpatient

hospital services in lieu of services in a physician's

office; and

"(iii) the effect of any revised payment methodology on the

delivery of drug therapies by hospital outpatient

departments.

"(D) Coordination with bbra study. - In making

recommendations under this paragraph, the Comptroller General

shall conclude and take into account the results of the study

provided for under section 213(a) of BBRA [Pub. L. 106-113,

Sec. 1000(a)(6) [title II, Sec. 213(a)], set out as a note

under section 1395l of this title] (113 Stat. 1501A-350).

"(b) Implementation of New Payment Methodology. -

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

based on the recommendations contained in the report under

subsection (a), the Secretary of Health and Human Services,

subject to paragraph (2), shall revise the payment methodology

under section 1842(o) of the Social Security Act (42 U.S.C.

1395u(o)) for drugs and biologicals furnished under part B of the

medicare program [this part]. To the extent the Secretary

determines appropriate, the Secretary may provide for the

adjustments to payments amounts referred to in subsection

(a)(3)(A)(i) or additional payments referred to in subsection

(a)(2)(A)(ii).

"(2) Limitation. - In revising the payment methodology under

paragraph (1), in no case may the estimated aggregate payments

for drugs and biologicals under the revised system (including

additional payments referred to in subsection (a)(3)(A)(ii))

exceed the aggregate amount of payment for such drugs and

biologicals, as projected by the Secretary, that would have been

made under the payment methodology in effect under such section

1842(o).

"(c) Moratorium on Decreases in Payment Rates. - Notwithstanding

any other provision of law, effective for drugs and biologicals

furnished on or after January 1, 2001, the Secretary may not

directly or indirectly decrease the rates of reimbursement (in

effect as of such date) for drugs and biologicals under the current

medicare payment methodology (provided under section 1842(o) of the

Social Security Act (42 U.S.C. 1395u(o))) until such time as the

Secretary has reviewed the report submitted under subsection

(a)(2)."

IMPLEMENTATION OF INHERENT REASONABLENESS (IR) AUTHORITY

Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 223(a),

(b)], Nov. 29, 1999, 113 Stat. 1536, 1501A-352, 1501A-353, provided

that:

"(a) Limitation on Use. - The Secretary of Health and Human

Services may not use, or permit fiscal intermediaries or carriers

to use, the inherent reasonableness authority provided under

section 1842(b)(8) of the Social Security Act (42 U.S.C.

1395u(b)(8)) until after -

"(1) the Comptroller General of the United States releases a

report pursuant to the request for such a report made on March 1,

1999, regarding the impact of the Secretary's, fiscal

intermediaries', and carriers' use of such authority; and

"(2) the Secretary has published a notice of final rulemaking

in the Federal Register that relates to such authority and that

responds to such report and to comments received in response to

the Secretary's interim final regulation relating to such

authority that was published in the Federal Register on January

7, 1998.

"(b) Reevaluation of IR Criteria. - In promulgating the final

regulation under subsection (a)(2), the Secretary shall -

"(1) reevaluate the appropriateness of the criteria included in

such interim final regulation for identifying payments which are

excessive or deficient; and

"(2) take appropriate steps to ensure the use of valid and

reliable data when exercising such authority."

INITIAL BUDGET NEUTRALITY

Section 4315(d) of Pub. L. 105-33 provided that: "The Secretary,

in developing a fee schedule for particular services (under the

amendments made by this section [amending this section and section

1395l of this title]), shall set amounts for the first year period

to which the fee schedule applies at a level so that the total

payments under title XVIII of the Social Security Act (42 U.S.C.

1395 et seq.) for those services for that year period shall be

approximately equal to the estimated total payments if such fee

schedule had not been implemented."

IMPROVEMENTS IN ADMINISTRATION OF LABORATORY TESTS BENEFIT

Section 4554 of Pub. L. 105-33 provided that:

"(a) Selection of Regional Carriers. -

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

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

"(A) divide the United States into no more than 5 regions,

and

"(B) designate a single carrier for each such region, for the

purpose of payment of claims under part B of title XVIII of the

Social Security Act [this part] with respect to clinical

diagnostic laboratory tests furnished on or after such date

(not later than July 1, 1999) as the Secretary specifies.

"(2) Designation. - In designating such carriers, the Secretary

shall consider, among other criteria -

"(A) a carrier's timeliness, quality, and experience in

claims processing, and

"(B) a carrier's capacity to conduct electronic data

interchange with laboratories and data matches with other

carriers.

"(3) Single data resource. - The Secretary shall select one of

the designated carriers to serve as a central statistical

resource for all claims information relating to such clinical

diagnostic laboratory tests handled by all the designated

carriers under such part.

"(4) Allocation of claims. - The allocation of claims for

clinical diagnostic laboratory tests to particular designated

carriers shall be based on whether a carrier serves the

geographic area where the laboratory specimen was collected or

other method specified by the Secretary.

"(5) Secretarial exclusion. - Paragraph (1) shall not apply

with respect to clinical diagnostic laboratory tests furnished by

physician office laboratories if the Secretary determines that

such offices would be unduly burdened by the application of

billing responsibilities with respect to more than one carrier.

"(b) Adoption of National Policies for Clinical Laboratory Tests

Benefit. -

"(1) In general. - Not later than January 1, 1999, the

Secretary shall first adopt, consistent with paragraph (2),

national coverage and administrative policies for clinical

diagnostic laboratory tests under part B of title XVIII of the

Social Security Act [this part], using a negotiated rulemaking

process under subchapter III of chapter 5 of title 5, United

States Code.

"(2) Considerations in design of national policies. - The

policies under paragraph (1) shall be designed to promote program

integrity and national uniformity and simplify administrative

requirements with respect to clinical diagnostic laboratory tests

payable under such part in connection with the following:

"(A) Beneficiary information required to be submitted with

each claim or order for laboratory tests.

"(B) The medical conditions for which a laboratory test is

reasonable and necessary (within the meaning of section

1862(a)(1)(A) of the Social Security Act [section

1395y(a)(1)(A) of this title]).

"(C) The appropriate use of procedure codes in billing for a

laboratory test, including the unbundling of laboratory

services.

"(D) The medical documentation that is required by a medicare

contractor at the time a claim is submitted for a laboratory

test in accordance with section 1833(e) of the Social Security

Act [section 1395l(e) of this title].

"(E) Recordkeeping requirements in addition to any

information required to be submitted with a claim, including

physicians' obligations regarding such requirements.

"(F) Procedures for filing claims and for providing

remittances by electronic media.

"(G) Limitation on frequency of coverage for the same tests

performed on the same individual.

"(3) Changes in laboratory policies pending adoption of

national policy. - During the period that begins on the date of

the enactment of this Act [Aug. 5, 1997] and ends on the date the

Secretary first implements national policies pursuant to

regulations promulgated under this subsection, a carrier under

such part may implement changes relating to requirements for the

submission of a claim for clinical diagnostic laboratory tests.

"(4) Use of interim policies. - After the date the Secretary

first implements such national policies, the Secretary shall

permit any carrier to develop and implement interim policies of

the type described in paragraph (1), in accordance with

guidelines established by the Secretary, in cases in which a

uniform national policy has not been established under this

subsection and there is a demonstrated need for a policy to

respond to aberrant utilization or provision of unnecessary

tests. Except as the Secretary specifically permits, no policy

shall be implemented under this paragraph for a period of longer

than 2 years.

"(5) Interim national policies. - After the date the Secretary

first designates regional carriers under subsection (a), the

Secretary shall establish a process under which designated

carriers can collectively develop and implement interim national

policies of the type described in paragraph (1). No such policy

shall be implemented under this paragraph for a period of longer

than 2 years.

"(6) Biennial review process. - Not less often than once every

2 years, the Secretary shall solicit and review comments

regarding changes in the national policies established under this

subsection. As part of such biennial review process, the

Secretary shall specifically review and consider whether to

incorporate or supersede interim policies developed under

paragraph (4) or (5). Based upon such review, the Secretary may

provide for appropriate changes in the national policies

previously adopted under this subsection.

"(7) Requirement and notice. - The Secretary shall ensure that

any policies adopted under paragraph (3), (4), or (5) shall apply

to all laboratory claims payable under part B of title XVIII of

the Social Security Act [this part], and shall provide for

advance notice to interested parties and a 45-day period in which

such parties may submit comments on the proposed change.

"(c) Inclusion of Laboratory Representative on Carrier Advisory

Committees. - The Secretary shall direct that any advisory

committee established by a carrier to advise such carrier with

respect to coverage and administrative policies under part B of

title XVIII of the Social Security Act [this part] shall include an

individual to represent the independent clinical laboratories and

such other laboratories as the Secretary deems appropriate. The

Secretary shall consider recommendations from national and local

organizations that represent independent clinical laboratories in

such selection."

WHOLESALE PRICE STUDY AND REPORT

Section 4556(c) of Pub. L. 105-33 provided that: "The Secretary

of Health and Human Services shall study the effect on the average

wholesale price of drugs and biologicals of the amendments made by

subsection (a) [amending this section] and shall report to the

Committees on Ways and Means and Commerce of the House of

Representatives and the Committee on Finance of the Senate the

result of such study not later than July 1, 1999."

BUDGET NEUTRALITY ADJUSTMENT

Section 13515(b) of Pub. L. 103-66 provided that:

"Notwithstanding any other provision of law, the Secretary of

Health and Human Services shall reduce the following values and

amounts for 1994 (to be applied for that year and subsequent years)

by such uniform percentage as the Secretary determines to be

required to assure that the amendments made by subsection (a)

[amending this section and section 1395w-4 of this title] will not

result in expenditures under part B of title XVIII of the Social

Security Act [this part] in 1994 that exceed the amount of such

expenditures that would have been made if such amendments had not

been made:

"(1) The relative values established under section 1848(c) of

such Act [section 1395w-4(c) of this title] for services (other

than anesthesia services) and, in the case of anesthesia

services, the conversion factor established under section 1848 of

such Act for such services.

"(2) The amounts determined under section 1848(a)(2)(B)(ii)(I)

of such Act.

"(3) The prevailing charges or fee schedule amounts to be

applied under such part for services of a health care

practitioner (as defined in section 1842(b)(4)(F)(ii)(I) of such

Act [subsec. (b)(4)(F)(ii)(I) of this section], as in effect

before the date of the enactment of this Act [Aug. 10, 1993])."

PROCEDURE CODES

Section 4101(b)(2) of Pub. L. 101-508, as amended by Pub. L.

103-432, title I, Sec. 126(a)(2), Oct. 31, 1994, 108 Stat. 4414,

provided that: "In applying section 1842(b)(16)(B) of the Social

Security Act [subsec. (b)(16)(B) of this section]:

"(A) The codes for the procedures specified in clause (ii) are

as follows: Hospital inpatient medical services (HCPCS codes

90200 through 90292), consultations (HCPCS codes 90600 through

90654), other visits (HCPCS code 90699), preventive medicine

visits (HCPCS codes 90750 through 90764), psychiatric services

(HCPCS codes 90801 through 90862), emergency care facility

services (HCPCS codes 99062 through 99065), and critical care

services (HCPCS codes 99160 through 99174).

"(B) The codes for the procedures specified in clause (iii) are

as follows: Partial mastectomy (HCPCS code 19160); tendon sheath

injections and small joint arthrocentesis (HCPCS codes 20550,

20600, 20605, and 20610); femoral fracture and trochanteric

fracture treatments (HCPCS codes 27230, 27232, 27234, 27238,

27240, 27242, 27246, and 27248); endotracheal intubation (HCPCS

code 31500); thoracentesis (HCPCS code 32000); thoracostomy

(HCPCS codes 32020, 32035, and 32036); aneurysm repair (HCPCS

codes 35111); cystourethroscopy (HCPCS code 52340); transurethral

fulguration and resection (HCPCS codes 52606 and 52620);

tympanoplasty with mastoidectomy (HCPCS code 69645); and

ophthalmoscopy (HCPCS codes 92250 and 92260)."

STUDY OF RELEASE OF PREPAYMENT MEDICAL REVIEW SCREEN PARAMETERS

Section 4111 of Pub. L. 101-508 directed Secretary of Health and

Human Services to conduct a study of effect of release of medicare

prepayment medical review screen parameters on physician billings

for services to which the parameters apply, such study to be based

upon the release of the screen parameters at a minimum of six

carriers, with Secretary to report results of study to Congress not

later than Oct. 1, 1992.

FREEZE IN CHARGES FOR PARENTERAL AND ENTERAL NUTRIENTS, SUPPLIES,

AND EQUIPMENT

Section 13541 of Pub. L. 103-66 provided that: "In determining

the amount of payment under part B of title XVIII of the Social

Security Act [this part] with respect to parenteral and enteral

nutrients, supplies, and equipment during 1994 and 1995, the

charges determined to be reasonable with respect to such nutrients,

supplies, and equipment may not exceed the charges determined to be

reasonable with respect to such nutrients, supplies, and equipment

during 1993."

Section 4152(d) of Pub. L. 101-508 provided that: "In determining

the amount of payment under part B of title XVIII of the Social

Security Act [this part] for enteral and parenteral nutrients,

supplies, and equipment furnished during 1991, the charges

determined to be reasonable with respect to such nutrients,

supplies, and equipment may not exceed the charges determined to be

reasonable with respect to such items for 1990."

PROHIBITION ON REGULATIONS CHANGING COVERAGE OF CONVENTIONAL

EYEWEAR

Section 4153(b)(1) of Pub. L. 101-508 provided that:

"(A) Notwithstanding any other provision of law (except as

provided in subparagraph (B)) the Secretary of Health and Human

Services (referred to in this subsection as the 'Secretary') may

not issue any regulation that changes the coverage of conventional

eyewear furnished to individuals (enrolled under part B of title

XVIII of the Social Security Act [this part]) following cataract

surgery with insertion of an intraocular lens.

"(B) Paragraph (1) shall not apply to any regulation issued for

the sole purpose of implementing the amendments made by paragraph

(2)."

DIRECTORY OF UNIQUE PHYSICIAN IDENTIFIER NUMBERS

Section 4164(c) of Pub. L. 101-508, as amended by Pub. L.

103-432, title I, Sec. 147(f)(7)(B), Oct. 31, 1994, 108 Stat. 4432,

provided that: "Not later than March 31, 1991, the Secretary of

Health and Human Services shall publish, and shall periodically

update, a directory of the unique physician identification numbers

of all physicians providing services for which payment may be made

under part B of title XVIII of the Social Security Act [this part],

and shall include in such directory the names, provider numbers,

and billing addressess [sic] of all listed physicians."

TREATMENT OF CERTAIN EYE EXAMINATION VISITS AS PRIMARY CARE

SERVICES

Section 6102(e)(10) of Pub. L. 101-239 provided that: "In

applying section 1842(i)(4) of the Social Security Act [subsec.

(i)(4) of this section] for services furnished on or after January

1, 1990, intermediate and comprehensive office visits for eye

examinations and treatments (codes 92002 and 92004) shall be

considered to be primary care services."

DELAY IN UPDATE UNTIL APRIL 1, 1990, AND REDUCTION IN PERCENTAGE

INCREASE IN MEDICARE ECONOMIC INDEX

Section 6107(a) of Pub. L. 101-239 provided that:

"(1) In general. - Subject to the amendments made by this section

[amending this section], any increase or adjustment in customary,

prevailing, or reasonable charges, fee schedule amounts, maximum

allowable actual charges, and other limits on actual charges with

respect to physicians' services and other items and services

described in paragraph (2) under part B of title XVIII of the

Social Security Act [this part] which would otherwise occur as of

January 1, 1990, shall be delayed so as to occur as of April 1,

1990, and, notwithstanding any other provision of law, the amount

of payment under such part for such items and services which are

furnished during the period beginning on January 1, 1990, and

ending on March 31, 1990, shall be determined on the same basis as

the amount of payment for such services furnished on December 31,

1989.

"(2) Items and services covered. - The items and services

described in this paragraph are items and services (other than

ambulance services and clinical diagnostic laboratory services) for

which payment is made under part B of title XVIII of the Social

Security Act on the basis of a reasonable charge or a fee schedule.

