Legislación
US (United States) Code. Title 42. Chapter 7: Social Security
-CITE-
42 USC Sec. 1384 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVI - SUPPLEMENTAL SECURITY INCOME FOR AGED, BLIND, AND
DISABLED
Part B - Procedural and General Provisions
-HEAD-
Sec. 1384. Omitted
-COD-
CODIFICATION
Section, act Aug. 14, 1935, ch. 531, title XVI, Sec. 1604, as
added July 25, 1962, Pub. L. 87-543, title I, Sec. 141(a), 76 Stat.
204, related to operation of State plans, prior to the general
revision of this subchapter by Pub. L. 92-603, Oct. 30, 1972, 86
Stat. 1465, eff. Jan. 1, 1974.
-MISC1-
PUERTO RICO, GUAM, AND VIRGIN ISLANDS
Enactment of subchapter XVI of the Social Security Act [this
subchapter] by Pub. L. 92-603, eff. Jan. 1, 1974, was not
applicable to Puerto Rico, Guam, and the Virgin Islands. See
section 303(b) of Pub. L. 92-603, set out as a note under section
301 of this title. Therefore, as to Puerto Rico, Guam, and the
Virgin Islands, section 1604 of the Social Security Act [this
section] as it existed prior to reenactment of this subchapter by
Pub. L. 92-603 continues to apply and reads as follows:
Sec. 1384. Operation of State plans
If the Commissioner of Social Security, after reasonable notice
and opportunity for hearing to the State agency administering or
supervising the administration of the State plan approved under
this subchapter, finds -
(1) that the plan has been so changed that it no longer
complies with the provisions of section 1332 of this title; or
(2) that in the administration of the plan there is a failure
to comply substantially with any such provision;
the Commissioner of Social Security shall notify such State agency
that further payments will not be made to the State (or, in the
Commissioner's discretion, that payments will be limited to
categories under or parts of the State plan not affected by such
failure), until the Commissioner of Social Security is satisfied
that there will no longer be any such failure to comply. Until the
Commissioner is so satisfied the Commissioner shall make no further
payments to such State (or shall limit payments to categories under
or parts of the State plan not affected by such failure).
(Aug. 14, 1935, ch. 531, title XVI, Sec. 1604, as added July 25,
1962, Pub. L. 87-543, title I, Sec. 141(a), 76 Stat. 204; amended
Aug. 15, 1994, Pub. L. 103-296, title I, Sec. 107(a)(4), 108 Stat.
1478.)
[Amendment by section 107(a)(4) of Pub. L. 103-296 effective Mar.
31, 1995, see section 110(a) of Pub. L. 103-296, set out as an
Effective Date of 1994 Amendment note under section 401 of this
title.]
-End-
-CITE-
42 USC Sec. 1385 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVI - SUPPLEMENTAL SECURITY INCOME FOR AGED, BLIND, AND
DISABLED
Part B - Procedural and General Provisions
-HEAD-
Sec. 1385. Omitted
-COD-
CODIFICATION
Section, act Aug. 14, 1935, ch. 531, title XVI, Sec. 1605, as
added July 25, 1962, Pub. L. 87-543, title I, Sec. 141(a), 76 Stat.
204; amended July 30, 1965, Pub. L. 89-97, title II, Secs.
221(d)(1), (2), 222(b), title IV, Sec. 402(b), 79 Stat. 358, 360,
416, defined "aid to the aged, blind, or disabled" and "medical
assistance for the aged", prior to the general revision of this
subchapter by Pub. L. 92-603, Oct. 30, 1972, 86 Stat. 1465, eff.
Jan. 1, 1974.
-MISC1-
PUERTO RICO, GUAM, AND VIRGIN ISLANDS
Enactment of subchapter XVI of the Social Security Act [this
subchapter] by section 301 of Pub. L. 92-603, eff. Jan. 1, 1974,
was not applicable to Puerto Rico, Guam, and the Virgin Islands.
See section 303(b) of Pub. L. 92-603, set out as a note under
section 301 of this title. Therefore, as to Puerto Rico, Guam, and
the Virgin Islands, section 1605 of the Social Security Act [this
section] as it existed prior to reenactment of this subchapter by
Pub. L. 92-603, and as amended, continues to apply and to read as
follows:
Sec. 1385. Definitions
(a) For purposes of this subchapter, the term "aid to the aged,
blind, or disabled" means money payments to needy individuals who
are 65 years of age or older, are blind, or are 18 years of age or
over and permanently and totally disabled, but such term does not
include -
(1) any such payments to or care in behalf of any individual
who is an inmate of a public institution (except as a patient in
a medical institution); or
(2) any such payments to or care in behalf of any individual
who has not attained 65 years of age and who is a patient in an
institution for tuberculosis or mental diseases.
Such term also includes payments which are not included within the
meaning of such term under the preceding sentence, but which would
be so included except that they are made on behalf of such a needy
individual to another individual who (as determined in accordance
with standards prescribed by the Commissioner of Social Security)
is interested in or concerned with the welfare of such needy
individual, but only with respect to a State whose State plan
approved under section 1382 of this title includes provision for -
(A) determination by the State agency that such needy
individual has, by reason of his physical or mental condition,
such inability to manage funds that making payments to him would
be contrary to his welfare and, therefore, it is necessary to
provide such aid through payments described in this sentence;
(B) making such payments only in cases in which such payments
will, under the rules otherwise applicable under the State plan
for determining need and the amount of aid to the aged, blind, or
disabled to be paid (and in conjunction with other income and
resources), meet all the need [sic] of the individuals with
respect to whom such payments are made;
(C) undertaking and continuing special efforts to protect the
welfare of such individual and to improve, to the extent
possible, his capacity for self-care and to manage funds;
(D) periodic review by such State agency of the determination
under clause (A) of this subsection to ascertain whether
conditions justifying such determination still exist, with
provision for termination of such payments if they do not and for
seeking judicial appointment of a guardian or other legal
representative, as described in section 1311 of this title, if
and when it appears that such action will best serve the
interests of such needy individual; and
(E) opportunity for a fair hearing before the State agency on
the determination referred to in clause (A) of this subsection
for any individual with respect to whom it is made.
At the option of a State (if its plan approved under this
subchapter so provides), such term (i) need not include money
payments to an individual who has been absent from such State for a
period in excess of ninety consecutive days (regardless of whether
he has maintained his residence in such State during such period)
until he has been present in such State for thirty consecutive days
in the case of such an individual who has maintained his residence
in such State during such period or ninety consecutive days in the
case of any other such individual, and (ii) may include rent
payments made directly to a public housing agency on behalf of a
recipient or a group or groups of recipients of aid under such
plan.
(b) Repealed. Pub. L. 97-35, title XXI, Sec. 2184(d)(6)(B), Aug.
13, 1981, 95 Stat. 818.
(Aug. 14, 1935, ch. 531, title XVI, Sec. 1605, as added July 25,
1962, Pub. L. 87-543, title I, Sec. 141(a), 76 Stat. 204; amended
July 30, 1965, Pub. L. 89-97, title II, Secs. 221(d)(1), (2),
222(b), title IV, Sec. 402(b), 79 Stat. 358, 360, 416; Oct. 30,
1972, Pub. L. 92-603, title IV, Secs. 408(d), 409(d), 86 Stat.
1490, 1491; Aug. 13, 1981, Pub. L. 97-35, title XXI, Sec.
2184(d)(6), 95 Stat. 818; Aug. 15, 1994, Pub. L. 103-296, title I,
Sec. 107(a)(4), 108 Stat. 1478.)
[Amendment by section 107(a)(4) of Pub. L. 103-296 effective Mar.
31, 1995, see section 110(a) of Pub. L. 103-296, set out as an
Effective Date of 1994 Amendment note under section 401 of this
title.]
-End-
-CITE-
42 USC SUBCHAPTER XVII - GRANTS FOR PLANNING
COMPREHENSIVE ACTION TO COMBAT MENTAL
RETARDATION 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO COMBAT
MENTAL RETARDATION
-HEAD-
SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO
COMBAT MENTAL RETARDATION
-SECREF-
SUBCHAPTER REFERRED TO IN OTHER SECTIONS
This subchapter is referred to in section 1320a-1 of this title.
-End-
-CITE-
42 USC Sec. 1391 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO COMBAT
MENTAL RETARDATION
-HEAD-
Sec. 1391. Authorization of appropriations
-STATUTE-
For the purpose of assisting the States (including the District
of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands,
Guam, and American Samoa) to plan for and take other steps leading
to comprehensive State and community action to combat mental
retardation, there is authorized to be appropriated the sum of
$2,200,000. There are also authorized to be appropriated, for
assisting such States in initiating the implementation and carrying
out of planning and other steps to combat mental retardation,
$2,750,000 for the fiscal year ending June 30, 1966, and $2,750,000
for the fiscal year ending June 30, 1967.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVII, Sec. 1701, as added Pub. L.
88-156, Sec. 5, Oct. 24, 1963, 77 Stat. 275; amended Pub. L. 89-97,
title II, Sec. 211(a), July 30, 1965, 79 Stat. 356.)
-MISC1-
AMENDMENTS
1965 - Pub. L. 89-97 authorized appropriations of $2,750,000 for
fiscal years ending June 30, 1966 and 1967 for implementation of
mental retardation planning.
SHORT TITLE
For short title of Pub. L. 88-156, which enacted this subchapter,
as the "Maternal and Child Health and Mental Retardation Planning
Amendments of 1963", see section 1 of Pub. L. 88-156, set out as a
Short Title of 1963 Amendment note under section 1305 of this
title.
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in section 1392 of this title.
-End-
-CITE-
42 USC Sec. 1392 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO COMBAT
MENTAL RETARDATION
-HEAD-
Sec. 1392. Availability of funds during certain fiscal years;
limitation on amount; utilization of grant
-STATUTE-
The sums appropriated pursuant to the first sentence of section
1391 of this title shall be available for grants to States by the
Secretary during the fiscal year ending June 30, 1964, and the
succeeding fiscal year; and the sums appropriated pursuant to the
second sentence of such section for the fiscal year ending June 30,
1966, shall be available for such grants during such year and the
next two fiscal years, and sums appropriated pursuant thereto for
the fiscal year ending June 30, 1967, shall be available for such
grants during such year and the succeeding fiscal year. Any such
grant to a State, which shall not exceed 75 per centum of the cost
of the planning and related activities involved, may be used by it
to determine what action is needed to combat mental retardation in
the State and the resources available for this purpose, to develop
public awareness of the mental retardation problem and of the need
for combating it, to coordinate State and local activities relating
to the various aspects of mental retardation and its prevention,
treatment, or amelioration, and to plan other activities leading to
comprehensive State and community action to combat mental
retardation.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVII, Sec. 1702, as added Pub. L.
88-156, Sec. 5, Oct. 24, 1963, 77 Stat. 275; amended Pub. L. 89-97,
title II, Sec. 211(b), July 30, 1965, 79 Stat. 356.)
-MISC1-
AMENDMENTS
1965 - Pub. L. 89-97 inserted provision making appropriations for
fiscal year ending June 30, 1966, available for grants during such
fiscal year and the next two fiscal years and the appropriation for
fiscal year ending June 30, 1967, available for grants during such
fiscal year and the succeeding fiscal year.
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in section 1393 of this title.
-End-
-CITE-
42 USC Sec. 1393 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO COMBAT
MENTAL RETARDATION
-HEAD-
Sec. 1393. Applications; single State agency designation; essential
planning services; plans for expenditure; final activities report
and other necessary reports; records; accounting
-STATUTE-
In order to be eligible for a grant under section 1392 of this
title, a State must submit an application therefor which -
(1) designates or establishes a single State agency, which may
be an interdepartmental agency, as the sole agency for carrying
out the purposes of this subchapter;
(2) indicates the manner in which provision will be made to
assure full consideration of all aspects of services essential to
planning for comprehensive State and community action to combat
mental retardation, including services in the fields of
education, employment, rehabilitation, welfare, health, and the
law, and services provided through community programs for and
institutions for the mentally retarded;
(3) sets forth its plans for expenditure of such grant, which
plans provide reasonable assurance of carrying out the purposes
of this subchapter;
(4) provides for submission of a final report of the activities
of the State agency in carrying out the purposes of this
subchapter, and for submission of such other reports, in such
form and containing such information, as the Secretary may from
time to time find necessary for carrying out the purposes of this
subchapter and for keeping such records and affording such access
thereto as he may find necessary to assure the correctness and
verification of such reports; and
(5) provides for such fiscal control and fund accounting
procedures as may be necessary to assure proper disbursement of
and accounting for funds paid to the State under this subchapter.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVII, Sec. 1703, as added Pub. L.
88-156, Sec. 5, Oct. 24, 1963, 77 Stat. 275.)
-End-
-CITE-
42 USC Sec. 1394 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVII - GRANTS FOR PLANNING COMPREHENSIVE ACTION TO COMBAT
MENTAL RETARDATION
-HEAD-
Sec. 1394. Payments to States; adjustments; advances or
reimbursement; installments; conditions
-STATUTE-
Payment of grants under this subchapter may be made (after
necessary adjustment on account of previously made underpayments or
overpayments) in advance or by way of reimbursement, and in such
installments and on such conditions, as the Secretary may
determine.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVII, Sec. 1704, as added Pub. L.
88-156, Sec. 5, Oct. 24, 1963, 77 Stat. 276.)
-End-
-CITE-
42 USC SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND
DISABLED 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-SECREF-
SUBCHAPTER REFERRED TO IN OTHER SECTIONS
This subchapter is referred to in sections 233, 254b, 254c-16,
254e, 254g, 254h, 256b, 263a, 273, 274c, 296, 297n, 299a, 299b-6,
299c-2, 300b-8, 300e-6, 300t-12, 300x-24, 300bb-2, 300bb-3, 401,
416, 417, 418, 423, 426-1, 434, 704, 902, 904, 907a, 912, 1301,
1302, 1306, 1320a-1, 1320a-3, 1320a-3a, 1320a-5, 1320a-7, 1320a-7a,
1320a-7b, 1320a-7d, 1320a-7f, 1320a-8, 1320b-4, 1320b-5, 1320b-8,
1320b-12, 1320b-13, 1320b-14, 1320c-2, 1320c-3, 1320c-4, 1320c-9,
1320c-10, 1383, 1395x, 1395gg, 1396a, 1396b, 1396d, 1396i, 1396l,
1396m, 1396r, 1396r-4, 1396t, 1396u-2, 1396u-4, 1397d, 1997, 3002,
3013, 5021, 10805, 14402 of this title; title 2 section 906; title
5 section 8904; title 7 sections 2012, 3178; title 8 sections 1182,
1611; title 10 sections 1079, 1086, 1095, 1095c; title 12 sections
1715w, 1715z-7; title 18 section 4006; title 20 sections 6082,
7182; title 23 section 157; title 24 section 170a; title 25
sections 1616m, 1641, 1643, 1644, 1645, 1680c; title 26 sections
220, 420, 856, 1402, 4980B, 6103, 7702B, 9703, 9704, 9712; title 29
sections 623, 720, 1162, 1163; title 31 section 3803; title 38
sections 1781, 7423, 8153; title 45 section 231r; title 49 section
5307.
-End-
-CITE-
42 USC Sec. 1395 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
Sec. 1395. Prohibition against any Federal interference
-STATUTE-
Nothing in this subchapter shall be construed to authorize any
Federal officer or employee to exercise any supervision or control
over the practice of medicine or the manner in which medical
services are provided, or over the selection, tenure, or
compensation of any officer or employee of any institution, agency,
or person providing health services; or to exercise any supervision
or control over the administration or operation of any such
institution, agency, or person.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1801, as added Pub. L.
89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 291.)
-MISC1-
SHORT TITLE
For short title of title I of Pub. L. 89-97, which enacted this
subchapter as the "Health Insurance for the Aged Act", see section
100 of Pub. L. 89-97, set out as a Short Title of 1965 Amendment
note under section 1305 of this title.
-End-
-CITE-
42 USC Sec. 1395a 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
Sec. 1395a. Free choice by patient guaranteed
-STATUTE-
(a) Basic freedom of choice
Any individual entitled to insurance benefits under this
subchapter may obtain health services from any institution, agency,
or person qualified to participate under this subchapter if such
institution, agency, or person undertakes to provide him such
services.
(b) Use of private contracts by medicare beneficiaries
(1) In general
Subject to the provisions of this subsection, nothing in this
subchapter shall prohibit a physician or practitioner from
entering into a private contract with a medicare beneficiary for
any item or service -
(A) for which no claim for payment is to be submitted under
this subchapter, and
(B) for which the physician or practitioner receives -
(i) no reimbursement under this subchapter directly or on a
capitated basis, and
(ii) receives no amount for such item or service from an
organization which receives reimbursement for such item or
service under this subchapter directly or on a capitated
basis.
(2) Beneficiary protections
(A) In general
Paragraph (1) shall not apply to any contract unless -
(i) the contract is in writing and is signed by the
medicare beneficiary before any item or service is provided
pursuant to the contract;
(ii) the contract contains the items described in
subparagraph (B); and
(iii) the contract is not entered into at a time when the
medicare beneficiary is facing an emergency or urgent health
care situation.
(B) Items required to be included in contract
Any contract to provide items and services to which paragraph
(1) applies shall clearly indicate to the medicare beneficiary
that by signing such contract the beneficiary -
(i) agrees not to submit a claim (or to request that the
physician or practitioner submit a claim) under this
subchapter for such items or services even if such items or
services are otherwise covered by this subchapter;
(ii) agrees to be responsible, whether through insurance or
otherwise, for payment of such items or services and
understands that no reimbursement will be provided under this
subchapter for such items or services;
(iii) acknowledges that no limits under this subchapter
(including the limits under section 1395w-4(g) of this title)
apply to amounts that may be charged for such items or
services;
(iv) acknowledges that Medigap plans under section 1395ss
of this title do not, and other supplemental insurance plans
may elect not to, make payments for such items and services
because payment is not made under this subchapter; and
(v) acknowledges that the medicare beneficiary has the
right to have such items or services provided by other
physicians or practitioners for whom payment would be made
under this subchapter.
Such contract shall also clearly indicate whether the physician
or practitioner is excluded from participation under the
medicare program under section 1320a-7 of this title.