"(3) Extension of participation agreements and related

provisions. - Notwithstanding any other provision of law -

"(A) subject to the last sentence of this paragraph, each

participation agreement in effect on December 31, 1989, under

section 1842(h)(1) of the Social Security Act [subsec. (h)(1) of

this section] shall remain in effect for the 3-month period

beginning on January 1, 1990;

"(B) the effective period for such agreements under such

section entered into for 1990 shall be the 9-month period

beginning on April 1, 1990, and the Secretary of Health and Human

Services shall provide an opportunity for physicians and

suppliers to enroll as participating physicians and suppliers

before April 1, 1990;

"(C) instead of publishing, under section 1842(h)(4) of the

Social Security Act [subsec. (h)(4) of this section], at the

beginning of 1990, directories of participating physicians and

suppliers for 1990, the Secretary shall provide for such

publication, at the beginning of the 9-month period beginning on

April 1, 1990, of such directories of participating physicians

and suppliers for such period; and

"(D) instead of providing to nonparticipating physicians under

section 1842(b)(3)(G) of the Social Security Act [subsec.

(b)(3)(G) of this section] at the beginning of 1990, a list of

maximum allowable actual charges for 1990, the Secretary shall

provide, at the beginning of the 9-month period beginning on

April 1, 1990, such physicians such a list for such 9-month

period.

An agreement with a participating physician or supplier described

in subparagraph (A) in effect on December 31, 1989, under section

1842(h)(1) of the Social Security Act shall not remain in effect

for the period described in subparagraph (A) if the participating

physician or supplier requests on or before December 31, 1989, that

the agreement be terminated."

STATE DEMONSTRATION PROJECTS ON APPLICATION OF LIMITATION ON VISITS

PER MONTH PER RESIDENT ON AGGREGATE BASIS FOR A TEAM

Section 6114(e) of Pub. L. 101-239 provided that: "The Secretary

of Health and Human Services shall provide for at least 1

demonstration project under which, in the application of section

1842(b)(2)(C) of the Social Security Act [subsec. (b)(2)(C) of this

section] (as added by subsection (c)(2) of this section) in one or

more States, the limitation on the number of visits per month per

resident would be applied on an average basis over the aggregate

total of residents receiving services from members of the team."

APPLICATION OF DIFFERENT PERFORMANCE STANDARDS FOR ELECTRONIC

SYSTEM FOR COVERED OUTPATIENT DRUGS

Section 202(e)(3)(B) of Pub. L. 100-360, as amended by Pub. L.

100-485, title VI, Sec. 608(d)(5)(E), Oct. 13, 1988, 102 Stat.

2414, which required Secretary of Health and Human Services, before

entering into contracts under section 1395u of this title with

respect to implementation and operation of electronic system for

covered outpatient drugs, to establish standards with respect to

performance with respect to such activities, was repealed by Pub.

L. 101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981.

DELAY IN APPLICATION OF COORDINATION OF BENEFITS WITH PRIVATE

HEALTH INSURANCE

Section 202(e)(4)(B) of Pub. L. 100-360, which provided that the

provisions of section 1395u(h)(3) of this title not apply to

covered outpatient drugs (other than drugs described in section

1395x(s)(2)(J) of this title as of July 1, 1988) dispensed before

January 1, 1993, was repealed by Pub. L. 101-234, title II, Sec.

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

EXTENSION OF PHYSICIAN PARTICIPATION AGREEMENTS AND RELATED

PROVISIONS

Section 4041(a)(2) of Pub. L. 100-203 provided that:

"Notwithstanding any other provision of law -

"(A) subject to the last sentence of this paragraph, each

agreement with a participating physician in effect on December

31, 1987, under section 1842(h)(1) of the Social Security Act

[subsec. (h)(1) of this section] shall remain in effect for the

3-month period beginning on January 1, 1988;

"(B) the effective period for agreements under such section

entered into for 1988 shall be the nine-month period beginning on

April 1, 1988, and the Secretary shall provide an opportunity for

physicians to enroll as participating physicians prior to April

1, 1988;

"(C) instead of publishing, under section 1842(h)(4) of the

Social Security Act [subsec. (h)(4) of this section] at the

beginning of 1988, directories of participating physicians for

1988, the Secretary shall provide for such publication, at the

beginning of the 9-month period beginning on April 1, 1988, of

such directories of participating physicians for such period; and

"(D) instead of providing to nonparticipating physicians, under

section 1842(b)(3)(G) of the Social Security Act [subsec.

(b)(3)(G) of this section] at the beginning of 1988, a list of

maximum allowable actual charges for 1988, the Secretary shall

provide, at the beginning of the 9-month period beginning on

April 1, 1988, to such physicians such a list for such 9-month

period.

An agreement with a participating physician in effect on December

31, 1987, under section 1842(h)(1) of the Social Security Act shall

not remain in effect for the period described in subparagraph (A)

if the participating physician requests on or before December 31,

1987, that the agreement be terminated."

DEVELOPMENT OF UNIFORM RELATIVE VALUE GUIDE

Section 4048(b) of Pub. L. 100-203, as amended by Pub. L.

101-508, title IV, Sec. 4118(h)(1), Nov. 5, 1990, 104 Stat.

1388-70, provided that: "The Secretary of Health and Human

Services, in consultation with groups representing physicians who

furnish anesthesia services, shall establish by regulation a

relative value guide for use in all carrier localities in making

payment for physician anesthesia services furnished under part B of

title XVIII of the Social Security Act [this part] on and after

March 1, 1989. Such guide shall be designed so as to result in

expenditures under such title [this subchapter] for such services

in an amount that would not exceed the amount of such expenditures

which would otherwise occur."

[Section 4118(h) of Pub. L. 101-508 provided that the amendment

by that section to section 4048(b) 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.]

STUDY OF PREVAILING CHARGES FOR ANESTHESIA SERVICES

Section 4048(c) of Pub. L. 100-203, which required Secretary of

Health and Human Services to study variations in conversion factors

used by carriers under section 1395u(b) of this title to determine

prevailing charge for anesthesia services and to report results of

study and make recommendations for appropriate adjustments in such

factors not later than Jan. 1, 1989, was repealed by Pub. L.

101-508, title IV, Sec. 4118(g)(2), Nov. 5, 1990, 104 Stat.

1388-70.

GAO STUDIES

Section 4048(d) of Pub. L. 100-203 provided that:

"(1) The Comptroller General shall conduct a study -

"(A) to determine the average anesthesia times reported for

medicare reimbursement purposes,

"(B) to verify those times from patient medical records,

"(C) to compare anesthesia times to average surgical times, and

"(D) to determine whether the current payments for physician

supervision of nurse anesthetists are excessive.

The Comptroller General shall report to Congress, by not later than

January 1, 1989, on such study and in the report include

recommendations regarding the appropriateness of the anesthesia

times recognized by medicare for reimbursement purposes and

recommendations regarding adjustments of payments for physician

supervision of nurse anesthetists.

"(2) The Comptroller General shall conduct a study on the impact

of the amendment made by subsection (a) [amending this section],

and shall report to Congress on the results of such study by April

1, 1990."

ADJUSTMENT IN MEDICARE PREVAILING CHARGES

Section 4051(b) of Pub. L. 100-203 provided that:

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

review payment levels under part B of title XVIII of the Social

Security Act [this part] for diagnostic tests (described in section

1861(s)(3) of such Act [section 1935x(s)(3) of this title], but

excluding clinical diagnostic laboratory tests) which are commonly

performed by independent suppliers, sold as a service to

physicians, and billed by such physicians, in order to determine

the reasonableness of payment amounts for such tests (and for

associated professional services component of such tests). The

Secretary may require physicians and suppliers to provide such

information on the purchase or sale price (net of any discounts)

for such tests as is necessary to complete the review and make the

adjustments under this subsection. The Secretary shall also review

the reasonableness of payment levels for comparable in-office

diagnostic tests.

"(2) Establishment of revised payment screens. - If, as a result

of such review, the Secretary determines, after notice and

opportunity of at least 60 days for public comment, that the

current prevailing charge levels (under the third and fourth

sentences of section 1842(b) of the Social Security Act [subsec.

(b) of this section]) for any such tests or associated professional

services are excessive, the Secretary shall establish such charge

levels at levels which, consistent with assuring that the test is

widely and consistently available to medicare beneficiaries,

reflect a reasonable price for the test without any markup.

Alternatively, the Secretary, pursuant to guidelines published

after notice and opportunity of at least 60 days for public

comment, may delegate to carriers with contracts under section 1842

of the Social Security Act the establishment of new prevailing

charge levels under this paragraph. When such charge levels are

established, the provisions of section 1842(j)(1)(D) of such Act

shall apply in the same manner as they apply to a reduction under

section 1842(b)(8)(A) of such Act."

ADJUSTMENT FOR MAXIMUM ALLOWABLE ACTUAL CHARGE

Section 4054(b), formerly Sec. 4053(b), 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 that: "In the case of a physician who

did not have actual charges under title XVIII of the Social

Security Act [this subchapter] for a procedure in the calendar

quarter beginning on April 1, 1984, but who establishes to the

satisfaction of a carrier that he or she had actual charges

(whether under such title or otherwise) for the procedure performed

prior to June 30, 1984, the carrier shall compute the maximum

allowable actual charge under section 1842(j) of the Social

Security Act [subsec. (j) of this section] for such procedure

performed by such physician in 1988 based on such physician's

actual charges for the procedure."

PHYSICIAN PAYMENT STUDIES; DEFINITIONS OF MEDICAL AND SURGICAL

PROCEDURES

Section 4056(a), formerly Sec. 4055(a), of Pub. L. 100-203, as

renumbered and amended by Pub. L. 100-360, title IV, Sec.

411(f)(13)(A), (14), July 1, 1988, 102 Stat. 781; Pub. L. 101-508,

title IV, Sec. 4118(g)(4), Nov. 5, 1990, 104 Stat. 1388-70,

provided that:

"(1) Report on variations in carrier payment practice. - The

Secretary of Health and Human Services (in this section referred to

as the 'Secretary') shall conduct a study of variations in payment

practices for physicians' services among the different carriers

under section 1842 of the Social Security Act [this section]. Such

study shall examine carrier variations in the services included in

global fees and pre- and post-operative services included in

payment for the operation.

"(2) Uniform definitions of procedures for payment purposes. -

The Secretary shall develop, in consultation with appropriate

national medical specialty societies and by not later than July 1,

1989, uniform definitions of physicians' services (including

appropriate classification scheme for procedures) which could serve

as the basis for making payments for such services under part B of

title XVIII of the Social Security Act [this part]. In developing

such definitions, to the extent practicable -

"(A) ancillary services commonly performed in conjunction with

a major procedure would be included with the major procedure;

"(B) pre- and post-procedure services would be included in the

procedure; and

"(C) similar procedures would be listed together if the

procedures are similar in resource requirements."

PAYMENTS FOR DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES,

ORTHOTICS, AND PROSTHETICS; 1-YEAR FREEZE ON CHARGE LIMITATIONS

Section 4062(a) of Pub. L. 100-203 provided that:

"(1) In general. - In imposing limitations on allowable charges

for items and services (other than physicians' services) furnished

in 1988 under part B of title XVIII of such Act [this part] and for

which payment is made on the basis of the reasonable charge for the

item or service, the Secretary of Health and Human Services shall

not impose any limitation at a level higher than the same level as

was in effect in December 1987.

"(2) Transition. - The provisions of section 4041(a)(2) (other

than subparagraph (D) thereof) of this subtitle [set out as a note

above] shall apply to suppliers of items and services described in

paragraph (1), and directories of participating suppliers of such

items and services, in the same manner as such section applies to

physicians furnishing physicians' services, and directories of

participating physicians."

SPECIAL RULE WITH RESPECT TO PAYMENT FOR INTRAOCULAR LENSES

Section 4063(d) of Pub. L. 100-203 provided that: "With respect

to the establishment of a reasonable charge limit under section

1842(b)(11)(C)(ii) of the Social Security Act [subsec.

(b)(11)(C)(ii) of this section], in applying section

1842(j)(1)(D)(i) of such Act, the matter beginning with 'plus'

shall be considered to have been deleted."

STUDY ON COST EFFECTIVENESS OF HEARING PRIOR TO HEARING BY

ADMINISTRATIVE LAW JUDGE ON CARRIER DETERMINATIONS; REPORT TO

CONGRESS

Section 4082(d) of Pub. L. 100-203 provided that: "The

Comptroller General shall conduct a study concerning the cost

effectiveness of requiring hearings with a carrier under part B of

title XVIII of the Social Security Act [this part] before having a

hearing before an administrative law judge respecting carrier

determinations under that part. The Comptroller General shall

report to the Congress on the results of such study by not later

than June 30, 1989."

CAPACITY TO SET GEOGRAPHIC PAYMENT LIMITS

Section 4085(e) of Pub. L. 100-203 provided that: "The Secretary

of Health and Human Services shall develop the capability to

implement (for services furnished on or after January 1, 1989)

geographic limits on charges and payments under part B of title

XVIII of the Social Security Act [this part] for physicians'

services based on statewide, regional, or national average (or

percentile in a distribution) of prevailing charges or payment

amounts (weighted by frequency of services). Any such limits shall

take into account adjustments for geographic differences in cost of

practice and cost of living."

UTILIZATION SCREENS FOR PHYSICIAN SERVICES PROVIDED TO PATIENTS IN

REHABILITATION HOSPITALS

Section 4114 of Pub. L. 101-508, as amended by Pub. L. 103-432,

title I, Sec. 126(g)(4), Oct. 31, 1994, 108 Stat. 4416, provided

that: "Not later than 180 days after the date of the enactment of

this Act [Nov. 5, 1990], the Secretary of Health and Human Services

shall issue guidelines to assure a uniform level of review of

physician visits to patients of a rehabilitation hospital or unit

after the medical review screen parameter established under section

4085(h) of the Omnibus Budget Reconciliation Act of 1987 [Pub. L.

100-203, set out below] has been exceeded."

Section 4085(h) of Pub. L. 100-203 provided that:

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

(in consultation with appropriate physician groups, including those

representing rehabilitative medicine) a separate utilization screen

for physician visits to patients in rehabilitation hospitals and

rehabilitative units (and patients in long-term care hospitals

receiving rehabilitation services) to be used by carriers under

section 1842 of the Social Security Act [this section] in

performing functions under subsection (a) of such section related

to the utilization practices of physicians in such hospitals and

units.

"(2) Not later than 12 months after the date of enactment of this

Act [Dec. 22, 1987], the Secretary of Health and Human Services

shall take appropriate steps to implement the utilization screen

established under paragraph (1)."

PLAN AMENDMENTS NOT REQUIRED UNTIL JANUARY 1, 1989

For provisions directing that if any amendments made by subtitle

A or subtitle C of title XI [Secs. 1101-1147 and 1171-1177] or

title XVIII [Secs. 1800-1899A] of Pub. L. 99-514 require an

amendment to any plan, such plan amendment shall not be required to

be made before the first plan year beginning on or after Jan. 1,

1989, see section 1140 of Pub. L. 99-514, as amended, set out as a

note under section 401 of Title 26, Internal Revenue Code.

AMENDMENTS IN CONTRACTS AND REGULATIONS

The Secretary of Health and Human Services to provide for such

timely amendments to contracts under this section, and regulations,

to such extent as may be necessary to implement Pub. L. 99-509 on a

timely basis, see section 9311(d)(3) of Pub. L. 99-509, set out as

an Effective Date of 1986 Amendment note under section 1395h of

this title.

MEDICARE ECONOMIC INDEX

Section 9331(c)(1), (2), (4)-(6) of Pub. L. 99-509 provided that:

"(1) For 1987. - Notwithstanding any other provision of law, for

purposes of part B of title XVIII of the Social Security Act [this

part] for physicians' services furnished in 1987, the percentage

increase in the MEI (as defined in section 1842(b)(4)(E)(ii) of the

Social Security Act [subsec. (b)(4)(E)(ii) of this section]) shall

be 3.2 percent.

"(2) Prohibiting retroactive adjustment of medicare economic

index. - The Secretary of Health and Human Services is not

authorized to revise the MEI in a manner that provides, for any

period before January 1, 1985, for the substitution of a rental

equivalence or rental substitution factor for the housing component

of the consumer price index."

"(4) Study. - The Secretary shall conduct a study of the extent

to which the MEI appropriately and equitably reflects economic

changes in the provision of the physicians' services to medicare

beneficiaries. In conducting such study the Secretary shall consult

with appropriate experts.

"(5) Limitation on changes in mei methodology. - The Secretary

shall not change the methodology (including the basis and elements)

used in the MEI from that in effect as of October 1, 1985, until

completion of the study under paragraph (4). After the completion

of the study, the Secretary may not change such methodology except

after providing notice in the Federal Register and opportunity for

public comment.

"(6) MEI defined. - In this subsection, the term 'MEI' means the

economic index referred to in the fourth sentence of section

1842(b)(3) of the Social Security Act [subsec. (b)(3) of this

section]."