(3) Physician or practitioner requirements
(A) In general
Paragraph (1) shall not apply to any contract entered into by
a physician or practitioner unless an affidavit described in
subparagraph (B) is in effect during the period any item or
service is to be provided pursuant to the contract.
(B) Affidavit
An affidavit is described in this subparagraph if -
(i) the affidavit identifies the physician or practitioner
and is in writing and is signed by the physician or
practitioner;
(ii) the affidavit provides that the physician or
practitioner will not submit any claim under this subchapter
for any item or service provided to any medicare beneficiary
(and will not receive any reimbursement or amount described
in paragraph (1)(B) for any such item or service) during the
2-year period beginning on the date the affidavit is signed;
and
(iii) a copy of the affidavit is filed with the Secretary
no later than 10 days after the first contract to which such
affidavit applies is entered into.
(C) Enforcement
If a physician or practitioner signing an affidavit under
subparagraph (B) knowingly and willfully submits a claim under
this subchapter for any item or service provided during the
2-year period described in subparagraph (B)(ii) (or receives
any reimbursement or amount described in paragraph (1)(B) for
any such item or service) with respect to such affidavit -
(i) this subsection shall not apply with respect to any
items and services provided by the physician or practitioner
pursuant to any contract on and after the date of such
submission and before the end of such period; and
(ii) no payment shall be made under this subchapter for any
item or service furnished by the physician or practitioner
during the period described in clause (i) (and no
reimbursement or payment of any amount described in paragraph
(1)(B) shall be made for any such item or service).
(4) Limitation on actual charge and claim submission requirement
not applicable
Section 1395w-4(g) of this title shall not apply with respect
to any item or service provided to a medicare beneficiary under a
contract described in paragraph (1).
(5) Definitions
In this subsection:
(A) Medicare beneficiary
The term "medicare beneficiary" means an individual who is
entitled to benefits under part A of this subchapter or
enrolled under part B of this subchapter.
(B) Physician
The term "physician" has the meaning given such term by
section 1395x(r)(1) of this title.
(C) Practitioner
The term "practitioner" has the meaning given such term by
section 1395u(b)(18)(C) of this title.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1802, as added Pub. L.
89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 291; amended
Pub. L. 105-33, title IV, Sec. 4507(a)(1), (2)(A), Aug. 5, 1997,
111 Stat. 439, 441.)
-REFTEXT-
REFERENCES IN TEXT
Parts A and B of this subchapter, referred to in subsec.
(b)(5)(A), are classified to sections 1395c et seq. and 1395j et
seq., respectively, of this title.
-MISC1-
AMENDMENTS
1997 - Pub. L. 105-33 designated existing provisions as subsec.
(a), inserted heading, and added subsec. (b).
EFFECTIVE DATE OF 1997 AMENDMENT
Section 4507(c) of Pub. L. 105-33 provided that: "The amendment
made by subsection (a) [amending this section and section 1395y of
this title] shall apply with respect to contracts entered into on
and after January 1, 1998."
REPORT TO CONGRESS ON EFFECT OF PRIVATE CONTRACTS
Section 4507(b) of title IV of Pub. L. 105-33 provided that: "Not
later than October 1, 2001, the Secretary of Health and Human
Services shall submit a report to Congress on the effect on the
program under this title [see Tables for classification] of private
contracts entered into under the amendment made by subsection (a)
[amending this section and section 1395y of this title]. Such
report shall include -
"(1) analyses regarding -
"(A) the fiscal impact of such contracts on total Federal
expenditures under title XVIII of the Social Security Act [this
subchapter] and on out-of-pocket expenditures by medicare
beneficiaries for health services under such title; and
"(B) the quality of the health services provided under such
contracts; and
"(2) recommendations as to whether medicare beneficiaries
should continue to be able to enter private contracts under
section 1802(b) of such Act [subsec. (b) of this section] (as
added by subsection (a)) and if so, what legislative changes, if
any should be made to improve such contracts."
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 1395x, 1395y of this
title.
-End-
-CITE-
42 USC Sec. 1395b 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
Sec. 1395b. Option to individuals to obtain other health insurance
protection
-STATUTE-
Nothing contained in this subchapter shall be construed to
preclude any State from providing, or any individual from
purchasing or otherwise securing, protection against the cost of
any health services.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1803, as added Pub. L.
89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 291.)
-MISC1-
IMPACT OF INCREASED INVESTMENTS IN HEALTH RESEARCH ON FUTURE
MEDICARE COSTS
Pub. L. 105-78, title II, Nov. 13, 1997, 111 Stat. 1484, provided
in part: "That in carrying out its legislative mandate, the
National Bipartisan Commission on the Future of Medicare shall
examine the impact of increased investments in health research on
future Medicare costs, and the potential for coordinating Medicare
with cost-effective long-term care services".
NATIONAL BIPARTISAN COMMISSION ON THE FUTURE OF MEDICARE
Pub. L. 105-33, title IV, Sec. 4021, Aug. 5, 1997, 111 Stat. 347,
established National Bipartisan Commission on the Future of
Medicare which was directed to review and analyze long-term
financial condition of medicare program, identify problems that
threaten financial integrity of Federal Hospital Insurance Trust
Fund and Federal Supplementary Medical Insurance Trust Fund,
analyze potential solutions that will ensure both financial
integrity of medicare program and provision of appropriate benefits
under such program, and make recommendations for, among other
things, restoring solvency of Federal Hospital Insurance Trust Fund
and financial integrity of Federal Supplementary Medical Insurance
Trust Fund, establishing appropriate financial structure of
medicare program as a whole, and establishing appropriate balance
of benefits covered and beneficiary contributions to medicare
program, further provided for membership of Commission, meetings,
personnel and staff matters, powers of Commission, appropriations,
submission of final report to Congress not later than Mar. 1, 1999,
and termination of Commission 30 days after submission of final
report.
EXCLUSION FROM WAGES AND COMPENSATION OF REFUNDS REQUIRED FROM
EMPLOYERS TO COMPENSATE FOR DUPLICATION OF MEDICARE BENEFITS BY
HEALTH CARE BENEFITS PROVIDED BY EMPLOYERS
Pub. L. 101-239, title X, Sec. 10202, Dec. 19, 1989, 103 Stat.
2473, provided that:
"(a) Old-Age, Survivors, and Disability, and Hospital Insurance
Programs. - For purposes of title II of the Social Security Act
[subchapter II of this chapter] and chapter 21 of the Internal
Revenue Code of 1986 [26 U.S.C. 3101 et seq.], the term 'wages'
shall not include the amount of any refund required under section
421 of the Medicare Catastrophic Coverage Act of 1988 [section 421
of Pub. L. 100-360, formerly set out as a note below].
"(b) Railroad Retirement Program. - For purposes of chapter 22 of
the Internal Revenue Code of 1986 [26 U.S.C. 3201 et seq.], the
term 'compensation' shall not include the amount of any refund
required under section 421 of the Medicare Catastrophic Coverage
Act of 1988.
"(c) Federal Unemployment Programs. -
"(1) Federal unemployment tax. - For purposes of chapter 23 of
the Internal Revenue Code of 1986 [26 U.S.C. 3301 et seq.], the
term 'wages' shall not include the amount of any refund required
under section 421 of the Medicare Catastrophic Coverage Act of
1988.
"(2) Railroad unemployment contributions. - For purposes of the
Railroad Unemployment Insurance Act [45 U.S.C. 351 et seq.], the
term 'compensation' shall not include the amount of any refund
required under section 421 of the Medicare Catastrophic Coverage
Act of 1988.
"(3) Railroad unemployment repayment tax. - For purposes of
chapter 23A of the Internal Revenue Code of 1986 [26 U.S.C. 3321
et seq.], the term 'rail wages' shall not include the amount of
any refund required under section 421 of the Medicare
Catastrophic Coverage Act of 1988.
"(d) Reporting Requirements. - Any refund required under section
421 of the Medicare Catastrophic Coverage Act of 1988 shall be
reported to the Secretary of the Treasury or his delegate and to
the person to whom such refund is made in such manner as the
Secretary of the Treasury or his delegate shall prescribe.
"(e) Effective Date. - This section shall apply with respect to
refunds provided on or after January 1, 1989."
UNITED STATES BIPARTISAN COMMISSION ON COMPREHENSIVE HEALTH CARE
Pub. L. 100-360, title IV, subtitle A, Secs. 401-408, July 1,
1988, 102 Stat. 765-768, as amended by Pub. L. 100-647, title VIII,
Sec. 8414, Nov. 10, 1988, 102 Stat. 3801; Pub. L. 101-239, title
VI, Sec. 6220, Dec. 19, 1989, 103 Stat. 2254, established the
United States Bipartisan Commission on Comprehensive Health Care,
also known as the "Claude Pepper Commission" or the "Pepper
Commission", and directed Commission to examine shortcomings in
health care delivery and financing mechanisms that limit or prevent
access of all individuals in United States to comprehensive health
care, and make specific recommendations respecting Federal
programs, policies, and financing needed to assure the availability
of comprehensive long-term care services for elderly and disabled,
as well as comprehensive health care services for all individuals
in the United States, and further provided for membership of
Commission, staff and consultants, powers, authorization of
appropriations, submission of findings and recommendations to
Congress not later than Nov. 9, 1989, and for termination of
Commission 30 days after submissions to Congress.
MAINTENANCE OF EFFORT REGARDING DUPLICATIVE BENEFITS
Pub. L. 100-360, title IV, Sec. 421, July 1, 1988, 102 Stat. 808,
as amended by Pub. L. 100-485, title VI, Sec. 608(a), Oct. 13,
1988, 102 Stat. 2411, which required employers who had been
providing health care benefits to employees that were duplicative
part A and part B benefits to provide the employees with additional
benefits equal to the total actuarial value of such duplicative
benefits, was repealed by Pub. L. 101-234, title III, Sec. 301(a),
Dec. 13, 1989, 103 Stat. 1985. [Repeal not applicable to
duplicative part A benefits for periods before Jan. 1, 1990, see
section 301(e)(1) of Pub. L. 101-234, set out as an Effective Date
of 1989 Amendment note under section 1395u of this title.]
TASK FORCE ON LONG-TERM HEALTH CARE POLICIES
Pub. L. 99-272, title IX, Sec. 9601, Apr. 7, 1986, 100 Stat. 221,
as amended by Pub. L. 105-362, title VI, Sec. 601(b)(3), Nov. 10,
1998, 112 Stat. 3286, directed Secretary of Health and Human
Services, in consultation with National Association of Insurance
Commissioners, to establish Task Force on Long-Term Health Care
Policies to develop recommendations for long-term health care
policies designed to limit marketing and agent abuse for those
policies, to assure dissemination of such information to consumers
as is necessary to permit informed choice in purchasing policies
and to reduce purchase of unnecessary or duplicative coverage, to
assure that benefits provided under policies are reasonable in
relationship to premiums charged, and to promote development and
availability of long-term health care policies which meet these
recommendations, and further provided for composition of Task
Force, definition of long-term health care policy, assurance of
States' jurisdiction, submission of recommendations to Secretary
and Congress not later than 18 months after Apr. 7, 1986, and
termination of Task Force 90 days after submission of
recommendations.
-End-
-CITE-
42 USC Sec. 1395b-1 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
Sec. 1395b-1. Incentives for economy while maintaining or improving
quality in provision of health services
-STATUTE-
(a) Grants and contracts to develop and engage in experiments and
demonstration projects
(1) The Secretary of Health and Human Services is authorized,
either directly or through grants to public or private agencies,
institutions, and organizations or contracts with public or private
agencies, institutions, and organizations, to develop and engage in
experiments and demonstration projects for the following purposes:
(A) to determine whether, and if so which, changes in methods
of payment or reimbursement (other than those dealt with in
section 222(a) of the Social Security Amendments of 1972) for
health care and services under health programs established by
this chapter, including a change to methods based on negotiated
rates, would have the effect of increasing the efficiency and
economy of health services under such programs through the
creation of additional incentives to these ends without adversely
affecting the quality of such services;
(B) to determine whether payments for services other than those
for which payment may be made under such programs (and which are
incidental to services for which payment may be made under such
programs) would, in the judgment of the Secretary, result in more
economical provision and more effective utilization of services
for which payment may be made under such program, where such
services are furnished by organizations and institutions which
have the capability of providing -
(i) comprehensive health care services,
(ii) mental health care services (as defined by section
2691(c) (!1) of this title),
(iii) ambulatory health care services (including surgical
services provided on an outpatient basis), or
(iv) institutional services which may substitute, at lower
cost, for hospital care;
(C) to determine whether the rates of payment or reimbursement
for health care services, approved by a State for purposes of the
administration of one or more of its laws, when utilized to
determine the amount to be paid for services furnished in such
State under the health programs established by this chapter,
would have the effect of reducing the costs of such programs
without adversely affecting the quality of such services;
(D) to determine whether payments under such programs based on
a single combined rate of reimbursement or charge for the
teaching activities and patient care which residents, interns,
and supervising physicians render in connection with a graduate
medical education program in a patient facility would result in
more equitable and economical patient care arrangements without
adversely affecting the quality of such care;
(E) to determine whether coverage of intermediate care facility
services and homemaker services would provide suitable
alternatives to posthospital benefits presently provided under
this subchapter; such experiment and demonstration projects may
include:
(i) counting each day of care in an intermediate care
facility as one day of care in a skilled nursing facility, if
such care was for a condition for which the individual was
hospitalized,
(ii) covering the services of homemakers for a maximum of 21
days, if institutional services are not medically appropriate,
(iii) determining whether such coverage would reduce
long-range costs by reducing the lengths of stay in hospitals
and skilled nursing facilities, and
(iv) establishing alternative eligibility requirements and
determining the probable cost of applying each alternative, if
the project suggests that such extension of coverage would be
desirable;
(F) to determine whether, and if so which type of, fixed price
or performance incentive contract would have the effect of
inducing to the greatest degree effective, efficient, and
economical performance of agencies and organizations making
payment under agreements or contracts with the Secretary for
health care and services under health programs established by
this chapter;
(G) to determine under what circumstances payment for services
would be appropriate and the most appropriate, equitable, and
noninflationary methods and amounts of reimbursement under health
care programs established by this chapter for services, which are
performed independently by an assistant to a physician, including
a nurse practitioner (whether or not performed in the office of
or at a place at which such physician is physically present), and
-
(i) which such assistant is legally authorized to perform by
the State or political subdivision wherein such services are
performed, and
(ii) for which such physician assumes full legal and ethical
responsibility as to the necessity, propriety, and quality
thereof;
(H) to establish an experimental program to provide day-care
services, which consist of such personal care, supervision, and
services as the Secretary shall by regulation prescribe, for
individuals eligible to enroll in the supplemental medical
insurance program established under part B of this subchapter and
subchapter XIX of this chapter, in day-care centers which meet
such standards as the Secretary shall by regulation establish;
(I) to determine whether the services of clinical psychologists
may be made more generally available to persons eligible for
services under this subchapter and subchapter XIX of this chapter
in a manner consistent with quality of care and equitable and
efficient administration;
(J) to develop or demonstrate improved methods for the
investigation and prosecution of fraud in the provision of care
or services under the health programs established by this
chapter; and
(K) to determine whether the use of competitive bidding in the
awarding of contracts, or the use of other methods of
reimbursement, under part B of subchapter XI of this chapter
would be efficient and effective methods of furthering the
purposes of that part.
For purposes of this subsection, "health programs established by
this chapter" means the program established by this subchapter and
a program established by a plan of a State approved under
subchapter XIX of this chapter.
(2) Grants, payments under contracts, and other expenditures made
for experiments and demonstration projects under paragraph (1)
shall be made in appropriate part from the Federal Hospital
Insurance Trust Fund (established by section 1395i of this title)
and the Federal Supplementary Medical Insurance Trust Fund
(established by section 1395t of this title) and from funds
appropriated under subchapter XIX of this chapter. Grants and
payments under contracts may be made either in advance or by way of
reimbursement, as may be determined by the Secretary, and shall be
made in such installments and on such conditions as the Secretary
finds necessary to carry out the purpose of this section. With
respect to any such grant, payment, or other expenditure, the
amount to be paid from each of such trust funds (and from funds
appropriated under such subchapter XIX of this chapter) shall be
determined by the Secretary, giving due regard to the purposes of
the experiment or project involved.
(b) Waiver of certain payment or reimbursement requirements; advice
and recommendations of specialists preceding experiments and
demonstration projects
In the case of any experiment or demonstration project under
subsection (a) of this section, the Secretary may waive compliance
with the requirements of this subchapter and subchapter XIX of this
chapter insofar as such requirements relate to reimbursement or
payment on the basis of reasonable cost, or (in the case of
physicians) on the basis of reasonable charge, or to reimbursement
or payment only for such services or items as may be specified in
the experiment; and costs incurred in such experiment or
demonstration project in excess of the costs which would otherwise
be reimbursed or paid under such subchapters may be reimbursed or
paid to the extent that such waiver applies to them (with such
excess being borne by the Secretary). No experiment or
demonstration project shall be engaged in or developed under
subsection (a) of this section until the Secretary obtains the
advice and recommendations of specialists who are competent to
evaluate the proposed experiment or demonstration project as to the
soundness of its objectives, the possibilities of securing
productive results, the adequacy of resources to conduct the
proposed experiment or demonstration project, and its relationship
to other similar experiments and projects already completed or in
process.
-SOURCE-
(Pub. L. 90-248, title IV, Sec. 402(a), (b), Jan. 2, 1968, 81 Stat.
930, 931; Pub. L. 92-603, title II, Secs. 222(b), 278(b)(2), Oct.
30, 1972, 86 Stat. 1391, 1453; Pub. L. 95-142, Sec. 17(d), Oct. 25,
1977, 91 Stat. 1202; Pub. L. 96-88, title V, Sec. 509(b), Oct. 17,
1979, 93 Stat. 695; Pub. L. 97-35, title XXI, Sec. 2193(d), Aug.
13, 1981, 95 Stat. 828; Pub. L. 97-248, title I, Sec. 147, Sept. 3,
1982, 96 Stat. 394; Pub. L. 98-369, div. B, title III, Sec.
2331(b), July 18, 1984, 98 Stat. 1088.)
-REFTEXT-
REFERENCES IN TEXT
Section 222(a) of the Social Security Amendments of 1972,
referred to in subsec. (a)(1)(A), is section 222(a) of Pub. L.
92-603, Oct. 30, 1972, 86 Stat. 1329, which is set out as a note
below.
Section 2691(c) of this title, referred to in subsec.
(a)(1)(B)(ii), was repealed by Pub. L. 94-103, title III, Sec.
302(c), Oct. 4, 1975, 89 Stat. 507.
Part B of this subchapter, referred to in subsec. (a)(1)(H), is
classified to section 1395j et seq. of this title.
Part B of subchapter XI of this chapter, referred to in subsec.
(a)(1)(K), is classified to section 1320c et seq. of this title.
-COD-
CODIFICATION
Section is comprised of subsecs. (a) and (b) of section 402 of
Pub. L. 90-248. Subsec. (c) of such section 402 amended section
1395ll(b) of this title.
Section was enacted as a part of the Social Security Amendments
of 1967, and not as a part of the Social Security Act which
comprises this chapter.
-MISC1-
AMENDMENTS
1984 - Subsec. (a)(1). Pub. L. 98-369 substituted "grants to
public or private agencies" for "grants to public or nonprofit
private agencies" in provisions preceding subpar. (A).
1982 - Subsec. (a)(1)(K). Pub. L. 97-248 added subpar. (K).
1981 - Subsec. (a)(1). Pub. L. 97-35, Sec. 2193(d)(1),
substituted "this subchapter and a program established by a plan of
a State approved under subchapter XIX of this chapter" for "this
subchapter, a program established by a plan of a State approved
under subchapter XIX of this chapter, and a program established by
a plan of a State approved under subchapter V of this chapter".
Subsec. (a)(2). Pub. L. 97-35, Sec. 2193(d)(2), substituted
reference to subchapter XIX of this chapter for reference to
subchapters V and XIX of this chapter in two places.
Subsec. (b). Pub. L. 97-35, Sec. 2193(d)(3), substituted
reference to subchapter XIX of this chapter for reference to
subchapters V and XIX of this chapter.
1977 - Subsec. (a)(1)(J). Pub. L. 95-142 added subpar. (J).
1972 - Subsec. (a). Pub. L. 92-603, Secs. 222(b)(1), 278(b)(2),
substituted provisions spelling out in detail the purposes for
which experiments and demonstration projects may be carried out for
a general statement setting out the increase in efficiency and
economy of health services as the purpose of experiments selected
by the Secretary, inserted references to demonstration projects,
and inserted references to the Federal Hospital Insurance Trust
Fund and the Federal Supplementary Medical Insurance Trust Fund.
Subsec. (b). Pub. L. 92-603, Sec. 222(b)(2), inserted references
to demonstration projects and inserted ", or to reimbursement or
payment only for such services or items as may be specified in the
experiment".
-CHANGE-
CHANGE OF NAME
"Secretary of Health and Human Services" substituted for
"Secretary of Health, Education, and Welfare" in subsec. (a)(1)
pursuant to section 509(b) Pub. L. 96-88, which is classified to
section 3508(b) of Title 20, Education.
-MISC2-
EFFECTIVE DATE OF 1984 AMENDMENT
Amendment by Pub. L. 98-369 effective July 18, 1984, see section
2331(c) of Pub. L. 98-369, set out as a note under section 1310 of
this title.
EFFECTIVE DATE OF 1982 AMENDMENT
Amendment by Pub. L. 97-248 effective with respect to contracts
entered into or renewed on or after Sept. 3, 1982, see section 149
of Pub. L. 97-248, set out as an Effective Date note under section
1320c of this title.
EFFECTIVE DATE OF 1981 AMENDMENT, SAVINGS, AND TRANSITIONAL
PROVISIONS
For effective date, savings, and transitional provisions relating
to amendment by Pub. L. 97-35, see section 2194 of Pub. L. 97-35,
set out as a note under section 701 of this title.
DEMONSTRATION PROJECT FOR DISEASE MANAGEMENT FOR SEVERELY
CHRONICALLY ILL MEDICARE BENEFICIARIES
Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 121], Dec. 21, 2000,
114 Stat. 2763, 2763A-474, provided that:
"(a) In General. - The Secretary of Health and Human Services
shall conduct a demonstration project under this section (in this
section referred to as the 'project') to demonstrate the impact on
costs and health outcomes of applying disease management to
medicare beneficiaries with diagnosed, advanced-stage congestive
heart failure, diabetes, or coronary heart disease. In no case may
the number of participants in the project exceed 30,000 at any
time.
"(b) Voluntary Participation. -
"(1) Eligibility. - Medicare beneficiaries are eligible to
participate in the project only if -
"(A) they meet specific medical criteria demonstrating the
appropriate diagnosis and the advanced nature of their disease;
"(B) their physicians approve of participation in the
project; and
"(C) they are not enrolled in a Medicare+Choice plan.
"(2) Benefits. - A beneficiary who is enrolled in the project
shall be eligible -
"(A) for disease management services related to their chronic
health condition; and
"(B) for payment for all costs for prescription drugs without
regard to whether or not they relate to the chronic health
condition, except that the project may provide for modest
cost-sharing with respect to prescription drug coverage.
"(c) Contracts With Disease Management Organizations. -
"(1) In general. - The Secretary of Health and Human Services
shall carry out the project through contracts with up to three
disease management organizations. The Secretary shall not enter
into such a contract with an organization unless the organization
demonstrates that it can produce improved health outcomes and
reduce aggregate medicare expenditures consistent with paragraph
(2).
"(2) Contract provisions. - Under such contracts -
"(A) such an organization shall be required to provide for
prescription drug coverage described in subsection (b)(2)(B);
"(B) such an organization shall be paid a fee negotiated and
established by the Secretary in a manner so that (taking into
account savings in expenditures under parts A and B of the
medicare program under title XVIII of the Social Security Act
[this subchapter]) there will be a net reduction in
expenditures under the medicare program as a result of the
project; and
"(C) such an organization shall guarantee, through an
appropriate arrangement with a reinsurance company or
otherwise, the net reduction in expenditures described in
subparagraph (B).
"(3) Payments. - Payments to such organizations shall be made
in appropriate proportion from the Trust Funds established under
title XVIII of the Social Security Act [this subchapter].
"(d) Application of Medigap Protections to Demonstration Project
Enrollees. - (1) Subject to paragraph (2), the provisions of
section 1882(s)(3) [section 1395ss(s)(3) of this title] (other than
clauses (i) through (iv) of subparagraph (B)) and 1882(s)(4) of the
Social Security Act shall apply to enrollment (and termination of
enrollment) in the demonstration project under this section, in the
same manner as they apply to enrollment (and termination of
enrollment) with a Medicare+Choice organization in a
Medicare+Choice plan.
"(2) In applying paragraph (1) -
"(A) any reference in clause (v) or (vi) of section
1882(s)(3)(B) of such Act [section 1395ss(s)(3)(B) of this title]
to 12 months is deemed a reference to the period of the
demonstration project; and
"(B) the notification required under section 1882(s)(3)(D) of
such Act [section 1395ss(s)(3)(D) of this title] shall be
provided in a manner specified by the Secretary of Health and
Human Services.
"(e) Duration. - The project shall last for not longer than 3
years.
"(f) Waiver. - The Secretary of Health and Human Services shall
waive such provisions of title XVIII of the Social Security Act
[this subchapter] as may be necessary to provide for payment for
services under the project in accordance with subsection (c)(3).
"(g) Report. - The Secretary of Health and Human Services shall
submit to Congress an interim report on the project not later than
2 years after the date it is first implemented and a final report
on the project not later than 6 months after the date of its
completion. Such reports shall include information on the impact of
the project on costs and health outcomes and recommendations on the
cost-effectiveness of extending or expanding the project."
CANCER PREVENTION AND TREATMENT DEMONSTRATION FOR ETHNIC AND RACIAL
MINORITIES
Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 122], Dec. 21, 2000,
114 Stat. 2763, 2763A-476, provided that:
"(a) Demonstration. -
"(1) In general. - The Secretary of Health and Human Services
(in this section referred to as the 'Secretary') shall conduct
demonstration projects (in this section referred to as
'demonstration projects') for the purpose of developing models
and evaluating methods that -
"(A) improve the quality of items and services provided to
target individuals in order to facilitate reduced disparities
in early detection and treatment of cancer;
"(B) improve clinical outcomes, satisfaction, quality of
life, and appropriate use of medicare-covered services and
referral patterns among those target individuals with cancer;
"(C) eliminate disparities in the rate of preventive cancer
screening measures, such as pap smears and prostate cancer
screenings, among target individuals; and
"(D) promote collaboration with community-based organizations
to ensure cultural competency of health care professionals and
linguistic access for persons with limited English proficiency.
"(2) Target individual defined. - In this section, the term
'target individual' means an individual of a racial and ethnic
minority group, as defined by section 1707 of the Public Health
Service Act [section 300u-6 of this title], who is entitled to
benefits under part A, and enrolled under part B, of title XVIII
of the Social Security Act [parts A and B of this subchapter].
"(b) Program Design. -
"(1) Initial design. - Not later than 1 year after the date of
the enactment of this Act [Dec. 21, 2000], the Secretary shall
evaluate best practices in the private sector, community
programs, and academic research of methods that reduce
disparities among individuals of racial and ethnic minority
groups in the prevention and treatment of cancer and shall design
the demonstration projects based on such evaluation.
"(2) Number and project areas. - Not later than 2 years after
the date of the enactment of this Act, the Secretary shall
implement at least nine demonstration projects, including the
following:
"(A) Two projects for each of the four following major racial
and ethnic minority groups:
"(i) American Indians, including Alaska Natives, Eskimos,
and Aleuts.
"(ii) Asian Americans and Pacific Islanders.
"(iii) Blacks.
"(iv) Hispanics.
The two projects must target different ethnic subpopulations.
"(B) One project within the Pacific Islands.
"(C) At least one project each in a rural area and inner-city
area.
"(3) Expansion of projects; implementation of demonstration
project results. - If the initial report under subsection (c)
contains an evaluation that demonstration projects -
"(A) reduce expenditures under the medicare program under
title XVIII of the Social Security Act [this subchapter]; or
"(B) do not increase expenditures under the medicare program
and reduce racial and ethnic health disparities in the quality
of health care services provided to target individuals and
increase satisfaction of beneficiaries and health care
providers;
the Secretary shall continue the existing demonstration projects
and may expand the number of demonstration projects.
"(c) Report to Congress. -
"(1) In general. - Not later than 2 years after the date the
Secretary implements the initial demonstration projects, and
biannually thereafter, the Secretary shall submit to Congress a
report regarding the demonstration projects.
"(2) Contents of report. - Each report under paragraph (1)
shall include the following:
"(A) A description of the demonstration projects.
"(B) An evaluation of -
"(i) the cost-effectiveness of the demonstration projects;
"(ii) the quality of the health care services provided to
target individuals under the demonstration projects; and
"(iii) beneficiary and health care provider satisfaction
under the demonstration projects.
"(C) Any other information regarding the demonstration
projects that the Secretary determines to be appropriate.
"(d) Waiver Authority. - The Secretary shall waive compliance
with the requirements of title XVIII of the Social Security Act
[this subchapter] to such extent and for such period as the
Secretary determines is necessary to conduct demonstration
projects.
"(e) Funding. -
"(1) Demonstration projects. -
"(A) State projects. - Except as provided in subparagraph
(B), the Secretary shall provide for the transfer from the
Federal Hospital Insurance Trust Fund and the Federal
Supplementary [Medical] Insurance Trust Fund under title XVIII
of the Social Security Act [this subchapter], in such
proportions as the Secretary determines to be appropriate, of
such funds as are necessary for the costs of carrying out the
demonstration projects.
"(B) Territory projects. - In the case of a demonstration
project described in subsection (b)(2)(B), amounts shall be
available only as provided in any Federal law making
appropriations for the territories.
"(2) Limitation. - In conducting demonstration projects, the
Secretary shall ensure that the aggregate payments made by the
Secretary do not exceed the sum of the amount which the Secretary
would have paid under the program for the prevention and
treatment of cancer if the demonstration projects were not
implemented, plus $25,000,000."
LIFESTYLE MODIFICATION PROGRAM DEMONSTRATION
Pub. L. 106-554, Sec. 1(a)(6) [title I, Sec. 128], Dec. 21, 2000,
114 Stat. 2763, 2763A-480, provided that:
"(a) In General. - The Secretary of Health and Human Services
shall carry out the demonstration project known as the Lifestyle
Modification Program Demonstration, as described in the Health Care
Financing Administration Memorandum of Understanding entered into
on November 13, 2000, and as subsequently modified, (in this
section referred to as the 'project') in accordance with the
following requirements:
"(1) The project shall include no fewer than 1,800 medicare
beneficiaries who complete under the project the entire course of
treatment under the Lifestyle Modification Program.
"(2) The project shall be conducted over a course of 4 years.
"(b) Study on Cost-Effectiveness. -
"(1) Study. - The Secretary shall conduct a study on the
cost-effectiveness of the Lifestyle Modification Program as
conducted under the project. In determining whether such Program
is cost-effective, the Secretary shall determine (using a control
group under a matched paired experimental design) whether
expenditures incurred for medicare beneficiaries enrolled under
the project exceed expenditures for the control group of medicare
beneficiaries with similar health conditions who are not enrolled
under the project.
"(2) Reports. -
"(A) Initial report. - Not later that [sic] 1 year after the
date on which 900 medicare beneficiaries have completed the
entire course of treatment under the Lifestyle Modification
Program under the project, the Secretary shall submit to
Congress an initial report on the study conducted under
paragraph (1).
"(B) Final report. - Not later that [sic] 1 year after the
date on which 1,800 medicare beneficiaries have completed the
entire course of treatment under such Program under the
project, the Secretary shall submit to Congress a final report
on the study conducted under paragraph (1)."
MEDICARE COORDINATED CARE DEMONSTRATION PROJECT
Pub. L. 105-33, title IV, Sec. 4016, Aug. 5, 1997, 111 Stat. 343,
as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V,
Sec. 535], Nov. 29, 1999, 113 Stat. 1536, 1501A-390, provided that:
"(a) Demonstration Projects. -
"(1) In general. - The Secretary of Health and Human Services
(in this section referred to as the 'Secretary') shall conduct
demonstration projects for the purpose of evaluating methods,
such as case management and other models of coordinated care,
that -
"(A) improve the quality of items and services provided to
target individuals; and
"(B) reduce expenditures under the medicare program under
title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.)
for items and services provided to target individuals.
"(2) Target individual defined. - In this section, the term
'target individual' means an individual that has a chronic
illness, as defined and identified by the Secretary, and is
enrolled under the fee-for-service program under parts A and B of
title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.;
1395j et seq.).
"(b) Program Design. -
"(1) Initial design. - The Secretary shall evaluate best
practices in the private sector of methods of coordinated care
for a period of 1 year and design the demonstration project based
on such evaluation.
"(2) Number and project areas. - Not later than 2 years after
the date of enactment of this Act [Aug. 5, 1997], the Secretary
shall implement at least 9 demonstration projects, including -
"(A) 5 projects in urban areas;
"(B) 3 projects in rural areas; and
"(C) 1 project within the District of Columbia which is
operated by a nonprofit academic medical center that maintains
a National Cancer Institute certified comprehensive cancer
center.
"(3) Expansion of projects; implementation of demonstration
project results. -
"(A) Expansion of projects. - If the initial report under
subsection (c) contains an evaluation that demonstration
projects -
"(i) reduce expenditures under the medicare program; or
"(ii) do not increase expenditures under the medicare
program and increase the quality of health care services
provided to target individuals and satisfaction of
beneficiaries and health care providers;
the Secretary shall continue the existing demonstration projects
and may expand the number of demonstration projects.
"(B) Implementation of demonstration project results. - If a
report under subsection (c) contains an evaluation as described
in subparagraph (A), the Secretary may issue regulations to
implement, on a permanent basis, the components of the
demonstration project that are beneficial to the medicare
program.
"(c) Report to Congress. -
"(1) In general. - Not later than 2 years after the Secretary
implements the initial demonstration projects under this section,
and biannually thereafter, the Secretary shall submit to Congress
a report regarding the demonstration projects conducted under
this section.
"(2) Contents of report. - The report in paragraph (1) shall
include the following:
"(A) A description of the demonstration projects conducted
under this section.
"(B) An evaluation of -
"(i) the cost-effectiveness of the demonstration projects;
"(ii) the quality of the health care services provided to
target individuals under the demonstration projects; and
"(iii) beneficiary and health care provider satisfaction
under the demonstration project.
"(C) Any other information regarding the demonstration
projects conducted under this section that the Secretary
determines to be appropriate.
"(d) Waiver Authority. - The Secretary shall waive compliance
with the requirements of title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) to such extent and for such period as the
Secretary determines is necessary to conduct demonstration
projects.
"(e) Funding. -
"(1) Demonstration projects. -
"(A) In general. -
"(i) State projects. - Except as provided in clause (ii),
the Secretary shall provide for the transfer from the Federal
Hospital Insurance Trust Fund and the Federal Supplementary
[Medical] Insurance Trust Fund under title XVIII of the
Social Security Act (42 U.S.C. 1395i, 1395t), in such
proportions as the Secretary determines to be appropriate, of
such funds as are necessary for the costs of carrying out the
demonstration projects under this section.
"(ii) Cancer hospital. - In the case of the project
described in subsection (b)(2)(C), the Secretary shall
provide for the transfer from the Federal Hospital Insurance
Trust Fund and the Federal Supplementary Insurance Trust Fund
[Medical] under title XVIII of the Social Security Act (42
U.S.C. 1395i, 1395t), in such proportions as the Secretary
determines to be appropriate, of such funds as are necessary
to cover costs of the project, including costs for
information infrastructure and recurring costs of case
management services, flexible benefits, and program
management.
"(B) Limitation. - In conducting the demonstration project
under this section, the Secretary shall ensure that the
aggregate payments made by the Secretary do not exceed the
amount which the Secretary would have paid if the demonstration
projects under this section were not implemented.
"(2) Evaluation and report. - There are authorized to be
appropriated such sums as are necessary for the purpose of
developing and submitting the report to Congress under subsection
(c)."