DEVELOPMENT AND USE OF HCFA COMMON PROCEDURE CODING SYSTEM

Section 9331(d) of Pub. L. 99-509 provided that:

"(1) Not later than July 1, 1989, the Secretary of Health and

Human Services (in this subsection referred to as the 'Secretary'),

after public notice and opportunity for public comment and after

consulation [consultation] with appropriate medical and other

experts, shall group the procedure codes contained in any HCFA

Common Procedure Coding System for payment purposes to minimize

inappropriate increases in the intensity or volume of services

provided as a result of coding distinctions which do not reflect

substantial differences in the services rendered.

"(2) Not later than January 1, 1990, each carrier with which the

Secretary has entered into a contract under section 1842 of the

Social Security Act [this section] shall make payments under part B

of title XVIII of such Act [this part] based on the grouping of

procedure codes effected under paragraph (1)."

MEASURING CARRIER PERFORMANCE; CARRIER BONUSES FOR GOOD PERFORMANCE

Section 9332(a)(2), (3) of Pub. L. 99-509, as amended by Pub. L.

100-203, title IV, Sec. 4085(i)(21)(B), Dec. 22, 1987, 101 Stat.

1330-133, which provided that the Secretary of Health and Human

Services was to provide, in the standards and criteria established

under section 1842(b)(2) of the Social Security Act [subsec. (b)(2)

of this section] for contracts under that section, a system to

measure a carrier's performance of the responsibilities described

in sections 1842(b)(3)(H) and 1842(h) of such Act and that, of the

amounts appropriated for administrative activities to carry out

part B of title XVIII of the Social Security Act [this part], the

Secretary of Health and Human Services was to provide payments,

totaling 1 percent of the total payments to carriers for claims

processing in any fiscal year, to carriers under section 1842 of

such Act, to reward such carriers for their success in increasing

the proportion of physicians in the carrier's service area who were

participating physicians or in increasing the proportion of total

payments for physicians' services which were payments for such

services rendered by participating physicians, was repealed by Pub.

L. 100-203, title IV, Sec. 4041(a)(3)(B)(i), Dec. 22, 1987, 101

Stat. 1330-84.

Section 9332(a)(4)(B), (C) of Pub. L. 99-509, as amended by Pub.

L. 100-203, title IV, Sec. 4041(a)(3)(B)(ii), (iii), Dec. 22, 1987,

101 Stat. 1330-84; Pub. L. 100-360, title IV, Sec. 411(f)(1)(C),

July 1, 1988, 102 Stat. 776, provided that:

"(B) Performance measures. - The Secretary of Health and Human

Services shall provide for the establishment of the standards and

criteria required under the last sentence of section 1842(b)(2) of

the Social Security Act [subsec. (b)(2) of this section] by not

later than October 1, 1987, which shall apply to contracts as of

October 1, 1987.

"(C) Carrier bonuses. - From the amounts appropriated for each

fiscal year (beginning with fiscal year 1988), the Secretary of

Health and Human Services shall first provide for payments of

bonuses to carriers under section 1842(c)(1)(B) of the Social

Security Act [subsec. (c)(1)(B) of this section] not later than

September 30, 1988, to reflect performance of carriers during the

enrollment period before April 1, 1988."

REVIEW OF PROCEDURES

Section 9333(c) of Pub. L. 99-509 provided that: "Not later than

October 1, 1987, the Secretary of Health and Human Services shall

review the inherent reasonableness of the reasonable charges for at

least 10 of the most costly procedures with respect to which

payment is made under part B of title XVIII of the Social Security

Act [this part] (determined on the basis of the aggregate annual

payments under such part with respect to each such procedure)."

RATIFICATION OF REGULATIONS

Section 9334(b) of Pub. L. 99-509, as amended by Pub. L. 100-203,

title IV, Sec. 4045(c)(2)(C), Dec. 22, 1987, 101 Stat. 1330-88,

provided that:

"(1) In general. - The Congress hereby ratifies the final

regulation of the Secretary of Health and Human Services published

on page 35693 of volume 51 of the Federal Register on October 7,

1986, relating to reasonable charge payment limits for anesthesia

services under the medicare program.

"(2) Patient protections. - In the case of any reduction in the

reasonable charge for physicians' services effected under the

regulation described in paragraph (1), the provisions of section

1842(j)(1)(D) of the Social Security Act [subsec. (j)(1)(D) of this

section] (added by the amendment made by subsection (a)(3)) shall

apply in the same manner and to the same extent as they apply to a

reduction in the reasonable charge for a physicians' service

effected under section 1842(b)(8) of such Act."

PAYMENT FOR PARENTERAL AND ENTERAL NUTRITION SUPPLIES AND EQUIPMENT

Section 9340 of Pub. L. 99-509 provided that: "The Secretary of

Health and Human Services shall apply the sixth sentence of section

1842(b)(3) of the Social Security Act [subsec. (b)(3) of this

section] to payment -

"(1) for enteral nutrition nutrients, supplies, and equipment

and parenteral nutrition supplies and equipment furnished on or

after January 1, 1987, and

"(2) for parenteral nutrition nutrients furnished on or after

October 1, 1987."

REPORTING OF OPD SERVICES USING HCPCS

Section 9343(g) of Pub. L. 99-509 provided that: "Not later than

July 1, 1987, each fiscal intermediary which processes claims under

part B of title XVIII of the Social Security Act [this part] shall

require hospitals, as a condition of payment for outpatient

hospital services under that part, to report claims for payment for

such services under such part using a HCFA Common Procedure Coding

System."

PERIOD FOR ENTERING INTO PARTICIPATION AGREEMENTS

Section 9301(b)(3) of Pub. L. 99-272 provided that: "The

Secretary of Health and Human Services shall provide, during the

month of April 1986, that physicians and suppliers may enter into

an agreement under section 1842(h)(1) of the Social Security Act

[subsec. (h)(1) of this section] for the 8-month period beginning

May 1, 1986, or terminate such an agreement previously entered into

for fiscal year 1986. In the case of a physician or supplier who

entered into such an agreement for fiscal year 1986, the physician

or supplier shall be deemed to have entered into such agreement for

such 8-month period and for each succeeding year unless the

physician or supplier terminates such agreement before the

beginning of the respective period. At the beginning of such

8-month period, the Secretary shall publish a new directory

(described in section 1842(h)(4) of that Act [subsec. (h)(4) of

this section], as redesignated by subsection (c)(3)(D) of this

section) of participating physicians and suppliers."

TRANSITIONAL PROVISIONS FOR MEDICARE PART B PAYMENTS

Section 9301(d)(5) of Pub. L. 99-272 provided that:

"Notwithstanding any other provision of law, for purposes of making

payment under part B of title XVIII of the Social Security Act

[this part], customary and prevailing charges (and the lowest

charges determined under the sixth sentence of section 1842(b)(3)

of such Act [subsec. (b)(3) of this section]) for items and

services furnished during the period beginning on October 1, 1986,

and ending on December 31, 1986, shall be determined on the same

basis as for items and services furnished on September 30, 1986."

COMPUTATION OF CUSTOMARY CHARGES FOR CERTAIN FORMER

HOSPITAL-COMPENSATED PHYSICIANS

Section 9304(b) of Pub. L. 99-272 provided that:

"(1) In applying section 1842(b) of the Social Security Act

[subsec. (b) of this section] to payment for physicians' services

performed during the 8-month period beginning May 1, 1986, in the

case of a physician who at anytime during the period beginning on

October 31, 1982, and ending on January 31, 1985, was a

hospital-compensated physician (as defined in paragraph (3)) but

who, as of February 1, 1985, was no longer a hospital-compensated

physician, the physician's customary charges shall -

"(A) be based upon the physician's actual charges billed during

the 12-month period ending on March 31, 1985, and

"(B) in the case of a physician who was not a participating

physician (as defined in section 1842(h)(1) of the Social

Security Act [subsec. (h)(1) of this section]) on September 30,

1985, and who is not such a physician on May 1, 1986, be deflated

(to take into account the legislative freeze on actual charges

for nonparticipating physicians' services) by multiplying the

physician's customary charges by .85.

"(2) In applying section 1842(b) of the Social Security Act

[subsec. (b) of this section] to payment for physicians' services

performed during the 8-month period beginning May 1, 1986, in the

case of a physician who during the period beginning on February 1,

1985, and ending on December 31, 1986, changes from being a

hospital-compensated physician to not being a hospital-compensated

physician, the physician's customary charges shall be determined in

the same manner as if the physician were considered to be a new

physician.

"(3) In this subsection, the term 'hospital-compensated

physician' means, with respect to services furnished to patients of

a hospital, a physician who is compensated by the hospital for the

furnishing of physicians' services for which payment may be made

under this part."

EXTENSION OF MEDICARE PHYSICIAN PAYMENT PROVISIONS

Period of 15 months referred to in subsec. (j)(1) of this section

for monitoring the charges of nonparticipating physicians to be

deemed to include the period Oct. 1, 1985, to Mar. 14, 1986, see

section 5(b) of Pub. L. 99-107, set out as a note under section

1395ww of this title.

SIMPLIFICATION OF PROCEDURES WITH RESPECT TO CLAIMS AND PAYMENTS

FOR CLINICAL DIAGNOSTIC LABORATORY TESTS

Section 2303(h) of Pub. L. 98-369 provided that: "The Secretary

of Health and Human Services shall simplify the procedures under

section 1842 of the Social Security Act [this section] with respect

to claims and payments for clinical diagnostic laboratory tests so

as to reduce unnecessary paperwork while assuring that sufficient

information is supplied to identify instances of fraud and abuse."

STUDY OF AMOUNTS BILLED FOR PHYSICIAN SERVICES AND PAID BY CARRIERS

UNDER SUBSECTION (B)(7) OF THIS SECTION; REPORT TO CONGRESS

Section 2307(c) of Pub. L. 98-369 directed Comptroller General to

conduct a study of the amounts billed for physician services and

paid by carriers under subsec. (b)(7) of this section to determine

whether such payments were made only where the physician satisfied

the requirements of subsec. (b)(7)(A)(i) of this section, and to

submit to Congress a report on results of such study not later than

18 months after July 18, 1984.

REPLACEMENT OF AGENCY, ORGANIZATION, OR CARRIER PROCESSING MEDICARE

CLAIMS; NUMBER OF AGREEMENTS AND CONTRACTS AUTHORIZED FOR FISCAL

YEARS 1985 THROUGH 1993

For provision authorizing two agreements under section 1395h of

this title and two contracts under this section for replacement of

an agency, organization, or carrier in the lowest 20th percentile,

see section 2326(a) of Pub. L. 98-369, as amended, set out as a

note under 1395h of this title.

RULES AND REGULATIONS

Section 113(b)(2) of Pub. L. 97-248 provided that: "The Secretary

of Health and Human Services shall first issue such final

regulations (whether on an interim or other basis) before October

1, 1982, as may be necessary to implement the amendment made by

subsection (a) [amending this section] on a timely basis. If such

regulations are promulgated on an interim final basis, the

Secretary shall take such steps as may be necessary to provide

opportunity for public comment, and appropriate revision based

thereon, so as to provide that such regulations are not on an

interim basis later than January 31, 1983."

REPORT ON REIMBURSEMENT OF CLINICAL LABORATORIES

Section 918(a)(3) of Pub. L. 96-499 provided that not later than

24 months after an effective date (not later than Apr. 1, 1981)

which was to have been prescribed by the Secretary of Health and

Human Services, the Secretary was to report to the Congress (A) the

proportion of bills and requests for payment submitted (during the

18-month period beginning on such effective date) under this

subchapter for laboratory tests which did not identify who

performed the tests, (B) the proportion of bills and requests for

payment submitted during such period for laboratory tests with

respect to which the amount paid under this subchapter was less

than the amount that would otherwise have been payable in the

absence of subsec. (h) of this section, (C) with respect to

requests for payment described in subparagraph (B) which were

submitted by patients, the average additional cost per laboratory

test to patients resulting from reductions in payment that would

otherwise have been made for such tests in the absence of such

subsec. (h), and (D) with respect to bills described in

subparagraph (B) which were submitted by physicians, the average

reduction in payment per laboratory test to physicians resulting

from the application of such subsec. (h).

PREVAILING CHARGE LEVELS FOR FISCAL YEAR BEGINNING JULY 1, 1975

Section 101(b) of Pub. L. 94-182 provided that: "The amendment

made by subsection (a) [amending subsec. (b)(3) of this section]

shall be applicable with respect to claims filed under part B of

title XVIII of the Social Security Act [this part] with a carrier

designated pursuant to section 1842 of such Act [this section] and

processed by such carrier after the appropriate changes were made

in the prevailing charge levels for the fiscal year beginning July

1, 1975, on the basis of economic index data under the third and

fourth sentences of section 1842(b)(3) of such Act [subsec. (b)(3)

of this section]; except that (1) if less than the correct amount

was paid (after the application of subsection (a) of this section)

on any claim processed prior to the enactment of this section [Dec.

31, 1975], the correct amount shall be paid by such carrier at such

time (not exceeding 6 months after the date of the enactment of

this section) [Dec. 31, 1975] as is administratively feasible, and

(2) no such payment shall be made on any claim where the difference

between the amount paid and the correct amount due is less than

$1."

REPORT BY HEALTH INSURANCE BENEFITS ADVISORY COUNCIL ON METHODS OF

REIMBURSEMENT OF PHYSICIANS FOR THEIR SERVICES

Section 224(b) of Pub. L. 92-603 directed Health Insurance

Benefits Advisory Council to conduct a study of methods of

reimbursement for physicians' services under Medicare with respect

to fees, extent of assignments accepted by physicians, and share of

physician-fee costs which Medicare program does not pay and submit

such study to Congress by Jan. 1, 1973.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 238m, 254g, 704, 1320a-3,

1320a-7a, 1320a-7b, 1320c-2, 1320c-3, 1395a, 1395k, 1395l, 1395m,

1395t, 1395v, 1395w-4, 1395w-27, 1395y, 1395cc, 1395cc-2, 1395ff,

1395gg, 1395mm, 1395pp, 1395qq, 1395ss, 1395vv, 1395ddd, 1395fff,

1396a, 1396b, 1396m, 1397d of this title; title 2 section 906;

title 5 section 8904; title 25 section 1616m.

-FOOTNOTE-

(!1) See References in Text note below.

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

(!3) So in original. The period probably should be ", and".

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

-End-

-CITE-

42 USC Sec. 1395v 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. 1395v. Agreements with States

-STATUTE-

(a) Duty of Secretary; enrollment of eligible individuals

The Secretary shall, at the request of a State made before

January 1, 1970, or during 1981 or after 1988, enter into an

agreement with such State pursuant to which all eligible

individuals in either of the coverage groups described in

subsection (b) of this section (as specified in the agreement) will

be enrolled under the program established by this part.

(b) Coverage of groups to which applicable

An agreement entered into with any State pursuant to subsection

(a) of this section may be applicable to either of the following

coverage groups:

(1) individuals receiving money payments under the plan of such

State approved under subchapter I of this chapter or subchapter

XVI of this chapter; or

(2) individuals receiving money payments under all of the plans

of such State approved under subchapters I, X, XIV, and XVI of

this chapter, and part A of subchapter IV of this chapter.

Except as provided in subsection (g) of this section, there shall

be excluded from any coverage group any individual who is entitled

to monthly insurance benefits under subchapter II of this chapter

or who is entitled to receive an annuity under the Railroad

Retirement Act of 1974 [45 U.S.C. 231 et seq.]. Effective January

1, 1974, and subject to section 1396a(f) of this title, the

Secretary shall, at the request of any State not eligible to

participate in the State plan program established under subchapter

XVI of this chapter, continue in effect the agreement entered into

under this section with such State subject to such modifications as

the Secretary may by regulations provide to take account of the

termination of any plans of such State approved under subchapters

I, X, XIV, and XVI of this chapter and the establishment of the

supplemental security income program under subchapter XVI of this

chapter.

(c) Eligible individuals

For purposes of this section, an individual shall be treated as

an eligible individual only if he is an eligible individual (within

the meaning of section 1395o of this title) on the date an

agreement covering him is entered into under subsection (a) of this

section or he becomes an eligible individual (within the meaning of

such section) at any time after such date; and he shall be treated

as receiving money payments described in subsection (b) of this

section if he receives such payments for the month in which the

agreement is entered into or any month thereafter.

(d) Monthly premiums; coverage periods

In the case of any individual enrolled pursuant to this section -

(1) the monthly premium to be paid by the State shall be

determined under section 1395r of this title (without any

increase under subsection (b) thereof);

(2) his coverage period shall begin on whichever of the

following is the latest:

(A) July 1, 1966;

(B) the first day of the third month following the month in

which the State agreement is entered into;

(C) the first day of the first month in which he is both an

eligible individual and a member of a coverage group specified

in the agreement under this section; or

(D) such date as may be specified in the agreement; and

(3) his coverage period attributable to the agreement with the

State under this section shall end on the last day of whichever

of the following first occurs:

(A) the month in which he is determined by the State agency

to have become ineligible both for money payments of a kind

specified in the agreement and (if there is in effect a

modification entered into under subsection (h) of this section)

for medical assistance, or

(B) the month preceding the first month for which he becomes

entitled to monthly benefits under subchapter II of this

chapter or to an annuity or pension under the Railroad

Retirement Act of 1974 [45 U.S.C. 231 et seq.].

(e) Subsection (d)(3) terminations deemed resulting in section

1395p enrollment

Any individual whose coverage period attributable to the State

agreement is terminated pursuant to subsection (d)(3) of this

section shall be deemed for purposes of this part (including the

continuation of his coverage period under this part) to have

enrolled under section 1395p of this title in the initial general

enrollment period provided by section 1395p(c) of this title. The

coverage period under this part of any such individual who (in the

last month of his coverage period attributable to the State

agreement or in any of the following six months) files notice that

he no longer wishes to participate in the insurance program

established by this part, shall terminate at the close of the month

in which the notice is filed.

(f) "Carrier" as including State agency; provisions facilitating

deductions, coinsurance, etc., and leading to economy and

efficiency of operation

With respect to eligible individuals receiving money payments

under the plan of a State approved under subchapter I, X, XIV, or

XVI of this chapter, or part A of subchapter IV of this chapter, or

eligible to receive medical assistance under the plan of such State

approved under subchapter XIX of this chapter, if the agreement

entered into under this section so provides, the term "carrier" as

defined in section 1395u(f) of this title also includes the State

agency, specified in such agreement, which administers or

supervises the administration of the plan of such State approved

under subchapter I, XVI, or XIX of this chapter. The agreement

shall also contain such provisions as will facilitate the financial

transactions of the State and the carrier with respect to

deductions, coinsurance, and otherwise, and as will lead to economy

and efficiency of operation, with respect to individuals receiving

money payments under plans of the State approved under subchapters

I, X, XIV, and XVI of this chapter, and part A of subchapter IV of

this chapter, and individuals eligible to receive medical

assistance under the plan of the State approved under subchapter

XIX of this chapter.

(g) Subsection (b) exclusions from coverage groups

(1) The Secretary shall, at the request of a State made before

January 1, 1970, or during 1981 or after 1988, enter into a

modification of an agreement entered into with such State pursuant

to subsection (a) of this section under which the second sentence

of subsection (b) of this section shall not apply with respect to

such agreement.

(2) In the case of any individual who would (but for this

subsection) be excluded from the applicable coverage group

described in subsection (b) of this section by the second sentence

of such subsection -

(A) subsections (c) and (d)(2) of this section shall be applied

as if such subsections referred to the modification under this

subsection (in lieu of the agreement under subsection (a) of this

section), and

(B) subsection (d)(3)(B) of this section shall not apply so

long as there is in effect a modification entered into by the

State under this subsection.

(h) Modifications respecting subsection (b) coverage groups

(1) The Secretary shall, at the request of a State made before

January 1, 1970, or during 1981 or after 1988, enter into a

modification of an agreement entered into with such State pursuant

to subsection (a) of this section under which the coverage group

described in subsection (b) of this section and specified in such

agreement is broadened to include (A) individuals who are eligible

to receive medical assistance under the plan of such State approved

under subchapter XIX of this chapter, or (B) qualified medicare

beneficiaries (as defined in section 1396d(p)(1) of this title).

(2) For purposes of this section, an individual shall be treated

as eligible to receive medical assistance under the plan of the

State approved under subchapter XIX of this chapter if, for the

month in which the modification is entered into under this

subsection or for any month thereafter, he has been determined to

be eligible to receive medical assistance under such plan. In the

case of any individual who would (but for this subsection) be

excluded from the agreement, subsections (c) and (d)(2) of this

section shall be applied as if they referred to the modification

under this subsection (in lieu of the agreement under subsection

(a) of this section), and subsection (d)(2)(C) of this section

shall be applied (except in the case of qualified medicare

beneficiaries, as defined in section 1396d(p)(1) of this title) by

substituting "second month following the first month" for "first

month".

(3) In this subsection, the term "qualified medicare beneficiary"

also includes an individual described in section

1396a(a)(10)(E)(iii) of this title.

(i) Enrollment of qualified medicare beneficiaries

For provisions relating to enrollment of qualified medicare

beneficiaries under part A of this subchapter, see section

1395i-2(g) of this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1843, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 312; amended

Pub. L. 89-384, Sec. 4(a), (b), Apr. 8, 1966, 80 Stat. 105; Pub. L.

90-248, title II, Secs. 222(a), (b), (e), 241(e), Jan. 2, 1968, 81

Stat. 900, 901, 917; Pub. L. 93-233, Sec. 18(l), Dec. 31, 1973, 87

Stat. 970; Pub. L. 93-445, title III, Sec. 308, Oct. 16, 1974, 88

Stat. 1358; Pub. L. 96-499, title IX, Secs. 945(e), 947(a), (c),

Dec. 5, 1980, 94 Stat. 2642, 2643; Pub. L. 98-21, title VI, Sec.

606(a)(3)(E), Apr. 20, 1983, 97 Stat. 171; Pub. L. 98-369, div. B,

title III, Sec. 2354(b)(15), July 18, 1984, 98 Stat. 1101; Pub. L.

100-360, title III, Sec. 301(e)(1), July 1, 1988, 102 Stat. 749;

Pub. L. 100-485, title VI, Sec. 608(d)(14)(H), Oct. 13, 1988, 102

Stat. 2416; Pub. L. 101-239, title VI, Sec. 6013(b), Dec. 19, 1989,

103 Stat. 2164; Pub. L. 101-508, title IV, Sec. 4501(d), Nov. 5,

1990, 104 Stat. 1388-165.)

-REFTEXT-

REFERENCES IN TEXT

Part A of subchapter IV of this chapter, referred to in subsecs.

(b)(2) and (f), is classified to section 601 et seq. of this title.

The Railroad Retirement Act of 1974, referred to in subsec.

(d)(3)(B), is act Aug. 29, 1935, ch. 812, as amended generally by

Pub. L. 93-445, title I, Sec. 101, Oct. 16, 1974, 88 Stat. 1305,

which is classified generally to subchapter IV (Sec. 231 et seq.)

of chapter 9 of Title 45, Railroads. For further details and

complete classification of this Act to the Code, see Codification

note set out preceding section 231 of Title 45, section 231t of

Title 45, and Tables.

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

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

-MISC1-

AMENDMENTS

1990 - Subsec. (h)(3). Pub. L. 101-508 added par. (3).

1989 - Subsec. (i). Pub. L. 101-239 added subsec. (i).

1988 - Subsecs. (a), (g)(1). Pub. L. 100-360, Sec. 301(e)(1)(A),

formerly Sec. 301(e)(1), as redesignated by Pub. L. 100-485, Sec.

608(d)(14)(H)(i), inserted "or after 1988" after "during 1981".

Subsec. (h)(1). Pub. L. 100-360, Sec. 301(e)(1)(A), formerly Sec.

301(e)(1), as redesignated by Pub. L. 100-485, Sec.

608(d)(14)(H)(i), inserted "or after 1988" after "during 1981".

Pub. L. 100-360, Sec. 301(e)(1)(B), as added by Pub. L. 100-485,

Sec. 608(d)(14)(H)(ii), inserted cl. (A) designation after

"include" and added cl. (B).

Subsec. (h)(2). Pub. L. 100-360, Sec. 301(e)(1)(C), as added by

Pub. L. 100-485, Sec. 608(d)(14)(H)(ii), inserted "(except in the

case of qualified medicare beneficiaries, as defined in section

1396d(p)(1) of this title)" after "shall be applied".

1984 - Subsec. (d)(3)(B). Pub. L. 98-369 substituted "1974" for

"1937".

1983 - Subsec. (d)(1). Pub. L. 98-21 substituted "without any

increase under subsection (b) thereof" for "without any increase

under subsection (c) thereof".

1980 - Subsec. (a). Pub. L. 96-499, Sec. 945(e), inserted "or

during 1981," after "January 1, 1970,".

Subsec. (e). Pub. L. 96-499, Sec. 947(a), inserted provision that

the coverage period under this part of any individual who filed

notice that he no longer wished to participate in the insurance

program established by this part was to terminate at the close of

the month in which the notice was filed.

Subsec. (g)(1). Pub. L. 96-499, Sec. 945(e), inserted "or during

1981," after "January 1, 1970,".

Subsec. (g)(2)(C). Pub. L. 96-499, Sec. 947(c)(3), struck out cl.

(C) which authorized individuals facing exclusion from the

applicable coverage group to terminate their enrollment under this

part by the filing of a notice indicating he no longer wished to

participate in the insurance program established by this part.

Subsec. (h)(1). Pub. L. 96-499, Sec. 945(e), inserted "or during

1981," after "January 1, 1970,".

1974 - Subsec. (b). Pub. L. 93-445 substituted "under the

Railroad Retirement Act of 1974" for "or pension under the Railroad

Retirement Act of 1937".

1973 - Subsec. (b). Pub. L. 93-233 provided for continuation of

State agreements for coverage of certain individuals in connection

with establishment of supplemental security income program.

1968 - Pub. L. 90-248, Sec. 222(b)(4), inserted "(or are eligible

for medical assistance)" in section catchline.

Subsec. (a). Pub. L. 90-248, Sec. 222(e)(1), substituted "1970"

for "1968".

Subsec. (b)(2). Pub. L. 90-248, Sec. 241(e)(1), struck out "IV,"

after "I," and inserted ", and part A of subchapter IV of this

chapter" after "XVI of this chapter".

Subsec. (c). Pub. L. 90-248, Sec. 222(e)(2), struck out "and

before January 1, 1968" after "such date" and "before January 1968"

after "thereafter" just before the period.

Subsec. (d)(2)(D). Pub. L. 90-248, Sec. 222(e)(3), struck out

"(not later than January 1, 1968)" after "such date".

Subsec. (d)(3)(A). Pub. L. 90-248, Sec. 222(b)(1), substituted

"ineligible both for money payments of a kind specified in the

agreement and (if there is in effect a modification entered into

under subsection (h) of this section) for medical assistance" for

"ineligible for money payments of a kind specified in the

agreement".

Subsec. (f). Pub. L. 90-248, Sec. 222(b)(2), inserted "or

eligible to receive medical assistance under the plan of such State

approved under subchapter XIX of this chapter" and ", and

individuals eligible to receive medical assistance under the plan

of the State approved under subchapter XIX of this chapter" after

"or part A of subchapter IV of this chapter" and ", and part A of

subchapter IV of this chapter", respectively.

Pub. L. 90-248, Sec. 241(e)(2), struck out "IV," before "X," in

two places, and inserted "or part A of subchapter IV of this

chapter," after "XVI of this chapter," first place it appears in

first sentence and ", and part A of subchapter IV of this chapter"

after "XVI of this chapter" in second sentence.

Subsec. (g)(1). Pub. L. 90-248, Sec. 222(b)(3), substituted

"1970" for "1968".

Subsec. (h). Pub. L. 90-248, Sec. 222(a), added subsec. (h).

1966 - Subsec. (b). Pub. L. 89-384, Sec. 4(a), inserted reference

to subsec. (g) in exclusionary provision.

Subsec. (g). Pub. L. 89-384, Sec. 4(b), added subsec. (g).

EFFECTIVE DATE OF 1990 AMENDMENT

Amendment by Pub. L. 101-508 applicable to calendar quarters

beginning on or after Jan. 1, 1991, without regard to whether or

not regulations to implement such amendment are promulgated by such

date, see section 4501(f) of Pub. L. 101-508, set out as a note

under section 1396a of this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by Pub. L. 101-239 effective Jan. 1, 1990, see section

6013(c) of Pub. L. 101-239, set out as a note under section 1395i-2

of this title.

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.

Section 301(e)(3) of Pub. L. 100-360 provided that: "The

amendment made by paragraph (1) [amending this section] shall take

effect on January 1, 1989, and the amendments made by paragraph (2)

[amending section 1396a of this title] shall take effect on July 1,

1989."

EFFECTIVE DATE OF 1984 AMENDMENT

Amendment by Pub. L. 98-369 effective July 18, 1984, but not to

be construed as changing or affecting any right, liability, status,

or interpretation which existed (under the provisions of law

involved) before that date, see section 2354(e)(1) of Pub. L.

98-369, set out as a note under section 1320a-1 of this title.

EFFECTIVE DATE OF 1983 AMENDMENT; TRANSITIONAL RULE

Amendment by Pub. L. 98-21 applicable to premiums for months

beginning with January 1984, but for months after June 1983 and

before January 1984, the monthly premium for June 1983 shall apply

to individuals enrolled under parts A and B of this subchapter, see

section 606(c) of Pub. L. 98-21, set out as a note under section

1395r of this title.

EFFECTIVE DATE OF 1980 AMENDMENT

Section 947(d) of Pub. L. 96-499 provided that: "The amendments

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

this title] apply to notices filed after the third calendar month

beginning after the date of the enactment of this Act [Dec. 5,

1980]."

EFFECTIVE DATE OF 1974 AMENDMENT

Amendment by Pub. L. 93-445 effective Jan. 1, 1975, see section

603 of Pub. L. 93-445, set out as a note under section 402 of this

title.

EFFECTIVE DATE OF 1973 AMENDMENT

Amendment by Pub. L. 93-233 effective Jan. 1, 1974, see section

18(z-3)(1) of Pub. L. 93-233.

TERMINATION PERIOD FOR CERTAIN INDIVIDUALS COVERED PURSUANT TO

STATE AGREEMENTS

Section 947(e) of Pub. L. 96-499 provided that: "The coverage

period under part B of title XVIII of the Social Security Act [this

part] of an individual whose coverage period attributable to a

State agreement under section 1843 of such Act [this section] is

terminated and who has filed notice before the end of the third

calendar month beginning after the date of the enactment of this

Act [Dec. 5, 1980] that he no longer wishes to participate in the

insurance program established by part B of title XVIII shall

terminate on the earlier of (1) the day specified in section 1838

[section 1395q of this title] without the amendments made by this

section, or (2) (unless the individual files notice before the day

specified in this clause that he wishes his coverage period to

terminate as provided in clause (1)) the day on which his coverage

period would terminate if the individual filed notice in the fourth

calendar month beginning after the date of the enactment of this

Act."

DISTRICT OF COLUMBIA; AGREEMENT OF COMMISSIONER WITH SECRETARY FOR

SUPPLEMENTARY MEDICAL INSURANCE

Pub. L. 90-227, Sec. 2, Dec. 27, 1967, 81 Stat. 745, provided

that: "The Commissioner [now Mayor of District of Columbia] may

enter into an agreement (and any modifications of such agreement)

with the Secretary under section 1843 of the Social Security Act

[this section] pursuant to which (1) eligible individuals (as

defined in section 1836 of the Social Security Act) [section 1395o

of this title] who are eligible to receive medical assistance under

the District of Columbia's plan for medical assistance approved

under title XIX of the Social Security Act [subchapter XIX of this

chapter] will be enrolled in the supplementary medical insurance

program established under part B of title XVIII of the Social

Security Act [this part], and (2) provisions will be made for

payment of the monthly premiums of such individuals for such

program."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1395i-2, 1395q, 1395s,

1396a of this title.

-End-

-CITE-

42 USC Sec. 1395w 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. 1395w. Appropriations to cover Government contributions and

contingency reserve

-STATUTE-

(a) In general

There are authorized to be appropriated from time to time, out of

any moneys in the Treasury not otherwise appropriated, to the

Federal Supplementary Medical Insurance Trust Fund -

(1)(A) a Government contribution equal to the aggregate

premiums payable for a month for enrollees age 65 and over under

this part and deposited in the Trust Fund, multiplied by the

ratio of -

(i) twice the dollar amount of the actuarially adequate rate

per enrollee age 65 and over as determined under section

1395r(a)(1) of this title for such month minus the dollar

amount of the premium per enrollee for such month, as

determined under section 1395r(a)(3) of this title, to

(ii) the dollar amount of the premium per enrollee for such

month, plus

(B) a Government contribution equal to the aggregate premiums

payable for a month for enrollees under age 65 under this part

and deposited in the Trust Fund, multiplied by the ratio of -

(i) twice the dollar amount of the actuarially adequate rate

per enrollee under age 65 as determined under section

1395r(a)(4) of this title for such month minus the dollar

amount of the premium per enrollee for such month, as

determined under section 1395r(a)(3) of this title, to

(ii) the dollar amount of the premium per enrollee for such

month; plus

(2) such sums as the Secretary deems necessary to place the

Trust Fund, at the end of any fiscal year occurring after June

30, 1967, in the same position in which it would have been at the

end of such fiscal year if (A) a Government contribution

representing the excess of the premiums deposited in the Trust

Fund during the fiscal year ending June 30, 1967, over the

Government contribution actually appropriated to the Trust Fund

during such fiscal year had been appropriated to it on June 30,

1967, and (B) the Government contribution for premiums deposited

in the Trust Fund after June 30, 1967, had been appropriated to

it when such premiums were deposited.