INFORMATICS, TELEMEDICINE, AND EDUCATION DEMONSTRATION PROJECT
Pub. L. 105-33, title IV, Sec. 4207, Aug. 5, 1997, 111 Stat. 379,
as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title IV,
Sec. 413], Nov. 29, 1999, 113 Stat. 1536, 1501A-377, provided that:
"(a) Purpose and Authorization. -
"(1) In general. - Not later than 9 months after the date of
enactment of this section [Aug. 5, 1997], the Secretary of Health
and Human Services shall provide for a demonstration project
described in paragraph (2). The Secretary shall make an award for
such project not later than 3 months after the date of the
enactment of the Medicare, Medicaid, and SCHIP Balanced Budget
Refinement Act of 1999 [Nov. 29, 1999]. The Secretary shall
accept the proposal adjudged to be the best technical proposal as
of such date of enactment without the need for additional review
or resubmission of proposals.
"(2) Description of project. -
"(A) In general. - The demonstration project described in
this paragraph is a single demonstration project to use
eligible health care provider telemedicine networks to apply
high-capacity computing and advanced networks to improve
primary care (and prevent health care complications) to
medicare beneficiaries with diabetes mellitus who are residents
of medically underserved rural areas or residents of medically
underserved inner-city areas that qualify as Federally
designated medically underserved areas or health professional
shortage areas at the time of enrollment of beneficiaries under
the project.
"(B) Medically underserved defined. - As used in this
paragraph, the term 'medically underserved' has the meaning
given such term in section 330(b)(3) of the Public Health
Service Act (42 U.S.C. 254b(b)(3)).
"(3) Waiver. - The Secretary shall waive such provisions of
title XVIII of the Social Security Act [this subchapter] as may
be necessary to provide for payment for services under the
project in accordance with subsection (d).
"(4) Duration of project. - The project shall be conducted over
a 4-year period.
"(b) Objectives of Project. - The objectives of the project
include the following:
"(1) Improving patient access to and compliance with
appropriate care guidelines for individuals with diabetes
mellitus through direct telecommunications link with information
networks in order to improve patient quality-of-life and reduce
overall health care costs.
"(2) Developing a curriculum to train health professionals
(particularly primary care health professionals) in the use of
medical informatics and telecommunications.
"(3) Demonstrating the application of advanced technologies,
such as video-conferencing from a patient's home, remote
monitoring of a patient's medical condition, interventional
informatics, and applying individualized, automated care
guidelines, to assist primary care providers in assisting
patients with diabetes in a home setting.
"(4) Application of medical informatics to residents with
limited English language skills.
"(5) Developing standards in the application of telemedicine
and medical informatics.
"(6) Developing a model for the cost-effective delivery of
primary and related care both in a managed care environment and
in a fee-for-service environment.
"(c) Eligible Health Care Provider Telemedicine Network Defined.
- For purposes of this section, the term 'eligible health care
provider telemedicine network' means a consortium that includes at
least one tertiary care hospital (but no more than 2 such
hospitals), at least one medical school, no more than 4 facilities
in rural or urban areas, and at least one regional
telecommunications provider and that meets the following
requirements:
"(1) The consortium is located in an area with a high
concentration of medical schools and tertiary care facilities in
the United States and has appropriate arrangements (within or
outside the consortium) with such schools and facilities,
universities, and telecommunications providers, in order to
conduct the project.
"(2) The consortium submits to the Secretary an application at
such time, in such manner, and containing such information as the
Secretary may require, including a description of the use to
which the consortium would apply any amounts received under the
project.
"(3) The consortium guarantees that it will be responsible for
payment for all costs of the project that are not paid under this
section and that the maximum amount of payment that may be made
to the consortium under this section shall not exceed the amount
specified in subsection (d)(3).
"(d) Coverage as Medicare Part B Services. -
"(1) In general. - Subject to the succeeding provisions of this
subsection, services related to the treatment or management of
(including prevention of complications from) diabetes for
medicare beneficiaries furnished under the project shall be
considered to be services covered under part B of title XVIII of
the Social Security Act [part B of this subchapter].
"(2) Payments. -
"(A) In general. - Subject to paragraph (3), payment for such
services shall be made for the costs that are related to the
provision of such services. In computing such costs, the
Secretary shall include costs described in subparagraph (B),
but may not include costs described in subparagraph (C).
"(B) Costs that may be included. - The costs described in
this subparagraph are the permissible costs (as recognized by
the Secretary) for the following:
"(i) The acquisition of telemedicine equipment for use in
patients' homes or at sites providing health care to patients
located in medically underserved areas.
"(ii) Curriculum development and training of health
professionals in medical informatics and telemedicine.
"(iii) Payment of telecommunications costs (including
salaries and maintenance of equipment), including costs of
telecommunications between patients' homes and the eligible
network and between the network and other entities under the
arrangements described in subsection (c)(1).
"(iv) Payments to practitioners and providers under the
medicare programs.
"(C) Costs not included. - The costs described in this
subparagraph are costs for any of the following:
"(i) The purchase or installation of transmission equipment
(other than such equipment used by health professionals for
activities related to the project).
"(ii) The establishment or operation of a
telecommunications common carrier network.
"(iii) Construction (except for minor renovations related
to the installation of reimbursable equipment) or the
acquisition or building of real property.
"(3) Limitation. - The total amount of the payments that may be
made under this section shall not exceed $30,000,000 for the
period of the project (described in subsection (a)(4)).
"(4) Cost-sharing. - The project may not impose cost-sharing on
a medicare beneficiary for the receipt of services under the
project. Project costs will cover all costs to medicare
beneficiaries and providers related to participation in the
project.
"(e) Reports. - The Secretary shall submit to the Committee on
Ways and Means and the Committee [on] Commerce [now Committee on
Energy and Commerce] of the House of Representatives and the
Committee on Finance of the Senate interim reports on the project
and a final report on the project within 6 months after the
conclusion of the project. The final report shall include an
evaluation of the impact of the use of telemedicine and medical
informatics on improving access of medicare beneficiaries to health
care services, on reducing the costs of such services, and on
improving the quality of life of such beneficiaries.
"(f) Definitions. - For purposes of this section:
"(1) Interventional informatics. - The term 'interventional
informatics' means using information technology and virtual
reality technology to intervene in patient care.
"(2) Medical informatics. - The term 'medical informatics'
means the storage, retrieval, and use of biomedical and related
information for problem solving and decision-making through
computing and communications technologies.
"(3) Project. - The term 'project' means the demonstration
project under this section."
CLARIFICATION OF SECRETARIAL WAIVER AUTHORITY FOR RURAL HOSPITAL
DEMONSTRATIONS
Pub. L. 101-508, title IV, Sec. 4008(i)(1), Nov. 5, 1990, 104
Stat. 1388-50, as amended by Pub. L. 103-66, title XIII, Sec.
13507, Aug. 10, 1993, 107 Stat. 579, provided that: "The Secretary
of Health and Human Services is authorized to waive such provisions
of title XVIII of the Social Security Act [this subchapter] as are
necessary to conduct any demonstration project for limited-service
rural hospitals with respect to which the Secretary has entered
into an agreement before the date of the enactment of the Omnibus
Budget Reconciliation Act of 1989 [Dec. 19, 1989]. The Secretary
shall continue any such demonstration project until at least July
1, 1997."
VOLUNTEER SENIOR AIDES DEMONSTRATION PROJECTS FOR BASIC MEDICAL
ASSISTANCE AND SUPPORT TO FAMILIES WITH DISABLED OR ILL CHILDREN
Pub. L. 101-239, title X, Sec. 10404, Dec. 19, 1989, 103 Stat.
2488, provided that:
"(a) Number of Projects. - In order to determine whether, and if
so, the extent to which, the use of volunteer senior aides to
provide basic medical assistance and support to families with
moderately or severely disabled or chronically ill children
contributes to reducing the costs of care for such children, not
more than 10 communities may conduct demonstration projects under
this section.
"(b) Duties of the Secretary. -
"(1) Consideration of applications. - The Secretary of Health
and Human Services (in this section referred to as the
'Secretary') shall consider all applications received from
communities desiring to conduct demonstration projects under this
section.
"(2) Approval of certain applications. - The Secretary shall
approve not more than 10 applications to conduct projects which
appear likely to contribute significantly to the achievement of
the purpose of this section.
"(3) Grants. - The Secretary shall make grants to each
community the application of which to conduct a demonstration
project under this section is approved by the Secretary to assist
the community in carrying out the project.
"(c) Requirements. - Each community receiving a grant with
respect to a demonstration project under this section shall conduct
the project in accordance with such requirements as the Secretary
may prescribe.
"(d) Limitation on Authorization of Appropriations. - For grants
under this section, there are authorized to be appropriated to the
Secretary of Health and Human Services not to exceed -
"(1) $1,000,000 for each of the fiscal years 1990 and 1991; and
"(2) $2,000,000 for each of the fiscal years 1992, 1993, and
1994.
"(e) Effective Date. - This section shall take effect on October
1, 1989."
TREATMENT OF CERTAIN NURSING EDUCATION PROGRAMS
Pub. L. 100-647, title VIII, Sec. 8411, Nov. 10, 1988, 102 Stat.
3800, as amended by Pub. L. 101-239, title VI, Sec. 6205(a)(1)(B),
Dec. 19, 1989, 103 Stat. 2243, provided that:
"(a) Demonstration of Joint Nursing Graduate Education Programs.
-
"(1) The Secretary of Health and Human Services shall provide
for demonstration programs under this subsection in each of 5
hospitals for cost reporting periods beginning on or after July
1, 1989, and before July 1, 1994.
"(2) Under each demonstration project, subject to paragraph
(4), the reasonable costs incurred by a hospital pursuant to a
written agreement with an educational institution for the
activities described in paragraph (3) conducted as part of an
approved educational program that -
"(A) involves a substantial clinical component (as determined
by the Secretary), and
"(B) leads to a master's or doctoral degree in nursing,
shall be allowable as reasonable costs under title XVIII of the
Social Security Act [this subchapter] and reimbursed under such
title on the same basis as if they were allowable direct costs of
a hospital-operated approved educational program (other than an
approved graduate medical education program).
"(3) The activities described in this paragraph are the
activities for which the reasonable costs of conducting such
activities are allowable under title XVIII of the Social Security
Act if conducted under a hospital-operated approved educational
program (other than an approved graduate medical education
program), but only to the extent such activities are directly
related to the operation of the educational program conducted
pursuant to the written agreement between the hospital and the
educational institution.
"(4) The amount paid under a demonstration program under this
subsection to a hospital for a cost reporting period may not
exceed $200,000.
"(5) The Secretary shall report to Congress, by not later than
January 1, 1995, on the demonstration programs conducted under
this subsection and on the supply and characteristics of nurses
trained under such programs.
"(b) Joint Undergraduate Education Program. - In the case of a
hospital which (1) was paid under a waiver under section 402 of the
Social Security Amendments of 1967 [section 402 of Pub. L. 90-248,
enacting this section and amending section 1395ll of this title]
and section 222 of the Social Security Amendments of 1972 [section
222 of Pub. L. 92-603, amending this section and section 1395ll of
this title and enacting provisions set out below], which waiver
expired on September 30, 1985, and (2) during its cost reporting
period beginning in fiscal year 1985 and for each subsequent cost
reporting period, has been and is associated with, and has incurred
and incurs substantial costs with respect to, a nursing college
with which it has shared and shares common directors, educational
activities of the nursing college shall be considered to be
educational activities operated directly by such hospital for
purposes of title XVIII of the Social Security Act [this
subchapter], and shall be allowable as reasonable costs under such
title and reimbursed under such title on the same basis as if they
were allowable direct costs of a hospital-operated approved
educational program (other than an approved graduate medical
education program), for hospital cost reporting periods beginning
in fiscal years 1986 though 1991."
RESEARCH ON LONG-TERM CARE SERVICES FOR MEDICARE BENEFICIARIES
Pub. L. 100-360, title II, Sec. 207, July 1, 1988, 102 Stat. 732,
which provided for research on issues relating to the delivery and
financing of long-term care services for medicare beneficiaries,
was repealed by Pub. L. 101-234, title II, Sec. 201(a), Dec. 13,
1989, 103 Stat. 1981.
ADJUSTMENT OF CONTRACTS WITH PREPAID HEALTH PLANS
For requirement that Secretary of Health and Human Services
modify contracts with health maintenance organizations under
subsec. (a) of this section and section 222(a) of Pub. L. 92-603,
set out below, so as to apply to such organizations and contracts
the requirements imposed by the amendments made by Pub. L. 100-360,
see section 222 of Pub. L. 100-360, set out as a note under section
1395mm of this title.
CASE MANAGEMENT DEMONSTRATION PROJECTS
Pub. L. 101-508, title IV, Sec. 4207(f), formerly Sec. 4027(f),
Nov. 5, 1990, 104 Stat. 1388-123, as renumbered by Pub. L. 103-432,
title I, Sec. 160(d)(4), Oct. 31, 1994, 108 Stat. 4444, provided
that:
"(1) In general. - Notwithstanding any other provision of law,
the Secretary of Health and Human Services shall resume the 3 case
management demonstration projects described in paragraph (2) and
approved under section 425 of the Medicare Catastrophic Coverage
Act of 1988 [Pub. L. 100-360, formerly set out below] (in this
subsection referred to as 'MCCA').
"(2) Project descriptions. - The demonstration projects referred
to in paragraph (1) are -
"(A) the project proposed to be conducted by Providence
Hospital for case management of the elderly at risk for acute
hospitalization as described in Project No. 18-P-99379/5-01;
"(B) the project proposed to be conducted by the Iowa
Foundation for Medical Care to study patients with chronic
congestive conditions to reduce repeated hospitalizations of such
patients as described in Project No. P-99399/4-01; and
"(C) the project proposed to be conducted by Key Care Health
Resources, Inc., to examine the effects of case management on
2,500 high cost medicare beneficiaries as described in Project
No. 18-P-99396/5.
"(3) Terms and conditions. - Except as provided in paragraph (4),
the demonstration projects resumed pursuant to paragraph (1) shall
be subject to the same terms and conditions established under
section 425 of MCCA. In determining the 2-year duration period of a
project resumed pursuant to paragraph (1), the Secretary may not
take into account any period of time for which the project was in
effect under section 425 of MCCA.
"(4) Authorization of appropriations. - Notwithstanding section
425(g) of MCCA, there are authorized to be appropriated for
administrative costs in carrying out the demonstration projects
resumed pursuant to paragraph (1) $2,000,000 in each of fiscal
years 1991 and 1992."
Pub. L. 100-360, title IV, Sec. 425, July 1, 1988, 102 Stat. 813,
which directed Secretary of Health and Human Services to establish
4 demonstration projects under which an appropriate entity agreed
to provide case management services, was repealed by Pub. L.
101-234, title III, Sec. 301(a), Dec. 13, 1989, 103 Stat. 1985.
DEMONSTRATION PROJECTS WITH RESPECT TO CHRONIC VENTILATOR-DEPENDENT
UNITS IN HOSPITALS
Pub. L. 100-360, title IV, Sec. 429, July 1, 1988, 102 Stat. 817,
as amended by Pub. L. 100-647, title VIII, Sec. 8404(a), Nov. 10,
1988, 102 Stat. 3800, directed Secretary of Health and Human
Services, in consultation with the Prospective Payment Assessment
Commission, to provide for at least 5 demonstration projects, for
at least 3 years each, to review appropriateness of classifying
chronic ventilator-dependent units in hospitals as rehabilitation
units.
RESEARCH AND DEMONSTRATION PROJECTS ON RURAL AND INNER-CITY HEALTH
ISSUES
Pub. L. 100-203, title IV, Sec. 4403, Dec. 22, 1987, 1330-226, as
amended by Pub. L. 100-360, title IV, Sec. 411(m)(2)(A), July 1,
1988, 102 Stat. 806, provided that:
"(a) Set Asides for Issues of Health Care in Rural Areas and In
Inner-City Areas. - (1) Not less than ten percent of the total
amounts annually appropriated to, and expended by, the Health Care
Financing Administration for the conduct of research and
demonstration projects in fiscal years 1988, 1989, and 1990 shall
be expended for research and demonstration projects relating
exclusively or substantially to rural health issues, including (but
not limited to) the impact of the payment methodology under section
1886(d) of the Social Security Act [section 1395ww(d) of this
title] on the financial viability of small rural hospitals, the
effect of medicare payment policies on the ability of rural areas
(and rural hospitals in particular) to attract and retain
physicians and other health professionals, the appropriateness of
medicare conditions of participation and staffing requirements for
small rural hospitals, and the impact of medicare policies on
access to (and the quality of) health care in rural areas.
"(2) Not less than ten percent of the total amounts annually
appropriated to, and expended by, the Health Care Financing
Administration for the conduct of research and demonstration
projects in fiscal years 1988, 1989, and 1990 shall be expended for
research and demonstration projects relating exclusively or
substantially to issues of providing health care in inner-city
areas, including (but not limited to) the impact of the payment
methodology under section 1886(d) of the Social Security Act on the
financial viability of inner-city hospitals and the impact of
medicare policies on access to (and the quality of) health care in
inner-city areas.
"(b) Agenda. - The Secretary of Health and Human Services shall
establish an agenda of research and demonstration projects,
relating exclusively or substantially to rural health issues or to
inner-city health issues, that are in progress or have been
proposed, and shall include such agenda in the annual report
submitted pursuant to section 1875(b) of the Social Security Act
[section 1395ll(b) of this title]. The agenda shall be accompanied
by a statement setting forth the amounts that have been obligated
and expended with respect to such projects in the current and most
recently completed fiscal years."
ALZHEIMER'S DISEASE DEMONSTRATION PROJECTS
Pub. L. 99-509, title IX, Sec. 9342, Oct. 21, 1986, 100 Stat.
2038, as amended by Pub. L. 101-508, title IV, Sec. 4164(a)(2),
Nov. 5, 1990, 104 Stat. 1388-101; Pub. L. 103-66, title XIII, Sec.
13552, Aug. 10, 1993, 107 Stat. 591, required Secretary of Health
and Human Services to conduct at least 5 (and not more than 10)
demonstration projects, each over a period of 5 years, to determine
effectiveness, cost, and impact on health status and functioning of
providing comprehensive services for individuals entitled to
benefits under this subchapter who are victims of Alzheimer's
disease or related disorders and to report to Congress upon
completion of the projects.