(b) Contingency reserve

In order to assure prompt payment of benefits provided under this

part and the administrative expenses thereunder during the early

months of the program established by this part, and to provide a

contingency reserve, there is also authorized to be appropriated,

out of any moneys in the Treasury not otherwise appropriated, to

remain available through the calendar year 1969 for repayable

advances (without interest) to the Trust Fund, an amount equal to

$18 multiplied by the number of individuals (as estimated by the

Secretary) who could be covered in July 1966 by the insurance

program established by this part if they had theretofore enrolled

under this part.

(c) Election under section 1395w-24

The Secretary shall determine the Government contribution under

subparagraphs (A) and (B) of subsection (a)(1) of this section

without regard to any premium reduction resulting from an election

under section 1395w-24(f)(1)(E) of this title.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1844, as added Pub. L.

89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 313; amended

Pub. L. 90-248, title I, Sec. 167, Jan. 2, 1968, 81 Stat. 874; Pub.

L. 92-603, title II, Sec. 203(e), Oct. 30, 1972, 86 Stat. 1377;

Pub. L. 97-248, title I, Sec. 124(c), Sept. 3, 1982, 96 Stat. 364;

Pub. L. 98-21, title VI, Sec. 606(a)(3)(F), (G), Apr. 20, 1983, 97

Stat. 171; Pub. L. 98-369, div. B, title III, Sec. 2354(b)(16),

July 18, 1984, 98 Stat. 1101; Pub. L. 100-360, title II, Sec.

211(c)(2), July 1, 1988, 102 Stat. 738; Pub. L. 101-234, title II,

Sec. 202(a), Dec. 13, 1989, 103 Stat. 1981; Pub. L. 105-33, title

IV, Sec. 4571(b)(2), Aug. 5, 1997, 111 Stat. 464; Pub. L. 106-554,

Sec. 1(a)(6) [title VI, Sec. 606(a)(2)(D)], Dec. 21, 2000, 114

Stat. 2763, 2763A-558.)

-MISC1-

AMENDMENTS

2000 - Subsec. (c). Pub. L. 106-554 added subsec. (c).

1997 - Subsec. (a)(1)(A)(i), (B)(i). Pub. L. 105-33 substituted

"section 1395r(a)(3) of this title" for "section 1395r(a)(3) or

1395r(e) of this title, as the case may be".

1989 - Subsec. (a). Pub. L. 101-234 repealed Pub. L. 100-360,

Sec. 211(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.

1988 - Subsec. (a). Pub. L. 100-360 inserted at end "In computing

the amount of aggregate premiums and premiums per enrollee under

paragraph (1), there shall not be taken into account premiums

attributable to section 1395r(g) of this title or section 59B of

the Internal Revenue Code of 1986."

1984 - Subsec. (a)(1)(B)(ii). Pub. L. 98-369 substituted "; plus"

for a period.

1983 - Subsec. (a)(1)(A)(i). Pub. L. 98-21, Sec. 606(a)(3)(F),

substituted "section 1395r(a)(1)" for "section 1395r(c)(1)" and

"section 1395r(a)(3) or 1395r(e)" for "section 1395r(c)(3) or

1395r(g)".

Subsec. (a)(1)(B)(i). Pub. L. 98-21, Sec. 606(a)(3)(G),

substituted "1395r(a)(4)" for "1395r(c)(4)" and "1395r(a)(3) or

1395r(e)" for "1395r(c)(3) or 1395r(g)".

1982 - Subsec. (a)(1)(A)(i), (B)(i). Pub. L. 97-248 substituted

"section 1395r(c)(3) or 1395r(g) of this title, as the case may be"

for "section 1395r(c)(3) of this title".

1972 - Subsec. (a)(1). Pub. L. 92-603 designated existing

provisions as subpar. (A), substituted provisions relating to

Government contributions equal to aggregate premiums payable for a

month for enrollees age 65 and over under this part and deposited

in Trust Fund, and multiplied by specified ratio, for provisions

relating to Government contributions equal to aggregate premiums

payable under this part and deposited in Trust Fund, and added

subpar. (B).

1968 - Subsec. (a). Pub. L. 90-248, Sec. 167(a), designated

existing provisions as par. (1), inserted provision for deposit of

Government contribution in Trust Fund, and added par. (2).

Subsec. (b). Pub. L. 90-248, Sec. 167(b), substituted "1969" for

"1967".

EFFECTIVE DATE OF 2000 AMENDMENT

Amendment by Pub. L. 106-554 applicable to years beginning with

2003, see section 1(a)(6) [title VI, Sec. 606(b)] of Pub. L.

106-554, set out as a note under section 1395r of this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, and

applicable to premiums for months beginning after Dec. 31, 1989,

see section 202(b) of Pub. L. 101-234, set out as a note under

section 401 of this title.

EFFECTIVE DATE OF 1988 AMENDMENT

Amendment by Pub. L. 100-360 applicable, except as otherwise

specified in such amendment, to monthly premiums for months

beginning with January 1989, see section 211(d) of Pub. L. 100-360,

set out as a note under section 1395r of this title.

EFFECTIVE DATE OF 1984 AMENDMENT

Amendment by Pub. L. 98-369 effective July 18, 1984, but not to

be construed as changing or affecting any right, liability, status,

or interpretation which existed (under the provisions of law

involved) before that date, see section 2354(e)(1) of Pub. L.

98-369, set out as a note under section 1320a-1 of this title.

EFFECTIVE DATE OF 1983 AMENDMENT; TRANSITIONAL RULE

Amendment by Pub. L. 98-21 applicable to premiums for months

beginning with January 1984, but for months after June 1983 and

before January 1984, the amount of Government contributions under

subsec. (a)(1) of this section shall be computed with the

actuarially adequate rate which would have been in effect but for

the amendments made by this section and using the amount of the

premium in effect for June 1983, see section 606(c) of Pub. L.

98-21, set out as a note under section 1395r of this title.

EFFECTIVE DATE OF 1972 AMENDMENT

Section 203(e) of Pub. L. 92-603 provided that the amendment made

by that section is effective with respect to enrollee premiums

payable for months after June 1973.

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 1320b-5 of this title.

-End-

-CITE-

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

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part B - Supplementary Medical Insurance Benefits for Aged and

Disabled

-HEAD-

Sec. 1395w-1. Repealed. Pub. L. 105-33, title IV, Sec.

4022(b)(2)(A), Aug. 5, 1997, 111 Stat. 354

-MISC1-

Section, act Aug. 14, 1935, ch. 531, title XVIII, Sec. 1845, as

added and amended Apr. 7, 1986, Pub. L. 99-272, title IX, Sec.

9305, 100 Stat. 190; Oct. 21, 1986, Pub. L. 99-509, title IX, Secs.

9331(e), 9344(a)(1), 100 Stat. 2021, 2042; Dec. 22, 1987, Pub. L.

100-203, title IV, Secs. 4045(b), 4083(a)(1), (c)(1), 4085(a),

(i)(8), 101 Stat. 1330-87, 1330-129, 1330-130, 1330-132; July 1,

1988, Pub. L. 100-360, title IV, Sec. 411(i)(4)(A), 102 Stat. 788;

Nov. 10, 1988, Pub. L. 100-647, title VIII, Sec. 8425(a), 102 Stat.

3803; Nov. 5, 1990, Pub. L. 101-508, title IV, Secs. 4002(g)(3),

4118(j)(1), 104 Stat. 1388-37, 1388-70; Oct. 31, 1994, Pub. L.

103-432, title I, Sec. 126(g)(8), 108 Stat. 4416, related to

Physician Payment Review Commission.

EFFECTIVE DATE OF REPEAL

Repeal effective Nov. 1, 1997, the date of termination of the

Prospective Payment Assessment Commission and the Physician Payment

Review Commission, see section 4022(c)(2) of Pub. L. 105-33 set out

as an Effective Date; Transition; Transfer of Functions note under

section 1395b-6 of this title.

-End-

-CITE-

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

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part B - Supplementary Medical Insurance Benefits for Aged and

Disabled

-HEAD-

Sec. 1395w-2. Intermediate sanctions for providers or suppliers of

clinical diagnostic laboratory tests

-STATUTE-

(a) If the Secretary determines that any provider or clinical

laboratory approved for participation under this subchapter no

longer substantially meets the conditions of participation or for

coverage specified under this subchapter with respect to the

provision of clinical diagnostic laboratory tests under this part,

the Secretary may (for a period not to exceed one year) impose

intermediate sanctions developed pursuant to subsection (b) of this

section, in lieu of terminating immediately the provider agreement

or cancelling immediately approval of the clinical laboratory.

(b)(1) The Secretary shall develop and implement -

(A) a range of intermediate sanctions to apply to providers or

clinical laboratories under the conditions described in

subsection (a), and

(B) appropriate procedures for appealing determinations

relating to the imposition of such sanctions.

(2)(A) The intermediate sanctions developed under paragraph (1)

shall include -

(i) directed plans of correction,

(ii) civil money penalties in an amount not to exceed $10,000

for each day of substantial noncompliance,

(iii) payment for the costs of onsite monitoring by an agency

responsible for conducting surveys, and

(iv) suspension of all or part of the payments to which a

provider or clinical laboratory would otherwise be entitled under

this subchapter with respect to clinical diagnostic laboratory

tests furnished on or after the date on which the Secretary

determines that intermediate sanctions should be imposed pursuant

to subsection (a) of this section.

The provisions of section 1320a-7a of this title (other than

subsections (a) and (b)) shall apply to a civil money penalty under

clause (ii) in the same manner as such provisions apply to a

penalty or proceeding under section 1320a-7a(a) of this title.

(B) The sanctions specified in subparagraph (A) are in addition

to sanctions otherwise available under State or Federal law.

(3) The Secretary shall develop and implement specific procedures

with respect to when and how each of the intermediate sanctions

developed under paragraph (1) is to be applied, the amounts of any

penalties, and the severity of each of these penalties. Such

procedures shall be designed so as to minimize the time between

identification of violations and imposition of these sanctions and

shall provide for the imposition of incrementally more severe

penalties for repeated or uncorrected deficiencies.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1846, as added Pub. L.

100-203, title IV, Sec. 4064(d)(1), Dec. 22, 1987, 101 Stat.

1330-111; amended Pub. L. 100-360, title II, Sec. 203(e)(4), title

IV, Sec. 411(g)(3)(G), July 1, 1988, 102 Stat. 725, 784; Pub. L.

100-485, title VI, Sec. 608(d)(22)(C), Oct. 13, 1988, 102 Stat.

2421; Pub. L. 101-234, title II, Sec. 201(a), Dec. 13, 1989, 103

Stat. 1981; Pub. L. 101-508, title IV, Sec. 4154(e)(2), Nov. 5,

1990, 104 Stat. 1388-86.)

-MISC1-

AMENDMENTS

1990 - Pub. L. 101-508 substituted "providers or suppliers of"

for "providers of" in section catchline.

1989 - Pub. L. 101-234 repealed Pub. L. 100-360, Sec. 203(e)(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.

1988 - Pub. L. 100-360, Sec. 203(e)(4)(A), inserted "and for

qualified home intravenous drug therapy providers" at end of

section catchline.

Subsec. (a). Pub. L. 100-360, Sec. 411(g)(3)(G)(i)(I), as amended

by Pub. L. 100-485, substituted "approved" for "certified".

Pub. L. 100-360, Sec. 411(g)(3)(G)(i)(II), inserted "or for

coverage" after "conditions of participation".

Pub. L. 100-360, Sec. 411(g)(3)(G)(i)(III), which directed

amendment of subsec. (a) by substituting "terminating immediately

the provider agreement or cancelling immediately approval of the

clinical laboratory" for "cancelling immediately the certification

of the provider or clinical laboratory", was executed by making the

substitution for "canceling immediately the certification of the

provider or clinical laboratory" to reflect the probable intent of

Congress.

Pub. L. 100-360, Sec. 203(e)(4)(B), inserted "or that a qualified

home intravenous drug therapy provider that is certified for

participation under this subchapter no longer substantially meets

the requirements of section 1395x(jj)(3) of this title" after

"under this part".

Subsec. (b)(1)(A). Pub. L. 100-360, Sec. 411(g)(3)(G)(ii), struck

out "certified" before "clinical laboratories".

Subsec. (b)(2)(A). Pub. L. 100-360, Sec. 411(g)(3)(G)(iv),

inserted at end "The provisions of section 1320a-7a of this title

(other than subsections (a) and (b)) shall apply to a civil money

penalty under clause (ii) in the same manner as such provisions

apply to a penalty or proceeding under section 1320a-7a(a) of this

title."

Subsec. (b)(2)(A)(ii). Pub. L. 100-360, Sec. 411(g)(3)(G)(iii),

substituted "civil money penalties in an amount not to exceed

$10,000 for each day of substantial noncompliance" for "civil fines

and penalties".

Subsec. (b)(2)(A)(iii). Pub. L. 100-360, Sec. 411(g)(3)(G)(v),

struck out "certification" before "surveys".

Subsec. (b)(2)(A)(iv). Pub. L. 100-360, Sec. 411(g)(3)(G)(ii),

(vi), struck out "certified" before "clinical laboratory" and

substituted "furnished on or after the date on" for "provided on or

after the date in".

Pub. L. 100-360, Sec. 203(e)(4)(C), inserted "or home intravenous

drug therapy services" after "clinical diagnostic laboratory

tests".

Subsec. (b)(3). Pub. L. 100-360, Sec. 411(g)(3)(G)(vii),

substituted "any penalties" for "any fines" and "severe penalties"

for "severe fines".

EFFECTIVE DATE OF 1990 AMENDMENT

Amendment by Pub. L. 101-508 effective as if included in the

enactment of the Omnibus Budget Reconciliation Act of 1989, Pub. L.

101-239, see section 4154(e)(5) of Pub. L. 101-508, set out as a

note under section 1395l of this title.

EFFECTIVE DATE OF 1989 AMENDMENT

Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section

201(c) of Pub. L. 101-234, set out as a note under section 1320a-7a

of this title.

EFFECTIVE DATE OF 1988 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 203(e)(4) of Pub. L. 100-360 applicable to

items and services furnished on or after Jan. 1, 1990, see section

203(g) of Pub. L. 100-360, set out as a note under section 1320c-3

of this title.

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

100-360, amendment by section 411(g)(3)(G) 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

Section 4064(d)(2) of Pub. L. 100-203 provided that: "The

amendment made by paragraph (1) [enacting this section] shall

become effective on January 1, 1990."

-End-

-CITE-

42 USC Sec. 1395w-3 01/06/03

-EXPCITE-

TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY

SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED

Part B - Supplementary Medical Insurance Benefits for Aged and

Disabled

-HEAD-

Sec. 1395w-3. Demonstration projects for competitive acquisition of

items and services

-STATUTE-

(a) Establishment of demonstration project bidding areas

(1) In general

The Secretary shall implement not more than 5 demonstration

projects under which competitive acquisition areas are

established for contract award purposes for the furnishing under

this part of the items and services described in subsection (d)

of this section.

(2) Project requirements

Each demonstration project under paragraph (1) -

(A) shall include such group of items and services as the

Secretary may prescribe,

(B) shall be conducted in not more than 3 competitive

acquisition areas, and

(C) shall be operated over a 3-year period.

(3) Criteria for establishment of competitive acquisition areas

Each competitive acquisition area established under a

demonstration project implemented under paragraph (1) -

(A) shall be, or shall be within, a metropolitan statistical

area (as defined by the Secretary of Commerce), and

(B) shall be chosen based on the availability and

accessibility of entities able to furnish items and services,

and the probable savings to be realized by the use of

competitive bidding in the furnishing of items and services in

such area.

(b) Awarding of contracts in areas

(1) In general

The Secretary shall conduct a competition among individuals and

entities supplying items and services described in subsection (c)

of this section for each competitive acquisition area established

under a demonstration project implemented under subsection (a) of

this section.