SPECIAL TREATMENT OF STATES FORMERLY UNDER WAIVER
For treatment of hospitals in States which have had a waiver
approved under this section, upon termination of waiver, see
section 9202(j) of Pub. L. 99-272, as amended, set out as a note
under section 1395ww of this title.
EXTENSION OF CERTAIN MEDICARE MUNICIPAL HEALTH SERVICES
DEMONSTRATION PROJECTS
Pub. L. 99-272, title IX, Sec. 9215, Apr. 7, 1986, 100 Stat. 180,
as amended by Pub. L. 101-239, title VI, Sec. 6135, Dec. 19, 1989,
103 Stat. 2222; Pub. L. 103-66, title XIII, Sec. 13557, Aug. 10,
1993, 107 Stat. 592; Pub. L. 105-33, title IV, Sec. 4017, Aug. 5,
1997, 111 Stat. 345; Pub. L. 106-113, div. B, Sec. 1000(a)(6)
[title V, Sec. 534], Nov. 29, 1999, 113 Stat. 1536, 1501A-390; Pub.
L. 106-554, Sec. 1(a)(6) [title VI, Sec. 633], Dec. 21, 2000, 114
Stat. 2763, 2763A-568, provided that:
"(a) The Secretary of Health and Human Services shall extend
through December 31, 1997, approval of four municipal health
services demonstration projects (located in Baltimore, Cincinnati,
Milwaukee, and San Jose) authorized under section 402(a) of the
Social Security Amendments of 1967 [subsec. (a) of this section].
The Secretary shall submit a report to Congress on the waiver
program with respect to the quality of health care, beneficiary
costs, costs to the medicaid program and other payers, access to
care, outcomes, beneficiary satisfaction, utilization differences
among the different populations served by the projects, and such
other factors as may be appropriate. Subject to subsection (c), the
Secretary may further extend such demonstration projects through
December 31, 2004, but only with respect to individuals who
received at least one service during the period beginning on
January 1, 1996, and ending on the date of the enactment of the
Balanced Budget Act of 1997 [Aug. 5, 1997].
"(b) The Secretary shall work with each such demonstration
project to develop a plan, to be submitted to the Committee on Ways
and Means and the Committee on Commerce of the House of
Representatives and the Committee on Finance of the Senate by March
31, 1998, for the orderly transition of demonstration projects and
the project participants to a non-demonstration project health care
delivery system, such as through integration with a private or
public health plan, including a medicaid managed care or
Medicare+Choice plan.
"(c) A demonstration project under subsection (a) which does not
develop and submit a transition plan under subsection (b) by March
31, 1998, or, if later, 6 months after the date of the enactment of
the Balanced Budget Act of 1997 [Aug. 5, 1997], shall be
discontinued as of December 31, 1998. The Secretary shall provide
appropriate technical assistance to assist in the transition so
that disruption of medical services to project participants may be
minimized."
DEMONSTRATION PROGRAM FOR REDUCTION OF DISABILITY AND DEPENDENCY
THROUGH PROVISION OF PREVENTIVE HEALTH SERVICES UNDER MEDICARE
Pub. L. 99-272, title IX, Sec. 9314, Apr. 7, 1986, 100 Stat. 194,
as amended by Pub. L. 99-509, title IX, Sec. 9344(d), Oct. 21,
1986, 100 Stat. 2042; Pub. L. 101-508, title IV, Sec. 4164(a)(1),
Nov. 5, 1990, 104 Stat. 1388-100, required Secretary of Health and
Human Services to establish a 5-year demonstration program designed
to reduce disability and dependency through the provision of
preventive health services to individuals entitled to benefits
under this subchapter and to submit reports to Congress including a
final report on the project not later than April 1, 1995.
PAYMENT FOR COSTS OF HOSPITAL-BASED MOBILE INTENSIVE CARE UNITS
Section 2320 of Pub. L. 98-369 provided that:
"(a)(1) In the case of a project described in subsection (b), the
Secretary of Health and Human Services shall provide, except as
provided in paragraph (2), that the amount of payments to hospitals
covered under the project during the period described in paragraph
(3) shall include payments for their operation of hospital-based
mobile intensive care units (as defined by State statute) if the
State provides satisfactory assurances that the total amount of
payments to such hospitals under titles XVIII and XIX of the Social
Security Act [this subchapter and subchapter XIX of this chapter]
under the demonstration project (including any such additional
amount of payment) would not exceed the total amount of payments
which would have been paid under such titles if the demonstration
project were not in effect.
"(2) Paragraph (1) shall not apply if the State in which the
project is located notifies the Secretary, within 30 days after the
date of the enactment of this section [July 18, 1984], that the
State does not want paragraph (1) to apply to that project.
"(3) The period referred to in paragraph (1) begins on the date
of the enactment of this section and continues so long as the
Secretary continues the Statewide waiver referred to in subsection
(b), but in no case ends earlier than 90 days after the date final
regulations to implement section 1886(c) of the Social Security Act
[section 1395ww(c) of this title] are published.
"(b) The project referred to in subsection (a) is the statewide
demonstration project established in the State of New Jersey under
section 402 of the Social Security Amendments of 1967, as amended
by section 222(b) of the Social Security Amendments of 1972 (Public
Law 92-603) [this section], which project provides for payments to
hospitals in the State on a prospective basis and related to a
classification of patients by diagnosis-related groups.
"(c) Payment for services described in this section shall be
considered to be payments for services under part A of title XVIII
of the Social Security Act [part A of this subchapter]."
CONTINUATION OF SECRETARY'S AUTHORITY REGARDING EXPERIMENTS AND
DEMONSTRATION PROJECTS
Pub. L. 98-21, title VI, Sec. 603(b), Apr. 20, 1983, 97 Stat.
167, provided that:
"(1) Except as provided in paragraph (2), the amendments made by
this title [amending sections 1320a-1, 1320c-2, 1395f, 1395i-2,
1395n, 1395r, 1395v, 1395w, 1395x, 1395y, 1395cc, 1395mm, 1395oo,
1395rr, 1395ww, and 1395xx of this title, enacting provisions set
out as notes under this section and sections 1395r, 1395x, 1395y,
1395cc, and 1395ww of this title, and amending provisions set out
as a note under section 1395x of this title] shall not affect the
authority of the Secretary to develop, carry out, or continue
experiments and demonstration projects.
"(2) The Secretary shall provide that, upon the request of a
State which has a demonstration project, for payment of hospitals
under title XVIII of the Social Security Act [this subchapter]
approved under section 402(a) of the Social Security Amendments of
1967 [subsec. (a) of this section] or section 222(a) of the Social
Security Amendments of 1972 [set out as a note below], which (A) is
in effect as of March 1, 1983, and (B) was entered into after
August 1982 (or upon the request of another party to demonstration
project agreement), the terms of the demonstration agreement shall
be modified so that the demonstration project is not required to
maintain the rate of increase in medicare hospital costs in that
State below the national rate of increase in medicare hospital
costs."
ALTERNATIVE CARE DEMONSTRATION PROJECTS IN HOSPITALS SHORT OF
SKILLED NURSING FACILITIES
Pub. L. 98-21, title VI, Sec. 603(d), Apr. 20, 1983, 97 Stat.
168, provided that: "The Secretary shall conduct demonstrations
with hospitals in areas with critical shortages of skilled nursing
facilities to study the feasibility of providing alternative
systems of care or methods of payment."
CONTINUATION OF HOSPICE DEMONSTRATION PROJECTS; REPORT TO CONGRESS
Section 122(i), formerly Sec. 122(h), of Pub. L. 97-248, as
redesignated and amended by Pub. L. 97-448, title III, Sec.
309(a)(6), (e), Jan. 12, 1983, 96 Stat. 2408, 2410, provided that:
"(1) Notwithstanding any provision of law which has the effect of
restricting the time period of a hospice demonstration project in
effect on July 15, 1982, pursuant to section 402(a) of the Social
Security Amendments of 1967 [subsec. (a) of this section], the
Secretary of Health and Human Services, upon request of the hospice
involved, shall permit continuation of the project until November
1, 1983, or, if later, the date on which payments can first be made
to any hospice program under the amendments made by this section.
"(2) Prior to September 30, 1983, the Secretary shall submit to
Congress a report on the effectiveness of demonstration projects
referred to in paragraph (1), including an evaluation of the
cost-effectiveness of hospice care, the reasonableness of the
40-percent cap amount for hospice care as provided in section
1814(i) of the Social Security Act [section 1395f(i) of this title]
(as added by this section), proposed methodology for determining
such cap amount, proposed standards for requiring and measuring the
maintenance of effort for utilizing volunteers as required under
section 1861(dd) of such Act [section 1395x(dd) of this title], an
evaluation of physician reimbursement for services furnished as a
part of hospice care and for services furnished to individuals
receiving hospice care but which are not reimbursed as a part of
the hospice care, and any proposed legislative changes in the
hospice care provisions of title XVIII of such Act [this
subchapter].
"(3)(A) Notwithstanding the provisions of paragraph (1), the
Secretary of Health and Human Services, upon request of the hospice
involved, shall permit continuation of a hospice demonstration
project described in paragraph (1) until September 30, 1986, if the
hospice involved in such demonstration project does not provide
hospice care directly but acts as a channeling agency for the
provision of hospice care.
"(B) During the period after the date on which a hospice
demonstration project described in subparagraph (A) would otherwise
have terminated under the provisions of paragraph (1), and prior to
September 30, 1986, any such hospice demonstration project shall be
subject to the same requirements as are imposed under the hospice
program provided for under the amendments made by this section
[amending sections 1395c to 1395f, 1395h, and 1395x to 1395cc of
this title and section 231f of Title 45, Railroads, and enacting
provisions set out as notes under sections 1395c and 1395f of this
title] with respect to reimbursement and benefits, other than the
requirement that certain benefits be provided directly by the
hospice involved."
STATE MEDICARE HOSPITAL REIMBURSEMENT DEMONSTRATION PROJECT
LIMITATION
Pub. L. 96-499, title IX, Sec. 903(c), Dec. 5, 1980, 94 Stat.
2615, which provided for a maximum number of six Statewide medicare
hospital reimbursement demonstration projects, was repealed by Pub.
L. 97-35, title XXI, Sec. 2154, Aug. 13, 1981, 95 Stat. 802.
STUDY OF NEED FOR DUAL PARTICIPATION OF SKILLED NURSING FACILITIES
Pub. L. 96-499, title IX, Sec. 919, Dec. 5, 1980, 94 Stat. 2627,
required study of need for dual participation of skilled nursing
facilities and submission of a report and recommendations to
Congress within one year after Dec. 5, 1980.
DEMONSTRATION PROJECTS FOR PHYSICIAN-DIRECTED CLINICS IN URBAN
MEDICALLY UNDERSERVED AREAS; REPORT SUBMITTED NO LATER THAN JANUARY
1, 1981
Pub. L. 95-210, Sec. 3, Dec. 13, 1977, 91 Stat. 1489, required
the Secretary to provide, through demonstration projects,
reimbursement on a cost basis for services provided by
physician-directed clinics in urban medically underserved areas for
which payment may be made under this subchapter and,
notwithstanding any other provision of this subchapter, for
services provided by a physician assistant or nurse practitioner
employed by such clinics which would otherwise be covered under
this subchapter if provided by a physician. The Secretary was to
evaluate the relative advantages and disadvantages of reimbursement
on the basis of costs and fee-for-service for physician-directed
clinics employing a physician assistant or nurse practitioner, the
appropriate method of determining the compensation for physician
services on a cost basis for the purposes of reimbursement of
services provided in such clinics, the appropriate definition for
such clinics, the appropriate criteria to use for the purposes of
designating urban medically underserved areas, and such other
possible changes in the provisions of this subchapter as might be
appropriate for the efficient and cost-effective reimbursement of
services provided in such clinics. Grants, payments under
contracts, and other expenditures made for demonstration projects
were to be made in appropriate part from the Federal Hospital
Insurance Trust Fund and the Federal Supplementary Medical
Insurance Trust Fund. The Secretary was to submit to the Congress,
no later than Jan. 1, 1981, a complete detailed report on the
demonstration projects.
SCOPE OF GRANTS FOR EXPERIMENTS AND DEMONSTRATION PROJECTS TO
DETERMINE METHODS FOR PROSPECTIVE PAYMENTS TO HOSPITALS, SKILLED
NURSING FACILITIES, AND OTHER PROVIDERS OF SERVICES
Pub. L. 94-182, title I, Sec. 107, Dec. 31, 1975, 89 Stat. 1053,
provided that: "Nothing contained in section 222(a) of Public Law
92-603 [set out below] shall be construed to preclude or prohibit
the Secretary of Health, Education, and Welfare [now Health and
Human Services] from including in any grant otherwise authorized to
be made under such section moneys which are to be used for
payments, to a participant in a demonstration or experiment with
respect to which the grant is made, for or on account of costs
incurred or services performed by such participant for a period
prior to the date that the project of such participant is placed in
operation, if -
"(1) the applicant for such grant is a State or an agency
thereof,
"(2) such participant is an individual practice association
which has been in existence for at least 3 years prior to the
date of enactment of this section [Dec. 31, 1975] and which has
in effect a contract with such State (or an agency thereof),
entered into prior to the date on which the grant is approved by
the Secretary, under which such association will, for a period
which begins before and ends after the date such grant is so
approved, provide health care services for individuals entitled
to care and services under the State plan of such State which is
approved under title XIX of the Social Security Act [subchapter
XIX of this chapter].
"(3) the purpose of the inclusion of the project of such
association is to test the utility of a particular rate-setting
methodology, designed to be employed in prepaid health plans, in
an individual practice association operation, and
"(4) the applicant for such grant affirms that the use of
moneys from such grant to make such payments to such individual
practice association is necessary or useful in assuring that such
association will be able to continue in operation and carry out
the project described in clause (3)."
EXPERIMENTS AND DEMONSTRATION PROJECTS TO DETERMINE METHODS FOR
PROSPECTIVE PAYMENTS TO HOSPITALS, SKILLED NURSING FACILITIES, AND
OTHER PROVIDERS OF SERVICES FOR CARE AND SERVICES FURNISHED; SCOPE;
WAIVER OF PAYMENT REQUIREMENTS; SOURCE AND MANNER OF PAYMENTS FOR
GRANTS, ETC.; REPORTS TO CONGRESS
Section 222(a) of Pub. L. 92-603, as amended by Pub. L. 97-35,
title XXI, Sec. 2193(e), Aug. 13, 1981, 95 Stat. 828, provided
that:
"(1) The Secretary of Health, Education, and Welfare [now Health
and Human Services], directly or through contracts with, or grants
to, public or private agencies or organizations, shall develop and
carry out experiments and demonstration projects designed to
determine the relative advantages and disadvantages of various
alternative methods of making payment on a prospective basis to
hospitals, skilled nursing facilities, and other providers of
services for care and services provided by them under title XVIII
of the Social Security Act [this subchapter] and under State plans
approved under title XIX of such Act [subchapter XIX of this
chapter], including alternative methods for classifying providers,
for establishing prospective rates of payment, and for implementing
on a gradual, selective, or other basis the establishment of a
prospective payment system, in order to stimulate such providers
through positive (or negative) financial incentives to use their
facilities and personnel more efficiently and thereby to reduce the
total costs of the health programs involved without adversely
affecting the quality of services by containing or lowering the
rate of increase in provider costs that has been and is being
experienced under the existing system of retroactive cost
reimbursement.
"(2) The experiments and demonstration projects developed under
paragraph (1) shall be of sufficient scope and shall be carried out
on a wide enough scale to permit a thorough evaluation of the
alternative methods of prospective payment under consideration
while giving assurance that the results derived from the
experiments and projects will obtain generally in the operation of
the programs involved (without committing such programs to the
adoption of any prospective payment system either locally or
nationally).
"(3) In the case of any experiment or demonstration project under
paragraph (1), the Secretary may waive compliance with the
requirements of titles XVIII and XIX of the Social Security Act
[this subchapter and subchapter XIX of this chapter] insofar as
such requirements relate to methods of payment for services
provided; and costs incurred in such experiment or project in
excess of those which would otherwise be reimbursed or paid under
such titles [subchapters] may be reimbursed or paid to the extent
that such waiver applies to them (with such excess being borne by
the Secretary). No experiment or demonstration project shall be
developed or carried out under paragraph (1) until the Secretary
obtains the advice and recommendations of specialists who are
competent to evaluate the proposed experiment or project as to the
soundness of its objectives, the possibilities of securing
productive results, the adequacy of resources to conduct it, and
its relationship to other similar experiments or projects already
completed or in process; and no such experiment or project shall be
actually placed in operation unless at least 30 days prior thereto
a written report, prepared for purposes of notification and
information only, containing a full and complete description
thereof has been transmitted to the Committee on Ways and Means of
the House of Representatives and to the Committee on Finance of the
Senate.
"(4) Grants, payments under contracts, and other expenditures
made for experiments and demonstration projects under this
subsection shall be made in appropriate part from the Federal
Hospital Insurance Trust Fund (established by section 1817 of the
Social Security Act [section 1395i of this title]) and the Federal
Supplementary Medical Insurance Trust Fund (established by section
1841 of the Social Security Act [section 1395t of this title]) and
from funds appropriated under title XIX of such Act [subchapter XIX
of this chapter]. Grants and payments under contracts may be made
either in advance or by way of reimbursement, as may be determined
by the Secretary, and shall be made in such installments and on
such conditions as the Secretary finds necessary to carry out the
purpose of this subsection. With respect to any such grant,
payment, or other expenditure, the amount to be paid from each of
such trust funds (and from funds appropriated under such title XIX)
shall be determined by the Secretary, giving due regard to the
purposes of the experiment or project involved.
"(5) The Secretary shall submit to the Congress no later than
July 1, 1974, a full report on the experiments and demonstration
projects carried out under this subsection and on the experience of
other programs with respect to prospective reimbursement together
with any related data and materials which he may consider
appropriate. Such report shall include detailed recommendations
with respect to the specific methods which could be used in the
full implementation of a system of prospective payment to providers
of services under the programs involved."
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 1395cc, 1395ll, 1395nn,
1395ww of this title.
-FOOTNOTE-
(!1) See References in Text note below.