(2) Conditions for awarding contract

The Secretary may not award a contract to any entity under the

competition conducted pursuant to paragraph (1) to furnish an

item or service unless the Secretary finds that the entity meets

quality standards specified by the Secretary and that the total

amounts to be paid under the contract are expected to be less

than the total amounts that would otherwise be paid.

(3) Contents of contract

A contract entered into with an entity under the competition

conducted pursuant to paragraph (1) is subject to terms and

conditions that the Secretary may specify.

(4) Limit on number of contractors

The Secretary may limit the number of contractors in a

competitive acquisition area to the number needed to meet

projected demand for items and services covered under the

contracts.

(c) Expansion of projects

(1) Evaluations

The Secretary shall evaluate the impact of the implementation

of the demonstration projects on medicare program payments,

access, diversity of product selection, and quality. The

Secretary shall make annual reports to the Committees on Ways and

Means and Commerce of the House of Representatives and the

Committee on Finance of the Senate on the results of the

evaluation described in the preceding sentence and a final report

not later than 6 months after the termination date specified in

subsection (e) of this section.

(2) Expansion

If the Secretary determines from the evaluations under

paragraph (1) that there is clear evidence that any demonstration

project -

(A) results in a decrease in Federal expenditures under this

subchapter, and

(B) does not reduce program access, diversity of product

selection, and quality under this subchapter,

the Secretary may expand the project to additional competitive

acquisition areas.

(d) Services described

The items and services to which this section applies are all

items and services covered under this part (except for physicians'

services as defined in section 1395x(s)(1) of this title) that the

Secretary may specify. At least one demonstration project shall

include oxygen and oxygen equipment.

(e) Termination

Notwithstanding any other provision of this section, all projects

under this section shall terminate not later than December 31,

2002.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1847, as added Pub. L.

105-33, title IV, Sec. 4319(a), Aug. 5, 1997, 111 Stat. 392;

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

321(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A-366.)

-MISC1-

PRIOR PROVISIONS

A prior section 1395w-3, act Aug. 14, 1935, ch. 531, title XVIII,

Sec. 1847, as added July 1, 1988, Pub. L. 100-360, title II, Sec.

202(j), 102 Stat. 719; amended Oct. 13, 1988, Pub. L. 100-485,

title VI, Sec. 608(d)(5)(I), 102 Stat. 2414, provided for

appointment of Prescription Drug Payment Review Commission by

Director of Congressional Office of Technology Assessment, prior to

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

1989, 103 Stat. 1981, effective Jan. 1, 1990.

AMENDMENTS

1999 - Subsec. (b)(2). Pub. L. 106-113 inserted "and" after

"specified by the Secretary".

EFFECTIVE DATE OF 1999 AMENDMENT

Amendment by 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.

STUDY BY GAO

Section 4319(c) of Pub. L. 105-33 provided that: "The Comptroller

of the United States shall study the effectiveness of the

establishment of competitive acquisition areas under section

1847(a) of the Social Security Act [subsec. (a) of this section],

as added by this section."

-SECREF-

SECTION REFERRED TO IN OTHER SECTIONS

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

-End-

-CITE-

42 USC Sec. 1395w-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 B - Supplementary Medical Insurance Benefits for Aged and

Disabled

-HEAD-

Sec. 1395w-4. Payment for physicians' services

-STATUTE-

(a) Payment based on fee schedule

(1) In general

Effective for all physicians' services (as defined in

subsection (j)(3) of this section) furnished under this part

during a year (beginning with 1992) for which payment is

otherwise made on the basis of a reasonable charge or on the

basis of a fee schedule under section 1395m(b) of this title,

payment under this part shall instead be based on the lesser of -

(A) the actual charge for the service, or

(B) subject to the succeeding provisions of this subsection,

the amount determined under the fee schedule established under

subsection (b) of this section for services furnished during

that year (in this subsection referred to as the "fee schedule

amount").

(2) Transition to full fee schedule

(A) Limiting reductions and increases to 15 percent in 1992

(i) Limit on increase

In the case of a service in a fee schedule area (as defined

in subsection (j)(2) of this section) for which the adjusted

historical payment basis (as defined in subparagraph (D)) is

less than 85 percent of the fee schedule amount for services

furnished in 1992, there shall be substituted for the fee

schedule amount an amount equal to the adjusted historical

payment basis plus 15 percent of the fee schedule amount

otherwise established (without regard to this paragraph).

(ii) Limit in reduction

In the case of a service in a fee schedule area for which

the adjusted historical payment basis exceeds 115 percent of

the fee schedule amount for services furnished in 1992, there

shall be substituted for the fee schedule amount an amount

equal to the adjusted historical payment basis minus 15

percent of the fee schedule amount otherwise established

(without regard to this paragraph).

(B) Special rule for 1993, 1994, and 1995

If a physicians' service in a fee schedule area is subject to

the provisions of subparagraph (A) in 1992, for physicians'

services furnished in the area -

(i) during 1993, there shall be substituted for the fee

schedule amount an amount equal to the sum of -

(I) 75 percent of the fee schedule amount determined

under subparagraph (A), adjusted by the update established

under subsection (d)(3) of this section for 1993, and

(II) 25 percent of the fee schedule amount determined

under paragraph (1) for 1993 without regard to this

paragraph;

(ii) during 1994, there shall be substituted for the fee

schedule amount an amount equal to the sum of -

(I) 67 percent of the fee schedule amount determined

under clause (i), adjusted by the update established under

subsection (d)(3) of this section for 1994 and as adjusted

under subsection (c)(2)(F)(ii) of this section and under

section 13515(b) of the Omnibus Budget Reconciliation Act

of 1993, and

(II) 33 percent of the fee schedule amount determined

under paragraph (1) for 1994 without regard to this

paragraph; and

(iii) during 1995, there shall be substituted for the fee

schedule amount an amount equal to the sum of -

(I) 50 percent of the fee schedule amount determined

under clause (ii) adjusted by the update established under

subsection (d)(3) of this section for 1995, and

(II) 50 percent of the fee schedule amount determined

under paragraph (1) for 1995 without regard to this

paragraph.

(C) Special rule for anesthesia and radiology services

With respect to physicians' services which are anesthesia

services, the Secretary shall provide for a transition in the

same manner as a transition is provided for other services

under subparagraph (B). With respect to radiology services,

"109 percent" and "9 percent" shall be substituted for "115

percent" and "15 percent", respectively, in subparagraph

(A)(ii).

(D) "Adjusted historical payment basis" defined

(i) In general

In this paragraph, the term "adjusted historical payment

basis" means, with respect to a physicians' service furnished

in a fee schedule area, the weighted average prevailing

charge applied in the area for the service in 1991 (as

determined by the Secretary without regard to physician

specialty and as adjusted to reflect payments for services

with customary charges below the prevailing charge or other

payment limitations imposed by law or regulation) adjusted by

the update established under subsection (d)(3) of this

section for 1992.

(ii) Application to radiology services

In applying clause (i) in the case of physicians' services

which are radiology services (including radiologist services,

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

excluding nuclear medicine services that are subject to

section 6105(b) of the Omnibus Budget Reconciliation Act of

1989, there shall be substituted for the weighted average

prevailing charge the amount provided under the fee schedule

established for the service for the fee schedule area under

section 1395m(b) of this title.

(iii) Nuclear medicine services

In applying clause (i) in the case of physicians' services

which are nuclear medicine services, there shall be

substituted for the weighted average prevailing charge the

amount provided under section 6105(b) of the Omnibus Budget

Reconciliation Act of 1989.

(3) Incentives for participating physicians and suppliers

In applying paragraph (1)(B) in the case of a nonparticipating

physician or a nonparticipating supplier or other person, the fee

schedule amount shall be 95 percent of such amount otherwise

applied under this subsection (without regard to this paragraph).

In the case of physicians' services (including services which the

Secretary excludes pursuant to subsection (j)(3) of this section)

of a nonparticipating physician, supplier, or other person for

which payment is made under this part on a basis other than the

fee schedule amount, the payment shall be based on 95 percent of

the payment basis for such services furnished by a participating

physician, supplier, or other person.

(4) Special rule for medical direction

(A) In general

With respect to physicians' services furnished on or after

January 1, 1994, and consisting of medical direction of two,

three, or four concurrent anesthesia cases, the fee schedule

amount to be applied shall be equal to one-half of the amount

described in subparagraph (B).

(B) Amount

The amount described in this subparagraph, for a physician's

medical direction of the performance of anesthesia services, is

the following percentage of the fee schedule amount otherwise

applicable under this section if the anesthesia services were

personally performed by the physician alone:

(i) For services furnished during 1994, 120 percent.

(ii) For services furnished during 1995, 115 percent.

(iii) For services furnished during 1996, 110 percent.

(iv) For services furnished during 1997, 105 percent.

(v) For services furnished after 1997, 100 percent.

(b) Establishment of fee schedules

(1) In general

Before November 1 of the preceding year, for each year

beginning with 1998, the Secretary shall establish, by

regulation, fee schedules that establish payment amounts for all

physicians' services furnished in all fee schedule areas (as

defined in subsection (j)(2) of this section) for the year.

Except as provided in paragraph (2), each such payment amount for

a service shall be equal to the product of -

(A) the relative value for the service (as determined in

subsection (c)(2) of this section),

(B) the conversion factor (established under subsection (d)

of this section) for the year, and

(C) the geographic adjustment factor (established under

subsection (e)(2) of this section) for the service for the fee

schedule area.

(2) Treatment of radiology services and anesthesia services

(A) Radiology services

With respect to radiology services (including radiologist

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

Secretary shall base the relative values on the relative value

scale developed under section 1395m(b)(1)(A) of this title,

with appropriate modifications of the relative values to assure

that the relative values established for radiology services

which are similar or related to other physicians' services are

consistent with the relative values established for those

similar or related services.

(B) Anesthesia services

In establishing the fee schedule for anesthesia services for

which a relative value guide has been established under section

4048(b) of the Omnibus Budget Reconciliation Act of 1987, the

Secretary shall use, to the extent practicable, such relative

value guide, with appropriate adjustment of the conversion

factor, in a manner to assure that the fee schedule amounts for

anesthesia services are consistent with the fee schedule

amounts for other services determined by the Secretary to be of

comparable value. In applying the previous sentence, the

Secretary shall adjust the conversion factor by geographic

adjustment factors in the same manner as such adjustment is

made under paragraph (1)(C).

(C) Consultation

The Secretary shall consult with the Physician Payment Review

Commission and organizations representing physicians or

suppliers who furnish radiology services and anesthesia

services in applying subparagraphs (A) and (B).

(3) Treatment of interpretation of electrocardiograms

The Secretary -

(A) shall make separate payment under this section for the

interpretation of electrocardiograms performed or ordered to be

performed as part of or in conjunction with a visit to or a

consultation with a physician, and

(B) shall adjust the relative values established for visits

and consultations under subsection (c) of this section so as

not to include relative value units for interpretations of

electrocardiograms in the relative value for visits and

consultations.

(c) Determination of relative values for physicians' services

(1) Division of physicians' services into components

In this section, with respect to a physicians' service:

(A) "Work component" defined

The term "work component" means the portion of the resources

used in furnishing the service that reflects physician time and

intensity in furnishing the service. Such portion shall -

(i) include activities before and after direct patient

contact, and

(ii) be defined, with respect to surgical procedures, to

reflect a global definition including pre-operative and

post-operative physicians' services.

(B) "Practice expense component" defined

The term "practice expense component" means the portion of

the resources used in furnishing the service that reflects the

general categories of expenses (such as office rent and wages

of personnel, but excluding malpractice expenses) comprising

practice expenses.

(C) "Malpractice component" defined

The term "malpractice component" means the portion of the

resources used in furnishing the service that reflects

malpractice expenses in furnishing the service.

(2) Determination of relative values

(A) In general

(i) Combination of units for components

The Secretary shall develop a methodology for combining the

work, practice expense, and malpractice relative value units,

determined under subparagraph (C), for each service in a

manner to produce a single relative value for that service.

Such relative values are subject to adjustment under

subparagraph (F)(i) and section 13515(b) of the Omnibus

Budget Reconciliation Act of 1993.

(ii) Extrapolation

The Secretary may use extrapolation and other techniques to

determine the number of relative value units for physicians'

services for which specific data are not available and shall

take into account recommendations of the Physician Payment

Review Commission and the results of consultations with

organizations representing physicians who provide such

services.

(B) Periodic review and adjustments in relative values

(i) Periodic review

The Secretary, not less often than every 5 years, shall

review the relative values established under this paragraph

for all physicians' services.

(ii) Adjustments

(I) In general

The Secretary shall, to the extent the Secretary

determines to be necessary and subject to subclause (II),

adjust the number of such units to take into account

changes in medical practice, coding changes, new data on

relative value components, or the addition of new

procedures. The Secretary shall publish an explanation of

the basis for such adjustments.

(II) Limitation on annual adjustments

The adjustments under subclause (I) for a year may not

cause the amount of expenditures under this part for the

year to differ by more than $20,000,000 from the amount of

expenditures under this part that would have been made if

such adjustments had not been made.

(iii) Consultation

The Secretary, in making adjustments under clause (ii),

shall consult with the Medicare Payment Advisory Commission

and organizations representing physicians.

(C) Computation of relative value units for components

For purposes of this section for each physicians' service -

(i) Work relative value units

The Secretary shall determine a number of work relative

value units for the service based on the relative resources

incorporating physician time and intensity required in

furnishing the service.

(ii) Practice expense relative value units

The Secretary shall determine a number of practice expense

relative value units for the service for years before 1999

equal to the product of -

(I) the base allowed charges (as defined in subparagraph

(D)) for the service, and

(II) the practice expense percentage for the service (as

determined under paragraph (3)(C)(ii)),

and for years beginning with 1999 based on the relative

practice expense resources involved in furnishing the

service. For 1999, such number of units shall be determined

based 75 percent on such product and based 25 percent on the

relative practice expense resources involved in furnishing

the service. For 2000, such number of units shall be

determined based 50 percent on such product and based 50

percent on such relative practice expense resources. For

2001, such number of units shall be determined based 25

percent on such product and based 75 percent on such relative

practice expense resources. For a subsequent year, such

number of units shall be determined based entirely on such

relative practice expense resources.

(iii) Malpractice relative value units

The Secretary shall determine a number of malpractice

relative value units for the service for years before 2000

equal to the product of -

(I) the base allowed charges (as defined in subparagraph

(D)) for the service, and

(II) the malpractice percentage for the service (as

determined under paragraph (3)(C)(iii)),

and for years beginning with 2000 based on the malpractice

expense resources involved in furnishing the service.

(D) "Base allowed charges" defined

In this paragraph, the term "base allowed charges" means,

with respect to a physician's service, the national average

allowed charges for the service under this part for services

furnished during 1991, as estimated by the Secretary using the

most recent data available.

(E) Reduction in practice expense relative value units for

certain services

(i) In general

Subject to clause (ii), the Secretary shall reduce the

practice expense relative value units applied to services

described in clause (iii) furnished in -

(I) 1994, by 25 percent of the number by which the number

of practice expense relative value units (determined for

1994 without regard to this subparagraph) exceeds the

number of work relative value units determined for 1994,

(II) 1995, by an additional 25 percent of such excess,

and

(III) 1996, by an additional 25 percent of such excess.

(ii) Floor on reductions

The practice expense relative value units for a physician's

service shall not be reduced under this subparagraph to a

number less than 128 percent of the number of work relative

value units.

(iii) Services covered

For purposes of clause (i), the services described in this

clause are physicians' services that are not described in

clause (iv) and for which -

(I) there are work relative value units, and

(II) the number of practice expense relative value units

(determined for 1994) exceeds 128 percent of the number of

work relative value units (determined for such year).

(iv) Excluded services

For purposes of clause (iii), the services described in

this clause are services which the Secretary determines at

least 75 percent of which are provided under this subchapter

in an office setting.

(F) Budget neutrality adjustments

The Secretary -

(i) shall reduce the relative values for all services

(other than anesthesia services) established under this

paragraph (and, in the case of anesthesia services, the

conversion factor established by the Secretary for such

services) by such percentage as the Secretary determines to

be necessary so that, beginning in 1996, the amendment made

by section 13514(a) of the Omnibus Budget Reconciliation Act

of 1993 would not result in expenditures under this section

that exceed the amount of such expenditures that would have

been made if such amendment had not been made, and

(ii) shall reduce the amounts determined under subsection

(a)(2)(B)(ii)(I) of this section by such percentage as the

Secretary determines to be required to assure that, taking

into account the reductions made under clause (i), the

amendment made by section 13514(a) of the Omnibus Budget

Reconciliation Act of 1993 would not result in expenditures

under this section in 1994 that exceed the amount of such

expenditures that would have been made if such amendment had

not been made.