-End-
-CITE-
42 USC Sec. 1395b-2 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
Sec. 1395b-2. Notice of medicare benefits; medicare and medigap
information
-STATUTE-
(a) Notice of medicare benefits
The Secretary shall prepare (in consultation with groups
representing the elderly and with health insurers) and provide for
distribution of a notice containing -
(1) a clear, simple explanation of the benefits available under
this subchapter and the major categories of health care for which
benefits are not available under this subchapter,
(2) the limitations on payment (including deductibles and
coinsurance amounts) that are imposed under this subchapter, and
(3) a description of the limited benefits for long-term care
services available under this subchapter and generally available
under State plans approved under subchapter XIX of this chapter.
Such notice shall be mailed annually to individuals entitled to
benefits under part A or part B of this subchapter and when an
individual applies for benefits under part A of this subchapter or
enrolls under part B of this subchapter.
(b) Medicare and medigap information
The Secretary shall provide information via a toll-free telephone
number on the programs under this subchapter.
(c) Contents of notice
The notice provided under subsection (a) of this section shall
include -
(1) a statement which indicates that because errors do occur
and because medicare fraud, waste, and abuse is a significant
problem, beneficiaries should carefully check any explanation of
benefits or itemized statement furnished pursuant to section
1395b-7 of this title for accuracy and report any errors or
questionable charges by calling the toll-free phone number
described in paragraph (4);
(2) a statement of the beneficiary's right to request an
itemized statement for medicare items and services (as provided
in section 1395b-7(b) of this title);
(3) a description of the program to collect information on
medicare fraud and abuse established under section 1395b-5(b) of
this title; and
(4) a toll-free telephone number maintained by the Inspector
General in the Department of Health and Human Services for the
receipt of complaints and information about waste, fraud, and
abuse in the provision or billing of services under this
subchapter.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1804, as added Pub. L.
100-360, title II, Sec. 223(a), July 1, 1988, 102 Stat. 747;
amended Pub. L. 103-432, title I, Sec. 171(j)(1), Oct. 31, 1994,
108 Stat. 4450; Pub. L. 105-33, title IV, Sec. 4311(a)(1), Aug. 5,
1997, 111 Stat. 384.)
-REFTEXT-
REFERENCES IN TEXT
Parts A and B of this subchapter, referred to in subsec. (a), are
classified to sections 1395c et seq. and 1395j et seq.,
respectively, of this title.
-MISC1-
AMENDMENTS
1997 - Subsec. (c). Pub. L. 105-33 added subsec. (c).
1994 - Pub. L. 103-432 inserted "; medicare and medigap
information" in section catchline, designated existing provisions
as subsec. (a), and added subsec. (b).
EFFECTIVE DATE OF 1997 AMENDMENT
Section 4311(a)(2) of Pub. L. 105-33 provided that: "The
amendment made by this subsection [amending this section] shall
apply to notices provided on or after January 1, 1998."
EFFECTIVE DATE OF 1994 AMENDMENT
Amendment by Pub. L. 103-432 effective as if included in the
enactment of Pub. L. 101-508, see section 171(l) of Pub. L.
103-432, set out as a note under section 1395ss of this title.
EFFECTIVE DATE
Section 223(d)(1) of Pub. L. 100-360 provided that: "The
Secretary of Health and Human Services shall first distribute the
notice required by the amendment made by subsection (a) [enacting
this section] not later than January 31, 1989."
STATE REGULATORY PROGRAMS
For provisions relating to changes required to conform State
regulatory programs to amendments by section 171 of Pub. L.
103-432, see section 171(m) of Pub. L. 103-432, set out as a note
under section 1395ss of this title.
DEMONSTRATION PROJECTS
Section 4361(b) of Pub. L. 101-508 provided that: "The Secretary
of Health and Human Services is authorized to conduct demonstration
projects in up to 5 States for the purpose of establishing
statewide toll-free telephone numbers for providing information on
medicare benefits, medicare supplemental policies available in the
State, and benefits under the State medicaid program."
NOTICE OF CHANGES UNDER REPEAL OF MEDICARE CATASTROPHIC COVERAGE
Pub. L. 101-234, title II, Sec. 203(c), Dec. 13, 1989, 103 Stat.
1984, provided that: "The Secretary of Health and Human Services
shall provide, in the notice of medicare benefits provided under
section 1804 of the Social Security Act [this section] for 1990,
for a description of the changes in benefits under title XVIII of
such Act [this subchapter] made by the amendments made by this Act
[see Tables for classification]."
BENEFITS COUNSELING AND ASSISTANCE DEMONSTRATION PROJECT FOR
CERTAIN MEDICARE AND MEDICAID BENEFICIARIES
Section 424 of Pub. L. 100-360, which directed Secretary of
Health and Human Services to establish a demonstration project to
demonstrate that its volunteers were adequately trained and
competent to render effective benefits counseling and assistance to
the elderly, was repealed by Pub. L. 101-234, title III, Sec.
301(a), Dec. 13, 1989, 103 Stat. 1985.
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 1395w-21, 1395ff of this
title.
-End-
-CITE-
42 USC Sec. 1395b-3 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
Sec. 1395b-3. Health insurance advisory service for medicare
beneficiaries
-STATUTE-
(a) In general
The Secretary of Health and Human Services shall establish a
health insurance advisory service program (in this section referred
to as the "beneficiary assistance program") to assist
medicare-eligible individuals with the receipt of services under
the medicare and medicaid programs and other health insurance
programs.
(b) Outreach elements
The beneficiary assistance program shall provide assistance -
(1) through operation using local Federal offices that provide
information on the medicare program,
(2) using community outreach programs, and
(3) using a toll-free telephone information service.
(c) Assistance provided
The beneficiary assistance program shall provide for information,
counseling, and assistance for medicare-eligible individuals with
respect to at least the following:
(1) With respect to the medicare program -
(A) eligibility,
(B) benefits (both covered and not covered),
(C) the process of payment for services,
(D) rights and process for appeals of determinations,
(E) other medicare-related entities (such as peer review
organizations, fiscal intermediaries, and carriers), and
(F) recent legislative and administrative changes in the
medicare program.
(2) With respect to the medicaid program -
(A) eligibility, benefits, and the application process,
(B) linkages between the medicaid and medicare programs, and
(C) referral to appropriate State and local agencies involved
in the medicaid program.
(3) With respect to medicare supplemental policies -
(A) the program under section 1395ss of this title and
standards required under such program,
(B) how to make informed decisions on whether to purchase
such policies and on what criteria to use in evaluating
different policies,
(C) appropriate Federal, State, and private agencies that
provide information and assistance in obtaining benefits under
such policies, and
(D) other issues deemed appropriate by the Secretary.
The beneficiary assistance program also shall provide such other
services as the Secretary deems appropriate to increase beneficiary
understanding of, and confidence in, the medicare program and to
improve the relationship between beneficiaries and the program.
(d) Educational material
The Secretary, through the Administrator of the Health Care
Financing Administration, shall develop appropriate educational
materials and other appropriate techniques to assist employees in
carrying out this section.
(e) Notice to beneficiaries
The Secretary shall take such steps as are necessary to assure
that medicare-eligible beneficiaries and the general public are
made aware of the beneficiary assistance program.
(f) Report
The Secretary shall include, in an annual report transmitted to
the Congress, a report on the beneficiary assistance program and on
other health insurance informational and counseling services made
available to medicare-eligible individuals. The Secretary shall
include in the report recommendations for such changes as may be
desirable to improve the relationship between the medicare program
and medicare-eligible individuals.
-SOURCE-
(Pub. L. 101-508, title IV, Sec. 4359, Nov. 5, 1990, 104 Stat.
1388-137.)
-COD-
CODIFICATION
Section was enacted as part of the Omnibus Budget Reconciliation
Act of 1990, and not as part of the Social Security Act which
comprises this chapter.
-MISC1-
QUALIFIED MEDICARE BENEFICIARY OUTREACH
Pub. L. 103-432, title I, Sec. 154, Oct. 31, 1994, 108 Stat.
4437, provided that: "Not later than 1 year after the date of the
enactment of this Act [Oct. 31, 1994], the Secretary of Health and
Human Services shall establish and implement a method for obtaining
information from newly eligible medicare beneficiaries that may be
used to determine whether such beneficiaries may be eligible for
medical assistance for medicare cost-sharing under State medicaid
plans as qualified medicare beneficiaries, and for transmitting
such information to the State in which such a beneficiary resides."
-End-
-CITE-
42 USC Sec. 1395b-4 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
Sec. 1395b-4. Health insurance information, counseling, and
assistance grants
-STATUTE-
(a) Grants
The Secretary of Health and Human Services (in this section
referred to as the "Secretary") shall make grants to States, with
approved State regulatory programs under section 1395ss of this
title, that submit applications to the Secretary that meet the
requirements of this section for the purpose of providing
information, counseling, and assistance relating to the procurement
of adequate and appropriate health insurance coverage to
individuals who are eligible to receive benefits under this
subchapter (in this section referred to as "eligible individuals").
The Secretary shall prescribe regulations to establish a minimum
level of funding for a grant issued under this section.
(b) Grant applications
(1) In submitting an application under this section, a State may
consolidate and coordinate an application that consists of parts
prepared by more than one agency or department of such State.
(2) As part of an application for a grant under this section, a
State shall submit a plan for a State-wide health insurance
information, counseling, and assistance program. Such program shall
-
(A) establish or improve upon a health insurance information,
counseling, and assistance program that provides counseling and
assistance to eligible individuals in need of health insurance
information, including -
(i) information that may assist individuals in obtaining
benefits and filing claims under this subchapter and subchapter
XIX of this chapter;
(ii) policy comparison information for medicare supplemental
policies (as described in section 1395ss(g)(1) of this title)
and information that may assist individuals in filing claims
under such medicare supplemental policies;
(iii) information regarding long-term care insurance; and
(iv) information regarding other types of health insurance
benefits that the Secretary determines to be appropriate;
(B) in conjunction with the health insurance information,
counseling, and assistance program described in subparagraph (A),
establish a system of referral to appropriate Federal or State
departments or agencies for assistance with problems related to
health insurance coverage (including legal problems), as
determined by the Secretary;
(C) provide for a sufficient number of staff positions
(including volunteer positions) necessary to provide the services
of the health insurance information, counseling, and assistance
program;
(D) provide assurances that staff members (including volunteer
staff members) of the health insurance information, counseling,
and assistance program have no conflict of interest in providing
the counseling described in subparagraph (A);
(E) provide for the collection and dissemination of timely and
accurate health care information to staff members;
(F) provide for training programs for staff members (including
volunteer staff members);
(G) provide for the coordination of the exchange of health
insurance information between the staff of departments and
agencies of the State government and the staff of the health
insurance information, counseling, and assistance program;
(H) make recommendations concerning consumer issues and
complaints related to the provision of health care to agencies
and departments of the State government and the Federal
Government responsible for providing or regulating health
insurance;
(I) establish an outreach program to provide the health
insurance information and counseling described in subparagraph
(A) and the referrals described in subparagraph (B) to eligible
individuals; and
(J) demonstrate, to the satisfaction of the Secretary, an
ability to provide the counseling and assistance required under
this section.
(c) Special grants
(1) A State that is conducting a health insurance information,
counseling, and assistance program that is substantially similar to
a program described in subsection (b)(2) of this section shall, as
a requirement for eligibility for a grant under this section,
demonstrate, to the satisfaction of the Secretary, that such State
shall maintain the activities of such program at least at the level
that such activities were conducted immediately preceding the date
of the issuance of any grant during the period of time covered by
such grant under this section.
(2) If the Secretary determines that the existing health
insurance information, counseling, and assistance program is
substantially similar to a program described in subsection (b)(2)
of this section, the Secretary may waive some or all of the
requirements described in such subsection and issue a grant to the
State for the purpose of increasing the number of services offered
by the health insurance information, counseling, and assistance
program, experimenting with new methods of outreach in conducting
such program, or expanding such program to geographic areas of the
State not previously served by the program.
(d) Criteria for issuing grants
In issuing a grant under this section, the Secretary shall
consider -
(1) the commitment of the State to carrying out the health
insurance information, counseling, and assistance program
described in subsection (b)(2) of this section, including the
level of cooperation demonstrated -
(A) by the office of the chief insurance regulator of the
State, or the equivalent State entity;
(B) other officials of the State responsible for overseeing
insurance plans issued by nonprofit hospital and medical
service associations; and
(C) departments and agencies of such State responsible for -
(i) administering funds under subchapter XIX of this
chapter, and
(ii) administering funds appropriated under the Older
Americans Act [42 U.S.C. 3001 et seq.];
(2) the population of eligible individuals in such State as a
percentage of the population of such State; and
(3) in order to ensure the needs of rural areas in such State,
the relative costs and special problems associated with
addressing the special problems of providing health care
information, counseling, and assistance eligible (!1) individuals
residing in rural areas of such State.
(e) Annual State report
A State that receives a grant under this section shall, not later
than 180 days after receiving such grant, and annually thereafter
during the period of the grant, issue a report to the Secretary
that includes information concerning -
(1) the number of individuals served by the health insurance
information, counseling and assistance program of such State;
(2) an estimate of the amount of funds saved by the State, and
by eligible individuals in the State, in the implementation of
such program; and
(3) the problems that eligible individuals in such State
encounter in procuring adequate and appropriate health care
coverage.
(f) Report to Congress
Beginning with 1992, and annually thereafter, the Secretary shall
issue a report to the Committee on Finance of the Senate, the
Special Committee on Aging of the Senate, the Committee on Ways and
Means of the House of Representatives, and the Committee on Energy
and Commerce of the House of Representatives that -
(1) summarizes the allocation of funds authorized for grants
under this section and the expenditure of such funds;
(2) outlines the problems that eligible individuals encounter
in procuring adequate and appropriate health care coverage;
(3) makes recommendations that the Secretary determines to be
appropriate to address the problems described in paragraph (3);
(!2) and
(4) in the case of the report issued 2 years after November 5,
1990, evaluates the effectiveness of counseling programs
established under this program, and makes recommendations
regarding continued authorization of funds for these purposes.
(g) Authorization of appropriations for grants
There are authorized to be appropriated, in equal parts from the
Federal Hospital Insurance Trust Fund and from the Federal
Supplementary Medical Insurance Trust Fund, $10,000,000 for each of
fiscal years 1991, 1992, 1993, 1994, 1995, and 1996, to fund the
grant programs described in this section.
-SOURCE-
(Pub. L. 101-508, title IV, Sec. 4360, Nov. 5, 1990, 104 Stat.
1388-138; Pub. L. 103-432, title I, Sec. 171(i), Oct. 31, 1994, 108
Stat. 4450; Pub. L. 103-437, Sec. 15(b), Nov. 2, 1994, 108 Stat.
4591; Pub. L. 105-362, title VI, Sec. 602(b)(2), Nov. 10, 1998, 112
Stat. 3286.)
-REFTEXT-
REFERENCES IN TEXT
The Older Americans Act, referred to in subsec. (d)(1)(C)(ii),
probably means the Older Americans Act of 1965, which is Pub. L.
89-73, July 14, 1965, 79 Stat. 218, as amended, and is classified
generally to chapter 35 (Sec. 3001 et seq.) of this title. For
complete classification of this Act to the Code, see Short Title
note set out under section 3001 of this title and Tables.
-COD-
CODIFICATION
Section was enacted as part of the Omnibus Budget Reconciliation
Act of 1990, and not as part of the Social Security Act which
comprises this chapter.
-MISC1-
AMENDMENTS
1998 - Subsec. (f). Pub. L. 105-362 substituted "Beginning with
1992" for "Not later than 180 days after November 5, 1990".
1994 - Subsec. (b)(2)(A)(ii). Pub. L. 103-432, Sec. 171(i)(1),
inserted closing parenthesis after "of this title".
Subsec. (b)(2)(D). Pub. L. 103-432, Sec. 171(i)(2), substituted
"counseling" for "services" before "described in subparagraph (A)".
Subsec. (b)(2)(I). Pub. L. 103-432, Sec. 171(i)(3), substituted
"referrals" for "assistance".
Subsec. (c)(1). Pub. L. 103-432, Sec. 171(i)(4), struck out "and
that such activities will continue to be maintained at such level"
after "covered by such grant under this section".
Subsec. (d)(3). Pub. L. 103-432, Sec. 171(i)(5), substituted
"eligible individuals residing in rural areas" for "to the rural
areas".
Subsec. (e). Pub. L. 103-432, Sec. 171(i)(6)(A), (B), in
introductory provisions, substituted "this section" for "subsection
(c) or (d) of this section" and "and annually thereafter during the
period of the grant, issue a report" for "and annually thereafter,
issue an annual report".
Subsec. (e)(1). Pub. L. 103-432, Sec. 171(i)(6)(C), struck out
"State-wide" before "health insurance information".
Subsec. (f). Pub. L. 103-437, Sec. 15(b)(1), in introductory
provisions, substituted "and the Committee on Energy and Commerce"
for "the Committee on Energy and Commerce of the House of
Representatives, and the Select Committee on Aging".
Pub. L. 103-432, Sec. 171(i)(8)(B), and Pub. L. 103-437, Sec.
15(b)(2), made identical amendments, redesignating subsec. (f),
relating to authorization of appropriations for grants, as (g).
Pub. L. 103-432, Sec. 171(i)(8)(A), in subsec. (f), relating to
authorization of appropriations for grants, substituted "1993,
1994, 1995, and 1996" for "and 1993".
Subsec. (f)(2) to (5). Pub. L. 103-432, Sec. 171(i)(7), in
subsec. (f), relating to report to Congress, redesignated pars. (3)
to (5) as (2) to (4), respectively, and struck out former par. (2)
which read as follows: "summarizes the scope and content of
training conferences convened under this section;".
Subsec. (g). Pub. L. 103-432, Sec. 171(i)(8)(B), and Pub. L.
103-437, Sec. 15(b)(2), made identical amendments, redesignating
subsec. (f), relating to authorization of appropriations for
grants, as (g).
-CHANGE-
CHANGE OF NAME
Committee on Energy and Commerce of House of Representatives
treated as referring to Committee on Commerce of House of
Representatives by section 1(a) of Pub. L. 104-14, set out as a
note preceding section 21 of Title 2, The Congress. Committee on
Commerce of House of Representatives changed to Committee on Energy
and Commerce of House of Representatives, and jurisdiction over
matters relating to securities and exchanges and insurance
generally transferred to Committee on Financial Services of House
of Representatives by House Resolution No. 5, One Hundred Seventh
Congress, Jan. 3, 2001.
-MISC2-
EFFECTIVE DATE OF 1994 AMENDMENT
Amendment by Pub. L. 103-432 effective as if included in the
enactment of Pub. L. 101-508, see section 171(l) of Pub. L.
103-432, set out as a note under section 1395ss of this title.
STATE REGULATORY PROGRAMS
For provisions relating to changes required to conform State
regulatory programs to amendments by section 171 of Pub. L.
103-432, see section 171(m) of Pub. L. 103-432, set out as a note
under section 1395ss of this title.
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in section 1395w-27 of this title.
-FOOTNOTE-
(!1) So in original. Probably should be preceded by "to".
(!2) So in original. Probably should be paragraph "(2)".
-End-
-CITE-
42 USC Sec. 1395b-5 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
Sec. 1395b-5. Beneficiary incentive programs
-STATUTE-
(a) Repealed. Pub. L. 105-33, title IV, Sec. 4311(b)(2), Aug. 5,
1997, 111 Stat. 386
(b) Program to collect information on fraud and abuse
(1) Establishment of program
Not later than 3 months after August 21, 1996, the Secretary
shall establish a program under which the Secretary shall
encourage individuals to report to the Secretary information on
individuals and entities who are engaging in or who have engaged
in acts or omissions which constitute grounds for the imposition
of a sanction under section 1320a-7, 1320a-7a, or 1320a-7b of
this title, or who have otherwise engaged in fraud and abuse
against the Medicare program under this subchapter for which
there is a sanction provided under law. The program shall
discourage provision of, and not consider, information which is
frivolous or otherwise not relevant or material to the imposition
of such a sanction.
(2) Payment of portion of amounts collected
If an individual reports information to the Secretary under the
program established under paragraph (1) which serves as the basis
for the collection by the Secretary or the Attorney General of
any amount of at least $100 (other than any amount paid as a
penalty under section 1320a-7b of this title), the Secretary may
pay a portion of the amount collected to the individual (under
procedures similar to those applicable under section 7623 of the
Internal Revenue Code of 1986 to payments to individuals
providing information on violations of such Code).
(c) Program to collect information on program efficiency
(1) Establishment of program
Not later than 3 months after August 21, 1996, the Secretary
shall establish a program under which the Secretary shall
encourage individuals to submit to the Secretary suggestions on
methods to improve the efficiency of the Medicare program.
(2) Payment of portion of program savings
If an individual submits a suggestion to the Secretary under
the program established under paragraph (1) which is adopted by
the Secretary and which results in savings to the program, the
Secretary may make a payment to the individual of such amount as
the Secretary considers appropriate.
-SOURCE-
(Pub. L. 104-191, title II, Sec. 203, Aug. 21, 1996, 110 Stat.
1998; Pub. L. 105-33, title IV, Sec. 4311(b)(2), Aug. 5, 1997, 111
Stat. 386.)
-REFTEXT-
REFERENCES IN TEXT
The Internal Revenue Code of 1986, referred to in subsec. (b)(2),
is classified generally to Title 26, Internal Revenue Code.
-COD-
CODIFICATION
Section was enacted as part of the Health Insurance Portability
and Accountability Act of 1996, and not as part of the Social
Security Act which comprises this chapter.
-MISC1-
AMENDMENTS
1997 - Subsec. (a). Pub. L. 105-33 struck out heading and text of
subsec. (a). Text read as follows: "The Secretary of Health and
Human Services (in this section referred to as the 'Secretary')
shall provide an explanation of benefits under the Medicare program
under this subchapter with respect to each item or service for
which payment may be made under the program which is furnished to
an individual, without regard to whether or not a deductible or
coinsurance may be imposed against the individual with respect to
the item or service."
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in section 1395b-2 of this title.
-End-
-CITE-
42 USC Sec. 1395b-6 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
Sec. 1395b-6. Medicare Payment Advisory Commission
-STATUTE-
(a) Establishment
There is hereby established the Medicare Payment Advisory
Commission (in this section referred to as the "Commission").
(b) Duties
(1) Review of payment policies and annual reports
The Commission shall -
(A) review payment policies under this subchapter, including
the topics described in paragraph (2);
(B) make recommendations to Congress concerning such payment
policies;
(C) by not later than March 1 of each year (beginning with
1998), submit a report to Congress containing the results of
such reviews and its recommendations concerning such policies;
and
(D) by not later than June 15 of each year, submit a report
to Congress containing an examination of issues affecting the
medicare program, including the implications of changes in
health care delivery in the United States and in the market for
health care services on the medicare program and including a
review of the estimate of the conversion factor submitted under
section 1395w-4(d)(1)(E)(ii) of this title.
(2) Specific topics to be reviewed
(A) Medicare+Choice program
Specifically, the Commission shall review, with respect to
the Medicare+Choice program under part C of this subchapter,
the following:
(i) The methodology for making payment to plans under such
program, including the making of differential payments and
the distribution of differential updates among different
payment areas.
(ii) The mechanisms used to adjust payments for risk and
the need to adjust such mechanisms to take into account
health status of beneficiaries.
(iii) The implications of risk selection both among
Medicare+Choice organizations and between the Medicare+Choice
option and the original medicare fee-for-service option.
(iv) The development and implementation of mechanisms to
assure the quality of care for those enrolled with
Medicare+ÐChoice organizations.
(v) The impact of the Medicare+Choice program on access to
care for medicare beneficiaries.
(vi) Other major issues in implementation and further
development of the Medicare+Choice program.
(B) Original medicare fee-for-service system
Specifically, the Commission shall review payment policies
under parts A and B of this subchapter, including -
(i) the factors affecting expenditures for services in
different sectors, including the process for updating
hospital, skilled nursing facility, physician, and other
fees,
(ii) payment methodologies, and
(iii) their relationship to access and quality of care for
medicare beneficiaries.
(C) Interaction of medicare payment policies with health care
delivery generally
Specifically, the Commission shall review the effect of
payment policies under this subchapter on the delivery of
health care services other than under this subchapter and
assess the implications of changes in health care delivery in
the United States and in the general market for health care
services on the medicare program.
(3) Comments on certain secretarial reports
If the Secretary submits to Congress (or a committee of
Congress) a report that is required by law and that relates to
payment policies under this subchapter, the Secretary shall
transmit a copy of the report to the Commission. The Commission
shall review the report and, not later than 6 months after the
date of submittal of the Secretary's report to Congress, shall
submit to the appropriate committees of Congress written comments
on such report. Such comments may include such recommendations as
the Commission deems appropriate.
(4) Agenda and additional reviews
The Commission shall consult periodically with the chairmen and
ranking minority members of the appropriate committees of
Congress regarding the Commission's agenda and progress towards
achieving the agenda. The Commission may conduct additional
reviews, and submit additional reports to the appropriate
committees of Congress, from time to time on such topics relating
to the program under this subchapter as may be requested by such
chairmen and members and as the Commission deems appropriate.
(5) Availability of reports
The Commission shall transmit to the Secretary a copy of each
report submitted under this subsection and shall make such
reports available to the public.
(6) Appropriate committees of Congress
For purposes of this section, the term "appropriate committees
of Congress" means the Committees on Ways and Means and Commerce
of the House of Representatives and the Committee on Finance of
the Senate.
(7) Voting and reporting requirements
With respect to each recommendation contained in a report
submitted under paragraph (1), each member of the Commission
shall vote on the recommendation, and the Commission shall
include, by member, the results of that vote in the report
containing the recommendation.
(c) Membership
(1) Number and appointment
The Commission shall be composed of 17 members appointed by the
Comptroller General.
(2) Qualifications
(A) In general
The membership of the Commission shall include individuals
with national recognition for their expertise in health finance
and economics, actuarial science, health facility management,
health plans and integrated delivery systems, reimbursement of
health facilities, allopathic and osteopathic physicians, and
other providers of health services, and other related fields,
who provide a mix of different professionals, broad geographic
representation, and a balance between urban and rural
representatives.
(B) Inclusion
The membership of the Commission shall include (but not be
limited to) physicians and other health professionals,
employers, third-party payers, individuals skilled in the
conduct and interpretation of biomedical, health services, and
health economics research and expertise in outcomes and
effectiveness research and technology assessment. Such
membership shall also include representatives of consumers and
the elderly.
(C) Majority nonproviders
Individuals who are directly involved in the provision, or
management of the delivery, of items and services covered under
this subchapter shall not constitute a majority of the
membership of the Commission.
(D) Ethical disclosure
The Comptroller General shall establish a system for public
disclosure by members of the Commission of financial and other
potential conflicts of interest relating to such members.
(3) Terms
(A) In general
The terms of members of the Commission shall be for 3 years
except that the Comptroller General shall designate staggered
terms for the members first appointed.
(B) Vacancies
Any member appointed to fill a vacancy occurring before the
expiration of the term for which the member's predecessor was
appointed shall be appointed only for the remainder of that
term. A member may serve after the expiration of that member's
term until a successor has taken office. A vacancy in the
Commission shall be filled in the manner in which the original
appointment was made.
(4) Compensation
While serving on the business of the Commission (including
traveltime), a member of the Commission shall be entitled to
compensation at the per diem equivalent of the rate provided for
level IV of the Executive Schedule under section 5315 of title 5;
and while so serving away from home and the member's regular
place of business, a member may be allowed travel expenses, as
authorized by the Chairman of the Commission. Physicians serving
as personnel of the Commission may be provided a physician
comparability allowance by the Commission in the same manner as
Government physicians may be provided such an allowance by an
agency under section 5948 of title 5, and for such purpose
subsection (i) of such section shall apply to the Commission in
the same manner as it applies to the Tennessee Valley Authority.
For purposes of pay (other than pay of members of the Commission)
and employment benefits, rights, and privileges, all personnel of
the Commission shall be treated as if they were employees of the
United States Senate.
(5) Chairman; Vice Chairman
The Comptroller General shall designate a member of the
Commission, at the time of appointment of the member as Chairman
and a member as Vice Chairman for that term of appointment,
except that in the case of vacancy of the Chairmanship or Vice
Chairmanship, the Comptroller General may designate another
member for the remainder of that member's term.
(6) Meetings
The Commission shall meet at the call of the Chairman.
(d) Director and staff; experts and consultants
Subject to such review as the Comptroller General deems necessary
to assure the efficient administration of the Commission, the
Commission may -
(1) employ and fix the compensation of an Executive Director
(subject to the approval of the Comptroller General) and such
other personnel as may be necessary to carry out its duties
(without regard to the provisions of title 5 governing
appointments in the competitive service);
(2) seek such assistance and support as may be required in the
performance of its duties from appropriate Federal departments
and agencies;
(3) enter into contracts or make other arrangements, as may be
necessary for the conduct of the work of the Commission (without
regard to section 5 of title 41);
(4) make advance, progress, and other payments which relate to
the work of the Commission;
(5) provide transportation and subsistence for persons serving
without compensation; and
(6) prescribe such rules and regulations as it deems necessary
with respect to the internal organization and operation of the
Commission.
(e) Powers
(1) Obtaining official data
The Commission may secure directly from any department or
agency of the United States information necessary to enable it to
carry out this section. Upon request of the Chairman, the head of
that department or agency shall furnish that information to the
Commission on an agreed upon schedule.
(2) Data collection
In order to carry out its functions, the Commission shall -
(A) utilize existing information, both published and
unpublished, where possible, collected and assessed either by
its own staff or under other arrangements made in accordance
with this section,
(B) carry out, or award grants or contracts for, original
research and experimentation, where existing information is
inadequate, and
(C) adopt procedures allowing any interested party to submit
information for the Commission's use in making reports and
recommendations.
(3) Access of GAO to information
The Comptroller General shall have unrestricted access to all
deliberations, records, and nonproprietary data of the
Commission, immediately upon request.
(4) Periodic audit
The Commission shall be subject to periodic audit by the
Comptroller General.
(f) Authorization of appropriations
(1) Request for appropriations
The Commission shall submit requests for appropriations in the
same manner as the Comptroller General submits requests for
appropriations, but amounts appropriated for the Commission shall
be separate from amounts appropriated for the Comptroller
General.
(2) Authorization
There are authorized to be appropriated such sums as may be
necessary to carry out the provisions of this section. Sixty
percent of such appropriation shall be payable from the Federal
Hospital Insurance Trust Fund, and 40 percent of such
appropriation shall be payable from the Federal Supplementary
Medical Insurance Trust Fund.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1805, as added Pub. L.
105-33, title IV, Sec. 4022(a), Aug. 5, 1997, 111 Stat. 350;
amended Pub. L. 105-277, div. J, title V, Sec. 5202(a), Oct. 21,
1998, 112 Stat. 2681-917; Pub. L. 106-113, div. B, Sec. 1000(a)(6)
[title II, Sec. 211(a)(2)(B)], Nov. 29, 1999, 113 Stat. 1536,
1501A-347; Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 544(a)(1),
(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A-551.)
-REFTEXT-
REFERENCES IN TEXT
Parts A, B, and C of this subchapter, referred to in subsec.
(b)(2)(A), (B), are classified to sections 1395c et seq., 1395j et
seq., and 1395w-21 et seq., respectively, of this title.
The provisions of title 5 governing appointments in the
competitive service, referred to in subsec. (d)(1), are classified
generally to section 3301 et seq. of Title 5, Government
Organization and Employees.
-MISC1-
AMENDMENTS
2000 - Subsec. (b)(1)(D). Pub. L. 106-554, Sec. 1(a)(6) [title V,
Sec. 544(a)(1)], substituted "June 15 of each year," for "June 1 of
each year (beginning with 1998),".
Subsec. (b)(7). Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec.
544(b)], added par. (7).
1999 - Subsec. (b)(1)(D). Pub. L. 106-113 inserted "and including
a review of the estimate of the conversion factor submitted under
section 1395w-4(d)(1)(E)(ii) of this title" before period at end.
1998 - Subsec. (c)(1). Pub. L. 105-277 substituted "17" for "15".
EFFECTIVE DATE OF 2000 AMENDMENT
Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 544(a)(2)], Dec. 21,
2000, 114 Stat. 2763, 2763A-551, provided that: "The amendment made
by paragraph (1) [amending this section] shall apply beginning with
2001."
EFFECTIVE DATE OF 1999 AMENDMENT
Amendment by Pub. L. 106-113 effective in determining conversion
factor under section 1395w-4(d) of this title for years beginning
with 2001 and not applicable to or affecting any update (or any
update adjustment factor) for any year before 2001, see section
1000(a)(6) [title II, Sec. 211(d)] of Pub. L. 106-113, set out as a
note under section 1395w-4 of this title.
EFFECTIVE DATE; TRANSITION; TRANSFER OF FUNCTIONS
Section 4022(c) of Pub. L. 105-33 provided that:
"(1) In general. - The Comptroller General shall first provide
for appointment of members to the Medicare Payment Advisory
Commission (in this subsection referred to as 'MedPAC') by not
later than September 30, 1997.
"(2) Transition. - As quickly as possible after the date a
majority of members of MedPAC are first appointed [Oct. 1, 1997,
see 62 FR 52131], the Comptroller General, in consultation with the
Prospective Payment Assessment Commission (in this subsection
referred to as 'ProPAC') and the Physician Payment Review
Commission (in this subsection referred to as 'PPRC'), shall
provide for the termination of the ProPAC and the PPRC. As of the
date of termination of the respective Commissions [Nov. 1, 1997,
see 62 FR 59356], the amendments made by paragraphs (1) and (2),
respectively, of subsection (b) [amending sections 1395w-4, 1395y,
and 1395ww of this title and repealing section 1395w-1 of this
title] become effective. The Comptroller General, to the extent
feasible, shall provide for the transfer to the MedPAC of assets
and staff of the ProPAC and the PPRC, without any loss of benefits
or seniority by virtue of such transfers. Fund balances available
to the ProPAC or the PPRC for any period shall be available to the
MedPAC for such period for like purposes.
"(3) Continuing responsibility for reports. - The MedPAC shall be
responsible for the preparation and submission of reports required
by law to be submitted (and which have not been submitted by the
date of establishment of the MedPAC) by the ProPAC and the PPRC,
and, for this purpose, any reference in law to either such
Commission is deemed, after the appointment of the MedPAC, to refer
to the MedPAC."
MEDPAC ANALYSIS OF IMPACT OF VOLUME ON PER UNIT COST OF RURAL
HOSPITALS WITH PSYCHIATRIC UNITS
Pub. L. 106-554, Sec. 1(a)(6) [title II, Sec. 214], Dec. 21,
2000, 114 Stat. 2763, 2763A-486, provided that: "The Medicare
Payment Advisory Commission, in its study conducted pursuant to
subsection (a) of section 411 of BBRA [Pub. L. 106-113, Sec.
1000(a)(6) [title IV, Sec. 411], set out as a note below] (113
Stat. 1501A-377), shall include -
"(1) in such study an analysis of the impact of volume on the
per unit cost of rural hospitals with psychiatric units; and
"(2) in its report under subsection (b) of such section a
recommendation on whether special treatment for such hospitals
may be warranted."
MEDPAC STUDY ON COMPLEXITY OF MEDICARE PROGRAM AND LEVELS OF
BURDENS PLACED ON PROVIDERS THROUGH FEDERAL REGULATIONS
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 229(c)],
Nov. 29, 1999, 113 Stat. 1536, 1501A-357, provided that:
"(1) Study. - The Medicare Payment Advisory Commission shall
undertake a comprehensive study to review the regulatory burdens
placed on all classes of health care providers under parts A and B
of the medicare program under title XVIII of the Social Security
Act [this subchapter] and to determine the costs these burdens
impose on the nation's health care system. The study shall also
examine the complexity of the current regulatory system and its
impact on providers.
"(2) Report. - Not later than December 31, 2001, the Commission
shall submit to Congress one or more reports on the study conducted
under paragraph (1). The report shall include recommendations
regarding -
"(A) how the Health Care Financing Administration can reduce
the regulatory burdens placed on patients and providers; and
"(B) legislation that may be appropriate to reduce the
complexity of the medicare program, including improvement of the
rules regarding billing, compliance, and fraud and abuse."
MEDPAC REPORT
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec.