(G) Adjustments in relative value units for 1998

(i) In general

The Secretary shall -

(I) subject to clauses (iv) and (v), reduce the practice

expense relative value units applied to any services

described in clause (ii) furnished in 1998 to a number

equal to 110 percent of the number of work relative value

units, and

(II) increase the practice expense relative value units

for office visit procedure codes during 1998 by a uniform

percentage which the Secretary estimates will result in an

aggregate increase in payments for such services equal to

the aggregate decrease in payments by reason of subclause

(I).

(ii) Services covered

For purposes of clause (i), the services described in this

clause are physicians' services that are not described in

clause (iii) and for which -

(I) there are work relative value units, and

(II) the number of practice expense relative value units

(determined for 1998) exceeds 110 percent of the number of

work relative value units (determined for such year).

(iii) Excluded services

For purposes of clause (ii), the services described in this

clause are services which the Secretary determines at least

75 percent of which are provided under this subchapter in an

office setting.

(iv) Limitation on aggregate reallocation

If the application of clause (i)(I) would result in an

aggregate amount of reductions under such clause in excess of

$390,000,000, such clause shall be applied by substituting

for 110 percent such greater percentage as the Secretary

estimates will result in the aggregate amount of such

reductions equaling $390,000,000.

(v) No reduction for certain services

Practice expense relative value units for a procedure

performed in an office or in a setting out of an office shall

not be reduced under clause (i) if the in-office or

out-of-office practice expense relative value, respectively,

for the procedure would increase under the proposed rule on

resource-based practice expenses issued by the Secretary on

June 18, 1997 (62 Federal Register 33158 et seq.).

(3) Component percentages

For purposes of paragraph (2), the Secretary shall determine a

work percentage, a practice expense percentage, and a malpractice

percentage for each physician's service as follows:

(A) Division of services by specialty

For each physician's service or class of physicians'

services, the Secretary shall determine the average percentage

of each such service or class of services that is performed,

nationwide, under this part by physicians in each of the

different physician specialties (as identified by the

Secretary).

(B) Division of specialty by component

The Secretary shall determine the average percentage division

of resources, among the work component, the practice expense

component, and the malpractice component, used by physicians in

each of such specialties in furnishing physicians' services.

Such percentages shall be based on national data that describe

the elements of physician practice costs and revenues, by

physician specialty. The Secretary may use extrapolation and

other techniques to determine practice costs and revenues for

specialties for which adequate data are not available.

(C) Determination of component percentages

(i) Work percentage

The work percentage for a service (or class of services) is

equal to the sum (for all physician specialties) of -

(I) the average percentage division for the work

component for each physician specialty (determined under

subparagraph (B)), multiplied by

(II) the proportion (determined under subparagraph (A))

of such service (or services) performed by physicians in

that specialty.

(ii) Practice expense percentage

For years before 2002, the practice expense percentage for

a service (or class of services) is equal to the sum (for all

physician specialties) of -

(I) the average percentage division for the practice

expense component for each physician specialty (determined

under subparagraph (B)), multiplied by

(II) the proportion (determined under subparagraph (A))

of such service (or services) performed by physicians in

that specialty.

(iii) Malpractice percentage

For years before 1999, the malpractice percentage for a

service (or class of services) is equal to the sum (for all

physician specialties) of -

(I) the average percentage division for the malpractice

component for each physician specialty (determined under

subparagraph (B)), multiplied by

(II) the proportion (determined under subparagraph (A))

of such service (or services) performed by physicians in

that specialty.

(D) Periodic recomputation

The Secretary may, from time to time, provide for the

recomputation of work percentages, practice expense

percentages, and malpractice percentages determined under this

paragraph.

(4) Ancillary policies

The Secretary may establish ancillary policies (with respect to

the use of modifiers, local codes, and other matters) as may be

necessary to implement this section.

(5) Coding

The Secretary shall establish a uniform procedure coding system

for the coding of all physicians' services. The Secretary shall

provide for an appropriate coding structure for visits and

consultations. The Secretary may incorporate the use of time in

the coding for visits and consultations. The Secretary, in

establishing such coding system, shall consult with the Physician

Payment Review Commission and other organizations representing

physicians.

(6) No variation for specialists

The Secretary may not vary the conversion factor or the number

of relative value units for a physicians' service based on

whether the physician furnishing the service is a specialist or

based on the type of specialty of the physician.

(d) Conversion factors

(1) Establishment

(A) In general

The conversion factor for each year shall be the conversion

factor established under this subsection for the previous year

(or, in the case of 1992, specified in subparagraph (B))

adjusted by the update (established under paragraph (3)) for

the year involved (for years before 2001) and, for years

beginning with 2001, multiplied by the update (established

under paragraph (4)) for the year involved.

(B) Special provision for 1992

For purposes of subparagraph (A), the conversion factor

specified in this subparagraph is a conversion factor

(determined by the Secretary) which, if this section were to

apply during 1991 using such conversion factor, would result in

the same aggregate amount of payments under this part for

physicians' services as the estimated aggregate amount of the

payments under this part for such services in 1991.

(C) Special rules for 1998

Except as provided in subparagraph (D), the single conversion

factor for 1998 under this subsection shall be the conversion

factor for primary care services for 1997, increased by the

Secretary's estimate of the weighted average of the three

separate updates that would otherwise occur were it not for the

enactment of chapter 1 of subtitle F of title IV of the

Balanced Budget Act of 1997.

(D) Special rules for anesthesia services

The separate conversion factor for anesthesia services for a

year shall be equal to 46 percent of the single conversion

factor established for other physicians' services, except as

adjusted for changes in work, practice expense, or malpractice

relative value units.

(E) Publication and dissemination of information

The Secretary shall -

(i) cause to have published in the Federal Register not

later than November 1 of each year (beginning with 2000) the

conversion factor which will apply to physicians' services

for the succeeding year, the update determined under

paragraph (4) for such succeeding year, and the allowed

expenditures under such paragraph for such succeeding year;

and

(ii) make available to the Medicare Payment Advisory

Commission and the public by March 1 of each year (beginning

with 2000) an estimate of the sustainable growth rate and of

the conversion factor which will apply to physicians'

services for the succeeding year and data used in making such

estimate.

(2) Repealed. Pub. L. 105-33, title IV, Sec. 4502(b), Aug. 5,

1997, 111 Stat. 433

(3) Update for 1999 and 2000

(A) In general

Unless otherwise provided by law, subject to subparagraph (D)

and the budget-neutrality factor determined by the Secretary

under subsection (c)(2)(B)(ii) of this section, the update to

the single conversion factor established in paragraph (1)(C)

for 1999 and 2000 is equal to the product of -

(i) 1 plus the Secretary's estimate of the percentage

increase in the MEI (as defined in section 1395u(i)(3) of

this title) for the year (divided by 100), and

(ii) 1 plus the Secretary's estimate of the update

adjustment factor for the year (divided by 100),

minus 1 and multiplied by 100.

(B) Update adjustment factor

For purposes of subparagraph (A)(ii), the "update adjustment

factor" for a year is equal (as estimated by the Secretary) to

-

(i) the difference between (I) the sum of the allowed

expenditures for physicians' services (as determined under

subparagraph (C)) for the period beginning April 1, 1997, and

ending on March 31 of the year involved, and (II) the amount

of actual expenditures for physicians' services furnished

during the period beginning April 1, 1997, and ending on

March 31 of the preceding year; divided by

(ii) the actual expenditures for physicians' services for

the 12-month period ending on March 31 of the preceding year,

increased by the sustainable growth rate under subsection (f)

of this section for the fiscal year which begins during such

12-month period.

(C) Determination of allowed expenditures

For purposes of this paragraph and paragraph (4), the allowed

expenditures for physicians' services for the 12-month period

ending with March 31 of -

(i) 1997 is equal to the actual expenditures for

physicians' services furnished during such 12-month period,

as estimated by the Secretary; or

(ii) a subsequent year is equal to the allowed expenditures

for physicians' services for the previous year, increased by

the sustainable growth rate under subsection (f) of this

section for the fiscal year which begins during such 12-month

period.

(D) Restriction on variation from medicare economic index

Notwithstanding the amount of the update adjustment factor

determined under subparagraph (B) for a year, the update in the

conversion factor under this paragraph for the year may not be

-

(i) greater than 100 times the following amount: (1.03 +

(MEI percentage/100)) -1; or

(ii) less than 100 times the following amount: (0.93 + (MEI

percentage/100)) -1,

where "MEI percentage" means the Secretary's estimate of the

percentage increase in the MEI (as defined in section

1395u(i)(3) of this title) for the year involved.

(4) Update for years beginning with 2001

(A) In general

Unless otherwise provided by law, subject to the

budget-neutrality factor determined by the Secretary under

subsection (c)(2)(B)(ii) of this section and subject to

adjustment under subparagraph (F), the update to the single

conversion factor established in paragraph (1)(C) for a year

beginning with 2001 is equal to the product of -

(i) 1 plus the Secretary's estimate of the percentage

increase in the MEI (as defined in section 1395u(i)(3) of

this title) for the year (divided by 100); and

(ii) 1 plus the Secretary's estimate of the update

adjustment factor under subparagraph (B) for the year.

(B) Update adjustment factor

For purposes of subparagraph (A)(ii), subject to subparagraph

(D), the "update adjustment factor" for a year is equal (as

estimated by the Secretary) to the sum of the following:

(i) Prior year adjustment component

An amount determined by -

(I) computing the difference (which may be positive or

negative) between the amount of the allowed expenditures

for physicians' services for the prior year (as determined

under subparagraph (C)) and the amount of the actual

expenditures for such services for that year;

(II) dividing that difference by the amount of the actual

expenditures for such services for that year; and

(III) multiplying that quotient by 0.75.

(ii) Cumulative adjustment component

An amount determined by -

(I) computing the difference (which may be positive or

negative) between the amount of the allowed expenditures

for physicians' services (as determined under subparagraph

(C)) from April 1, 1996, through the end of the prior year

and the amount of the actual expenditures for such services

during that period;

(II) dividing that difference by actual expenditures for

such services for the prior year as increased by the

sustainable growth rate under subsection (f) of this

section for the year for which the update adjustment factor

is to be determined; and

(III) multiplying that quotient by 0.33.

(C) Determination of allowed expenditures

For purposes of this paragraph:

(i) Period up to April 1, 1999

The allowed expenditures for physicians' services for a

period before April 1, 1999, shall be the amount of the

allowed expenditures for such period as determined under

paragraph (3)(C).

(ii) Transition to calendar year allowed expenditures

Subject to subparagraph (E), the allowed expenditures for -

(I) the 9-month period beginning April 1, 1999, shall be

the Secretary's estimate of the amount of the allowed

expenditures that would be permitted under paragraph (3)(C)

for such period; and

(II) the year of 1999, shall be the Secretary's estimate

of the amount of the allowed expenditures that would be

permitted under paragraph (3)(C) for such year.

(iii) Years beginning with 2000

The allowed expenditures for a year (beginning with 2000)

is equal to the allowed expenditures for physicians' services

for the previous year, increased by the sustainable growth

rate under subsection (f) of this section for the year

involved.

(D) Restriction on update adjustment factor

The update adjustment factor determined under subparagraph

(B) for a year may not be less than -0.07 or greater than 0.03.

(E) Recalculation of allowed expenditures for updates beginning

with 2001

For purposes of determining the update adjustment factor for

a year beginning with 2001, the Secretary shall recompute the

allowed expenditures for previous periods beginning on or after

April 1, 1999, consistent with subsection (f)(3) of this

section.

(F) Transitional adjustment designed to provide for budget

neutrality

Under this subparagraph the Secretary shall provide for an

adjustment to the update under subparagraph (A) -

(i) for each of 2001, 2002, 2003, and 2004, of -0.2

percent; and

(ii) for 2005 of +0.8 percent.

(e) Geographic adjustment factors

(1) Establishment of geographic indices

(A) In general

Subject to subparagraphs (B) and (C), the Secretary shall

establish -

(i) an index which reflects the relative costs of the mix

of goods and services comprising practice expenses (other

than malpractice expenses) in the different fee schedule

areas compared to the national average of such costs,

(ii) an index which reflects the relative costs of

malpractice expenses in the different fee schedule areas

compared to the national average of such costs, and

(iii) an index which reflects 1/4 of the difference

between the relative value of physicians' work effort in each

of the different fee schedule areas and the national average

of such work effort.

(B) Class-specific geographic cost-of-practice indices

The Secretary may establish more than one index under

subparagraph (A)(i) in the case of classes of physicians'

services, if, because of differences in the mix of goods and

services comprising practice expenses for the different classes

of services, the application of a single index under such

clause to different classes of such services would be

substantially inequitable.

(C) Periodic review and adjustments in geographic adjustment

factors

The Secretary, not less often than every 3 years, shall, in

consultation with appropriate representatives of physicians,

review the indices established under subparagraph (A) and the

geographic index values applied under this subsection for all

fee schedule areas. Based on such review, the Secretary may

revise such index and adjust such index values, except that, if

more than 1 year has elasped (!1) since the date of the last

previous adjustment, the adjustment to be applied in the first

year of the next adjustment shall be 1/2 of the adjustment

that otherwise would be made.

(D) Use of recent data

In establishing indices and index values under this

paragraph, the Secretary shall use the most recent data

available relating to practice expenses, malpractice expenses,

and physician work effort in different fee schedule areas.

(2) Computation of geographic adjustment factor

For purposes of subsection (b)(1)(C) of this section, for all

physicians' services for each fee schedule area the Secretary

shall establish a geographic adjustment factor equal to the sum

of the geographic cost-of-practice adjustment factor (specified

in paragraph (3)), the geographic malpractice adjustment factor

(specified in paragraph (4)), and the geographic physician work

adjustment factor (specified in paragraph (5)) for the service

and the area.

(3) Geographic cost-of-practice adjustment factor

For purposes of paragraph (2), the "geographic cost-of-practice

adjustment factor", for a service for a fee schedule area, is the

product of -

(A) the proportion of the total relative value for the

service that reflects the relative value units for the practice

expense component, and

(B) the geographic cost-of-practice index value for the area

for the service, based on the index established under paragraph

(1)(A)(i) or (1)(B) (as the case may be).

(4) Geographic malpractice adjustment factor

For purposes of paragraph (2), the "geographic malpractice

adjustment factor", for a service for a fee schedule area, is the

product of -

(A) the proportion of the total relative value for the

service that reflects the relative value units for the

malpractice component, and

(B) the geographic malpractice index value for the area,

based on the index established under paragraph (1)(A)(ii).

(5) Geographic physician work adjustment factor

For purposes of paragraph (2), the "geographic physician work

adjustment factor", for a service for a fee schedule area, is the

product of -

(A) the proportion of the total relative value for the

service that reflects the relative value units for the work

component, and

(B) the geographic physician work index value for the area,

based on the index established under paragraph (1)(A)(iii).

(f) Sustainable growth rate

(1) Publication

The Secretary shall cause to have published in the Federal

Register not later than -

(A) November 1, 2000, the sustainable growth rate for 2000

and 2001; and

(B) November 1 of each succeeding year the sustainable growth

rate for such succeeding year and each of the preceding 2

years.

(2) Specification of growth rate

The sustainable growth rate for all physicians' services for a

fiscal year (beginning with fiscal year 1998 and ending with

fiscal year 2000) and a year beginning with 2000 shall be equal

to the product of -

(A) 1 plus the Secretary's estimate of the weighted average

percentage increase (divided by 100) in the fees for all

physicians' services in the applicable period involved,

(B) 1 plus the Secretary's estimate of the percentage change

(divided by 100) in the average number of individuals enrolled

under this part (other than Medicare+Choice plan enrollees)

from the previous applicable period to the applicable period

involved,

(C) 1 plus the Secretary's estimate of the projected

percentage growth in real gross domestic product per capita

(divided by 100) from the previous applicable period to the

applicable period involved, and

(D) 1 plus the Secretary's estimate of the percentage change

(divided by 100) in expenditures for all physicians' services

in the applicable period (compared with the previous applicable

period) which will result from changes in law and regulations,

determined without taking into account estimated changes in

expenditures resulting from the update adjustment factor

determined under subsection (d)(3)(B) or (d)(4)(B) of this

section, as the case may be,

minus 1 and multiplied by 100.

(3) Data to be used

For purposes of determining the update adjustment factor under

subsection (d)(4)(B) of this section for a year beginning with

2001, the sustainable growth rates taken into consideration in

the determination under paragraph (2) shall be determined as

follows:

(A) For 2001

For purposes of such calculations for 2001, the sustainable

growth rates for fiscal year 2000 and the years 2000 and 2001

shall be determined on the basis of the best data available to

the Secretary as of September 1, 2000.

(B) For 2002

For purposes of such calculations for 2002, the sustainable

growth rates for fiscal year 2000 and for years 2000, 2001, and

2002 shall be determined on the basis of the best data

available to the Secretary as of September 1, 2001.

(C) For 2003 and succeeding years

For purposes of such calculations for a year after 2002 -

(i) the sustainable growth rates for that year and the

preceding 2 years shall be determined on the basis of the

best data available to the Secretary as of September 1 of the

year preceding the year for which the calculation is made;

and

(ii) the sustainable growth rate for any year before a year

described in clause (i) shall be the rate as most recently

determined for that year under this subsection.

Nothing in this paragraph shall be construed as affecting the

sustainable growth rates established for fiscal year 1998 or

fiscal year 1999.

(4) Definitions

In this subsection:

(A) Services included in physicians' services

The term "physicians' services" includes other items and

services (such as clinical diagnostic laboratory tests and

radiology services), specified by the Secretary, that are

commonly performed or furnished by a physician or in a

physician's office, but does not include services furnished to

a Medicare+ÐChoice plan enrollee.

(B) Medicare+Choice plan enrollee

The term "Medicare+Choice plan enrollee" means, with respect

to a fiscal year, an individual enrolled under this part who

has elected to receive benefits under this subchapter for the

fiscal year through a Medicare+Choice plan offered under part C

of this subchapter, and also includes an individual who is

receiving benefits under this part through enrollment with an

eligible organization with a risk-sharing contract under

section 1395mm of this title.

(C) Applicable period

The term "applicable period" means -

(i) a fiscal year, in the case of fiscal year 1998, fiscal

year 1999, and fiscal year 2000; or

(ii) a calendar year with respect to a year beginning with

2000;

as the case may be.

(g) Limitation on beneficiary liability

(1) Limitation on actual charges

(A) In general

In the case of a nonparticipating physician or

nonparticipating supplier or other person (as defined in

section 1395u(i)(2) of this title) who does not accept payment

on an assignment-related basis for a physician's service

furnished with respect to an individual enrolled under this

part, the following rules apply:

(i) Application of limiting charge

No person may bill or collect an actual charge for the

service in excess of the limiting charge described in

paragraph (2) for such service.

(ii) No liability for excess charges

No person is liable for payment of any amounts billed for

the service in excess of such limiting charge.

(iii) Correction of excess charges

If such a physician, supplier, or other person bills, but

does not collect, an actual charge for a service in violation

of clause (i), the physician, supplier, or other person shall

reduce on a timely basis the actual charge billed for the

service to an amount not to exceed the limiting charge for

the service.

(iv) Refund of excess collections

If such a physician, supplier, or other person collects an

actual charge for a service in violation of clause (i), the

physician, supplier, or other person shall provide on a

timely basis a refund to the individual charged in the amount

by which the amount collected exceeded the limiting charge

for the service. The amount of such a refund shall be reduced

to the extent the individual has an outstanding balance owed

by the individual to the physician.

(B) Sanctions

If a physician, supplier, or other person -

(i) knowingly and willfully bills or collects for services

in violation of subparagraph (A)(i) on a repeated basis, or

(ii) fails to comply with clause (iii) or (iv) of

subparagraph (A) on a timely basis,

the Secretary may apply sanctions against the physician,

supplier, or other person in accordance with paragraph (2) of

section 1395u(j) of this title. In applying this subparagraph,

paragraph (4) of such section applies in the same manner as

such paragraph applies to such section and any reference in

such section to a physician is deemed also to include a

reference to a supplier or other person under this

subparagraph.

(C) Timely basis

For purposes of this paragraph, a correction of a bill for an

excess charge or refund of an amount with respect to a

violation of subparagraph (A)(i) in the case of a service is

considered to be provided "on a timely basis", if the reduction

or refund is made not later than 30 days after the date the

physician, supplier, or other person is notified by the carrier

under this part of such violation and of the requirements of

subparagraph (A).

(2) "Limiting charge" defined

(A) For 1991

For physicians' services of a physician furnished during

1991, other than radiologist services subject to section

1395m(b) of this title, the "limiting charge" shall be the same

percentage (or, if less, 25 percent) above the recognized

payment amount under this part with respect to the physician

(as a nonparticipating physician) as the percentage by which -

(i) the maximum allowable actual charge (as determined

under section 1395u(j)(1)(C) of this title as of December 31,

1990, or, if less, the maximum actual charge otherwise

permitted for the service under this part as of such date)

for the service of the physician, exceeds

(ii) the recognized payment amount for the service of the

physician (as a nonparticipating physician) as of such date.

In the case of evaluation and management services (as specified

in section 1395u(b)(16)(B)(ii) of this title), the preceding

sentence shall be applied by substituting "40 percent" for "25

percent".

(B) For 1992

For physicians' services furnished during 1992, other than

radiologist services subject to section 1395m(b) of this title,

the "limiting charge" shall be the same percentage (or, if

less, 20 percent) above the recognized payment amount under

this part for nonparticipating physicians as the percentage by

which -

(i) the limiting charge (as determined under subparagraph

(A) as of December 31, 1991) for the service, exceeds

(ii) the recognized payment amount for the service for

nonparticipating physicians as of such date.

(C) After 1992

For physicians' services furnished in a year after 1992, the

"limiting charge" shall be 115 percent of the recognized

payment amount under this part for nonparticipating physicians

or for nonparticipating suppliers or other persons.

(D) Recognized payment amount

In this section, the term "recognized payment amount" means,

for services furnished on or after January 1, 1992, the fee

schedule amount determined under subsection (a) of this section

(or, if payment under this part is made on a basis other than

the fee schedule under this section, 95 percent of the other

payment basis), and, for services furnished during 1991, the

applicable percentage (as defined in section 1395u(b)(4)(A)(iv)

of this title) of the prevailing charge (or fee schedule

amount) for nonparticipating physicians for that year.

(3) Limitation on charges for medicare beneficiaries eligible for

medicaid benefits

(A) In general

Payment for physicians' services furnished on or after April

1, 1990, to an individual who is enrolled under this part and

eligible for any medical assistance (including as a qualified

medicare beneficiary, as defined in section 1396d(p)(1) of this

title) with respect to such services under a State plan

approved under subchapter XIX of this chapter may only be made

on an assignment-related basis and the provisions of section

1396a(n)(3)(A) of this title apply to further limit permissible

charges under this section.

(B) Penalty

A person may not bill for physicians' services subject to

subparagraph (A) other than on an assignment-related basis. No

person is liable for payment of any amounts billed for such a

service in violation of the previous sentence. If a person

knowingly and willfully bills for physicians' services in

violation of the first sentence, the Secretary may apply

sanctions against the person in accordance with section

1395u(j)(2) of this title.

(4) Physician submission of claims

(A) In general

For services furnished on or after September 1, 1990, within

1 year after the date of providing a service for which payment

is made under this part on a reasonable charge or fee schedule

basis, a physician, supplier, or other person (or an employer

or facility in the cases described in section 1395u(b)(6)(A) of

this title) -

(i) shall complete and submit a claim for such service on a

standard claim form specified by the Secretary to the carrier

on behalf of a beneficiary, and

(ii) may not impose any charge relating to completing and

submitting such a form.

(B) Penalty

(i) With respect to an assigned claim wherever a physician,

provider, supplier or other person (or an employer or facility

in the cases described in section 1395u(b)(6)(A) of this title)

fails to submit such a claim as required in subparagraph (A),

the Secretary shall reduce by 10 percent the amount that would

otherwise be paid for such claim under this part.

(ii) If a physician, supplier, or other person (or an

employer or facility in the cases described in section

1395u(b)(6)(A) of this title) fails to submit a claim required

to be submitted under subparagraph (A) or imposes a charge in

violation of such subparagraph, the Secretary shall apply the

sanction with respect to such a violation in the same manner as

a sanction may be imposed under section 1395u(p)(3) of this

title for a violation of section 1395u(p)(1) of this title.

(5) Electronic billing; direct deposit

The Secretary shall encourage and develop a system providing

for expedited payment for claims submitted electronically. The

Secretary shall also encourage and provide incentives allowing

for direct deposit as payments for services furnished by

participating physicians. The Secretary shall provide physicians

with such technical information as necessary to enable such

physicians to submit claims electronically. The Secretary shall

submit a plan to Congress on this paragraph by May 1, 1990.

(6) Monitoring of charges

(A) In general

The Secretary shall monitor -

(i) the actual charges of nonparticipating physicians for

physicians' services furnished on or after January 1, 1991,

to individuals enrolled under this part, and

(ii) changes (by specialty, type of service, and geographic

area) in (I) the proportion of expenditures for physicians'

services provided under this part by participating

physicians, (II) the proportion of expenditures for such

services for which payment is made under this part on an

assignment-related basis, and (III) the amounts charged above

the recognized payment amounts under this part.

(B) Report

The Secretary shall, by not later than April 15 of each year

(beginning in 1992), report to the Congress information on the

extent to which actual charges exceed limiting charges, the

number and types of services involved, and the average amount

of excess charges and information regarding the changes

described in subparagraph (A)(ii).

(C) Plan

If the Secretary finds that there has been a significant

decrease in the proportions described in subclauses (I) and

(II) of subparagraph (A)(ii) or an increase in the amounts

described in subclause (III) of that subparagraph, the

Secretary shall develop a plan to address such a problem and

transmit to Congress recommendations regarding the plan. The

Medicare Payment Advisory Commission shall review the

Secretary's plan and recommendations and transmit to Congress

its comments regarding such plan and recommendations.

(7) Monitoring of utilization and access

(A) In general

The Secretary shall monitor -

(i) changes in the utilization of and access to services

furnished under this part within geographic, population, and

service related categories,

(ii) possible sources of inappropriate utilization of

services furnished under this part which contribute to the

overall level of expenditures under this part, and

(iii) factors underlying these changes and their

interrelationships.

(B) Report

The Secretary shall by not later than April 15,(!2) of each

year (beginning with 1991) report to the Congress on the

changes described in subparagraph (A)(i) and shall include in

the report an examination of the factors (including factors

relating to different services and specific categories and

groups of services and geographic and demographic variations in

utilization) which may contribute to such changes.

(C) Recommendations

The Secretary shall include in each annual report under

subparagraph (B) recommendations -

(i) addressing any identified patterns of inappropriate

utilization,

(ii) on utilization review,

(iii) on physician education or patient education,

(iv) addressing any problems of beneficiary access to care

made evident by the monitoring process, and

(v) on such other matters as the Secretary deems

appropriate.

The Medicare Payment Advisory Commission shall comment on the

Secretary's recommendations and in developing its comments, the

Commission shall convene and consult a panel of physician

experts to evaluate the implications of medical utilization

patterns for the quality of and access to patient care.

(h) Sending information to physicians

Before the beginning of each year (beginning with 1992), the

Secretary shall send to each physician or nonparticipating supplier

or other person furnishing physicians' services (as defined in

subsection (j)(3) of this section) furnishing physicians' services

under this part, for services commonly performed by the physician,

supplier, or other person, information on fee schedule amounts that

apply for the year in the fee schedule area for participating and

non-participating physicians, and the maximum amount that may be

charged consistent with subsection (g)(2) of this section. Such

information shall be transmitted in conjunction with notices to

physicians, suppliers, and other persons under section 1395u(h) of

this title (relating to the participating physician program) for a

year.

(i) Miscellaneous provisions

(1) Restriction on administrative and judicial review

There shall be no administrative or judicial review under

section 1395ff of this title or otherwise of -

(A) the determination of the adjusted historical payment

basis (as defined in subsection (a)(2)(D)(i) of this section),

(B) the determination of relative values and relative value

units under subsection (c) of this section, including

adjustments under subsection (c)(2)(F) of this section and

section 13515(b) of the Omnibus Budget Reconciliation Act of

1993,

(C) the determination of conversion factors under subsection

(d) of this section,

(D) the establishment of geographic adjustment factors under

subsection (e) of this section, and

(E) the establishment of the system for the coding of

physicians' services under this section.

(2) Assistants-at-surgery

(A) In general

Subject to subparagraph (B), in the case of a surgical

service furnished by a physician, if payment is made separately

under this part for the services of a physician serving as an

assistant-at-surgery, the fee schedule amount shall not exceed

16 percent of the fee schedule amount otherwise determined

under this section for the global surgical service involved.

(B) Denial of payment in certain cases

If the Secretary determines, based on the most recent data

available, that for a surgical procedure (or class of surgical

procedures) the national average percentage of such procedure

performed under this part which involve the use of a physician

as an assistant at surgery is less than 5 percent, no payment

may be made under this part for services of an assistant at

surgery involved in the procedure.

(3) No comparability adjustment

For physicians' services for which payment under this part is

determined under this section -

(A) a carrier may not make any adjustment in the payment

amount under section 1395u(b)(3)(B) of this title on the basis

that the payment amount is higher than the charge applicable,

for a (!3) comparable services and under comparable

circumstances, to the policyholders and subscribers of the

carrier,

(B) no payment adjustment may be made under section

1395u(b)(8) of this title, and

(C) section 1395u(b)(9) of this title shall not apply.

(j) Definitions

In this section:

(1) Category

For services furnished before January 1, 1998, the term

"category" means, with respect to physicians' services, surgical

services, and all physicians' services other than surgical

services (as defined by the Secretary and including anesthesia

services), primary care services (as defined in section

1395u(i)(4) of this title), and all other physicians' services.

The Secretary shall define surgical services and publish such

definition in the Federal Register no later than May 1, 1990,

after consultation with organizations representing physicians.

(2) Fee schedule area

The term "fee schedule area" means a locality used under

section 1395u(b) of this title for purposes of computing payment

amounts for physicians' services.

(3) Physicians' services

The term "physicians' services" includes items and services

described in paragraphs (1), (2)(A), (2)(D), (2)(G), (2)(P) (with

respect to services described in subparagraphs (A) and (C) of

section 1395x(oo)(2) of this title), (2)(R) (with respect to

services described in subparagraphs (B), (C), and (D) of section

1395x(pp)(1) of this title), (2)(S), (3), (4), (13), (14) (with

respect to services described in section 1395x(nn)(2) of this

title), and (15) of section 1395x(s) of this title (other than

clinical diagnostic laboratory tests and, except for purposes of

subsections (a)(3), (g), and (h) of this section (!4) such other

items and services as the Secretary may specify).

(4) Practice expenses

The term "practice expenses" includes all expenses for

furnishing physicians' services, excluding malpractice expenses,

physician compensation, and other physician fringe benefits.

-SOURCE-

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1848, as added Pub. L.

101-239, title VI, Sec. 6102(a), Dec. 19, 1989, 103 Stat. 2169;

amended Pub. L. 101-508, title IV, Secs. 4102(b), (g)(2),

4104(b)(2), 4105(a)(3), (c), 4106(b)(1), 4107(a)(1), 4109(a), 4116,

4118(b)-(f)(1), (k), Nov. 5, 1990, 104 Stat. 1388-56, 1388-57,

1388-59 to 1388-63, 1388-65, 1388-67, 1388-68, 1388-71; Pub. L.

103-66, title XIII, Secs. 13511(a), 13512-13514(c), 13515(a)(1),

(c), 13516(a)(1), 13517(a), 13518(a), Aug. 10, 1993, 107 Stat.

580-583, 585, 586; Pub. L. 103-432, title I, Secs. 121(b)(1), (2),

122(a), (b), 123(a), (d), 126(b)(6), (g)(2)(B), (5)-(7), (10)(A),

Oct. 31, 1994, 108 Stat. 4409, 4410, 4412, 4415, 4416; Pub. L.

105-33, title IV, Secs. 4022(b)(2)(B), (C), 4102(d), 4103(d),

4104(d), 4105(a)(2), 4106(b), 4501, 4502(a)(1), (b), 4503, 4504(a),

4505(a), (b), (e), (f)(1), 4644(d), 4714(b)(2), Aug. 5, 1997, 111

Stat. 354, 355, 361, 362, 365, 366, 368, 432-437, 488, 510; Pub. L.

106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 211(a)(1), (2)(A),

(3)(A), (b), title III, Sec. 321(k)(5)], Nov. 29, 1999, 113 Stat.

1536, 1501A-345 to 1501A-348, 1501A-366; Pub. L. 106-554, Sec.

1(a)(6) [title I, Sec. 104(a)], Dec. 21, 2000, 114 Stat. 2763,

2763A-469.)