312(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A-365, provided that:
"The Medicare Payment Advisory Commission shall include in its
report submitted to Congress in March of 2001 recommendations
regarding the appropriateness of the initial residency period used
under section 1886(h)(5)(F) of the Social Security Act (42 U.S.C.
1395ww(h)(5)(F)) for other residency training programs in a
specialty that require preliminary years of study in another
specialty."
MEDPAC STUDY OF RURAL PROVIDERS
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title IV, Sec. 411],
Nov. 29, 1999, 113 Stat. 1536, 1501A-377, provided that:
"(a) Study. - The Medicare Payment Advisory Commission shall
conduct a study of rural providers furnishing items and services
for which payment is made under title XVIII of the Social Security
Act [this subchapter]. Such study shall examine and evaluate the
adequacy and appropriateness of the categories of special payments
(and payment methodologies) established for rural hospitals under
the medicare program, and the impact of such categories on
beneficiary access and quality of health care services.
"(b) Report. - Not later than 18 months after the date of the
enactment of this Act [Nov. 29, 1999], the Medicare Payment
Advisory Commission shall submit to Congress a report on the study
conducted under subsection (a)."
QUALITY IMPROVEMENT STANDARDS
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 520(c)],
Nov. 29, 1999, 113 Stat. 1536, 1501A-386, provided that:
"(1) Study. - The Medicare Payment Advisory Commission shall
conduct a study on the appropriate quality improvement standards
that should apply to -
"(A) each type of Medicare+Choice plan described in section
1851(a)(2) of the Social Security Act (42 U.S.C. 1395w-21(a)(2)),
including each type of Medicare+Choice plan that is a coordinated
care plan (as described in subparagraph (A) of such section); and
"(B) the original medicare fee-for-service program under parts
A and B [sic] title XVIII of such Act (42 U.S.C. 1395 et seq.)
[parts A and B of this subchapter].
"(2) Considerations. - Such study shall specifically examine the
effects, costs, and feasibility of requiring entities, physicians,
and other health care providers that provide items and services
under the original medicare fee-for-service program to comply with
quality standards and related reporting requirements that are
comparable to the quality standards and related reporting
requirements that are applicable to Medicare+Choice organizations.
"(3) Report. - Not later than 2 years after the date of the
enactment of this Act [Nov. 29, 1999], such Commission shall submit
a report to Congress on the study conducted under this subsection,
together with any recommendations for legislation that it
determines to be appropriate as a result of such study."
INITIAL TERMS OF ADDITIONAL MEMBERS
Pub. L. 105-277, div. J, title V, Sec. 5202(b), Oct. 21, 1998,
112 Stat. 2681-917, provided that:
"(1) In general. - For purposes of staggering the initial terms
of members of the Medicare Payment Advisory Commission (under
section 1805(c)(3) of such Act (42 U.S.C. 1395b-6(c)(3))[)], the
initial terms of the two additional members of the Commission
provided for by the amendment under subsection (a) [amending this
section] are as follows:
"(A) One member shall be appointed for one year.
"(B) One member shall be appointed for two years.
"(2) Commencement of terms. - Such terms shall begin on May 1,
1999."
INFORMATION INCLUDED IN ANNUAL RECOMMENDATIONS
Section 4804(c) of Pub. L. 105-33 provided that: "The Medicare
Payment Advisory Commission shall include in its annual report
under section 1805(b)(1)(B) of the Social Security Act [subsec.
(b)(1)(B) of this section] recommendations on the methodology and
level of payments made to PACE providers under sections 1894(d) and
1934(d) of such Act [sections 1395eee(d) and 1396u-4(d) of this
title] and on the treatment of private, for-profit entities as PACE
providers."
-End-
-CITE-
42 USC Sec. 1395b-7 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
-HEAD-
Sec. 1395b-7. Explanation of medicare benefits
-STATUTE-
(a) In general
The Secretary shall furnish to each individual for whom payment
has been made under this subchapter (or would be made without
regard to any deductible) a statement which -
(1) lists the item or service for which payment has been made
and the amount of such payment for each item or service; and
(2) includes a notice of the individual's right to request an
itemized statement (as provided in subsection (b) of this
section).
(b) Request for itemized statement for medicare items and services
(1) In general
An individual may submit a written request to any physician,
provider, supplier, or any other person (including an
organization, agency, or other entity) for an itemized statement
for any item or service provided to such individual by such
person with respect to which payment has been made under this
subchapter.
(2) 30-day period to furnish statement
(A) In general
Not later than 30 days after the date on which a request
under paragraph (1) has been made, a person described in such
paragraph shall furnish an itemized statement describing each
item or service provided to the individual requesting the
itemized statement.
(B) Penalty
Whoever knowingly fails to furnish an itemized statement in
accordance with subparagraph (A) shall be subject to a civil
money penalty of not more than $100 for each such failure. Such
penalty shall be imposed and collected in the same manner as
civil money penalties under subsection (a) of section 1320a-7a
of this title are imposed and collected under that section.
(3) Review of itemized statement
(A) In general
Not later than 90 days after the receipt of an itemized
statement furnished under paragraph (1), an individual may
submit a written request for a review of the itemized statement
to the Secretary.
(B) Specific allegations
A request for a review of the itemized statement shall
identify -
(i) specific items or services that the individual believes
were not provided as claimed, or
(ii) any other billing irregularity (including duplicate
billing).
(4) Findings of Secretary
The Secretary shall, with respect to each written request
submitted under paragraph (3), determine whether the itemized
statement identifies specific items or services that were not
provided as claimed or any other billing irregularity (including
duplicate billing) that has resulted in unnecessary payments
under this subchapter.
(5) Recovery of amounts
The Secretary shall take all appropriate measures to recover
amounts unnecessarily paid under this subchapter with respect to
a statement described in paragraph (4).
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1806, as added Pub. L.
105-33, title IV, Sec. 4311(b)(1), Aug. 5, 1997, 111 Stat. 385.)
-MISC1-
EFFECTIVE DATE
Section 4311(b)(3) of Pub. L. 105-33 provided that:
"(A) Statement by secretary. - Paragraph (1) of section 1806(a)
of the Social Security Act [subsec. (a)(1) of this section], as
added by paragraph (1), and the repeal made by paragraph (2)
[amending section 1395b-5 of this title] shall take effect on the
date of the enactment of this Act [Aug. 5, 1997].
"(B) Itemized statement. - Paragraph (2) of section 1806(a) and
section 1806(b) of the Social Security Act [subsecs. (a)(2) and (b)
of this section], as so added, shall take effect not later than
January 1, 1999."
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in section 1395b-2 of this title.
-End-
-CITE-
42 USC Part A - Hospital Insurance Benefits for Aged and
Disabled 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
PART A - HOSPITAL INSURANCE BENEFITS FOR AGED AND DISABLED
-SECREF-
PART REFERRED TO IN OTHER SECTIONS
This part is referred to in sections 300dd-3, 300gg, 300gg-41,
402, 426, 426-1, 426a, 1320a-3, 1320a-7a, 1320b-1, 1320d, 1383c,
1395a, 1395b-2, 1395b-6, 1395l, 1395m, 1395o, 1395p, 1395q, 1395u,
1395v, 1395w-21, 1395w-22, 1395w-23, 1395w-24, 1395w-27, 1395w-28,
1395x, 1395y, 1395aa, 1395cc, 1395cc-1, 1395cc-2, 1395ff, 1395ll,
1395mm, 1395pp, 1395rr, 1395ss, 1395vv, 1395ww, 1395yy, 1395eee,
1395ggg, 1396a, 1396b, 1396d, 1396n, 1396u-4 of this title; title 5
sections 8904, 8910; title 8 sections 1182, 1611; title 10 sections
1079, 1086, 1087, 1108, 1111; title 26 sections 35, 6103, 9801;
title 29 sections 1181, 2918; title 31 section 3806; title 45
section 231f.
-End-
-CITE-
42 USC Sec. 1395c 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395c. Description of program
-STATUTE-
The insurance program for which entitlement is established by
sections 426 and 426-1 of this title provides basic protection
against the costs of hospital, related post-hospital, home health
services, and hospice care in accordance with this part for (1)
individuals who are age 65 or over and are eligible for retirement
benefits under subchapter II of this chapter (or would be eligible
for such benefits if certain government employment were covered
employment under such subchapter) or under the railroad retirement
system, (2) individuals under age 65 who have been entitled for not
less than 24 months to benefits under subchapter II of this chapter
(or would have been so entitled to such benefits if certain
government employment were covered employment under such
subchapter) or under the railroad retirement system on the basis of
a disability, and (3) certain individuals who do not meet the
conditions specified in either clause (1) or (2) but who are
medically determined to have end stage renal disease.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1811, as added Pub. L.
89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 291; amended
Pub. L. 92-603, title II, Sec. 201(a)(2), Oct. 30, 1972, 86 Stat.
1371; Pub. L. 95-292, Sec. 4(a), June 13, 1978, 92 Stat. 315; Pub.
L. 96-265, title I, Sec. 103(a)(2), June 9, 1980, 94 Stat. 444;
Pub. L. 96-473, Sec. 2(b), Oct. 19, 1980, 94 Stat. 2263; Pub. L.
96-499, title IX, Sec. 930(a), Dec. 5, 1980, 94 Stat. 2631; Pub. L.
97-248, title I, Sec. 122(a)(1), title II, Sec. 278(b)(3), Sept. 3,
1982, 96 Stat. 356, 561; Pub. L. 99-272, title XIII, Sec.
13205(b)(2)(C)(i), Apr. 7, 1986, 100 Stat. 317; Pub. L. 100-360,
title I, Sec. 104(d)(1), July 1, 1988, 102 Stat. 688; Pub. L.
101-234, title I, Sec. 101(a), Dec. 13, 1989, 103 Stat. 1979.)
-MISC1-
AMENDMENTS
1989 - Pub. L. 101-234 repealed Pub. L. 100-360, Sec. 104(d)(1),
and provided that the provisions of law amended or repealed by such
section are restored or revived as if such section had not been
enacted, see 1988 Amendment note below.
1988 - Pub. L. 100-360 substituted "inpatient hospital services,
extended care services" for "hospital, related post-hospital".
1986 - Pub. L. 99-272 substituted "government employment" for
"Federal employment" in cls. (1) and (2).
1982 - Pub. L. 97-248, Sec. 122(a)(1), substituted "home health
services, and hospice care" for "and home health services".
Pub. L. 97-248, Sec. 278(b)(3), inserted "(or would be eligible
for such benefits if certain Federal employment were covered
employment under such subchapter)" after "subchapter II of this
chapter" in cl. (1), and inserted "(or would have been so entitled
to such benefits if certain Federal employment were covered
employment under such subchapter)" after "subchapter II of this
chapter" in cl. (2).
1980 - Pub. L. 96-499 substituted ", related post-hospital, and
home health services" for "and related post-hospital services".
Pub. L. 96-473 substituted "are eligible for" for "are entitled
to".
Pub. L. 96-265 substituted "not less than 24 months" for "not
less than 24 consecutive months".
1978 - Pub. L. 95-292 inserted references to section 426-1 of
this title and to individuals who do not meet the conditions
specified in either clause (1) or (2) but who are medically
determined to have end stage renal disease.
1972 - Pub. L. 92-603 designated existing provisions as cl. (1)
and added cl. (2).
EFFECTIVE DATE OF 1989 AMENDMENT
Section 101(d) of Pub. L. 101-234 provided that: "The provisions
of this section [amending this section and sections 1395d, 1395e,
1395f, 1395k, 1395x, 1395cc, and 1395tt of this title, enacting
provisions set out as notes under sections 1395e and 1395ww of this
title, and amending provisions set out as notes under sections
1395e and 1395ww of this title] shall take effect January 1, 1990,
except that the amendments made by subsection (c) [amending
provisions set out as a note under section 1395ww of this title]
shall be effective as if included in the enactment of MCCA [Pub. L.
100-360]."
EFFECTIVE DATE OF 1988 AMENDMENT
Amendment by Pub. L. 100-360 effective Jan. 1, 1989, except as
otherwise provided, and applicable to inpatient hospital deductible
for 1989 and succeeding years, to care and services furnished on or
after Jan. 1, 1989, to premiums for January 1989 and succeeding
months, and to blood or blood cells furnished on or after Jan. 1,
1989, see section 104(a) of Pub. L. 100-360, set out as a note
under section 1395d of this title.
EFFECTIVE DATE OF 1986 AMENDMENT
Amendment by Pub. L. 99-272 effective after Mar. 31, 1986, with
no individual to be considered under disability for any period
beginning before Apr. 1, 1986, for purposes of hospital insurance
benefits, see section 13205(d)(2) of Pub. L. 99-272, set out as a
note under section 410 of this title.
EFFECTIVE DATE OF 1982 AMENDMENT
Section 122(h)(1) of Pub. L. 97-248, as amended by Pub. L.
99-272, title IX, Sec. 9123(a), Apr. 7, 1986, 100 Stat. 168,
provided that: "The amendments made by this section [amending this
section and sections 1395d to 1395f, 1395h, and 1395x to 1395cc of
this title and section 231f of Title 45, Railroads, and enacting
provisions set out as notes under sections 1395b-1 and 1395f of
this title] apply to hospice care provided on or after November 1,
1983."
Amendment by section 278(b)(3) of Pub. L. 97-248 effective on and
after Jan. 1, 1983, and applicable to remuneration (for medicare
qualified Federal employment) paid after Dec. 31, 1982, see section
278(c)(2)(A) of Pub. L. 97-248, set out as a note under section 426
of this title.
EFFECTIVE DATE OF 1980 AMENDMENTS
Amendment by Pub. L. 96-499 effective with respect to services
furnished on or after July 1, 1981, see section 930(s)(1) of Pub.
L. 96-499, set out as a note under section 1395x of this title.
Amendment by Pub. L. 96-473 effective after second month
beginning after Oct. 19, 1980, see section 2(d) of Pub. L. 96-473,
set out as a note under section 426 of this title.
Amendment by Pub. L. 96-265 applicable with respect to hospital
insurance or supplementary medical insurance benefits for services
provided on or after first day of sixth month which begins after
June 9, 1980, see section 103(c) of Pub. L. 96-265, set out as a
note under section 426 of this title.
EFFECTIVE DATE OF 1978 AMENDMENT
Amendment by Pub. L. 95-292 effective with respect to services,
supplies, and equipment furnished after the third calendar month
beginning after June 13, 1978, except that provisions for the
implementation of an incentive reimbursement system for dialysis
services furnished in facilities and providers to become effective
with respect to a facility's or provider's first accounting period
beginning after the last day of the twelfth month following the
month of June 1978, and except that provisions for reimbursement
rates for home dialysis to become effective on Apr. 1, 1979, see
section 6 of Pub. L. 95-292, set out as a note under section 426 of
this title.
ADVISORY COUNCIL TO STUDY COVERAGE OF DISABLED UNDER THIS
SUBCHAPTER
Pub. L. 90-248, title I, Sec. 140, Jan. 2, 1968, 81 Stat. 854,
directed Secretary of Health, Education, and Welfare to appoint an
Advisory Council to study need for coverage of disabled under the
health insurance programs of this subchapter, directed Council to
submit a report on such study to Secretary by Jan. 1, 1969, and
directed Secretary in turn to transmit such report to Congress,
resulting in termination of Council's existence.
REIMBURSEMENT OF CHARGES UNDER PART A FOR SERVICES TO PATIENTS
ADMITTED PRIOR TO 1968 TO CERTAIN HOSPITALS
Pub. L. 90-248, title I, Sec. 142, Jan. 2, 1968, 81 Stat. 855,
provided that:
"(a) Notwithstanding any provision of title XVIII of the Social
Security Act [this subchapter] an individual who is entitled to
hospital insurance benefits under section 226 of such Act [section
426 of this title] may, subject to subsections (b) and (c),
receive, on the basis of an itemized bill, reimbursement for
charges to him for inpatient hospital services (as defined in
section 1861 of such Act [section 1395x of this title], but without
regard to subsection (e) of such section) furnished by, or under
arrangements (as defined in section 1861(w) of such Act [section
1395x(w) of this title] with, a hospital if -
"(1) the hospital did not have an agreement in effect under
section 1866 of such Act [section 1395cc of this title] but would
have been eligible for payment under part A of title XVIII of
such Act [this part] with respect to such services if at the time
such services were furnished the hospital had such an agreement
in effect;
"(2) the hospital (A) meets the requirements of paragraphs (5)
and (7) of section 1861(e) of such Act [section 1395x(e) of this
title], (B) is not primarily engaged in providing the services
described in section 1961(j)(1)(A) of such Act [section
1395x(j)(1)(A) of this title], and (C) is primarily engaged in
providing, by or under the supervision of individuals referred to
in paragraph (1) of section 1861(r) of such Act [section 1395x(r)
of this title], to inpatients (i) diagnostic services and
therapeutic services for medical diagnosis, treatment, and care
of injured, disabled, or sick persons, or (ii) rehabilitation
services for the rehabilitation of injured, disabled, or sick
persons;
"(3) the hospital did not meet the requirements that must be
met to permit payment to the hospital under part A of title XVIII
of such Act [this part]; and
"(4) an application is filed (submitted in such form and manner
and by such person, and containing and supported by such
information, as the Secretary shall by regulations prescribe) for
reimbursement before January 1, 1969.
"(b) Payments under this section may not be made for inpatient
hospital services (as described in subsection (a)) furnished to an
individual -
"(1) prior to July 1, 1966,
"(2) after December 31, 1967, unless furnished with respect to
an admission to the hospital prior to January 1, 1968, and
"(3) for more than -
"(A) 90 days in any spell of illness, but only if (i) prior
to January 1, 1969, the hospital furnishing such services
entered into an agreement under section 1866 of the Social
Security Act [section 1395cc of this title] and (ii) the
hospital's plan for utilization review, as provided for in
section 1861(k) of such Act [section 1395x(k) of this title],
has, in accordance with section 1814 of such Act [section 1395f
of this title], been applied to the services furnished such
individual, or
"(B) 20 days in any spell of illness, if the hospital did not
meet the conditions of clauses (i) and (ii) of subparagraph
(A).
"(c)(1) The amounts payable in accordance with subsection (a)
with respect to inpatient hospital services shall, subject to
paragraph (2) of this subsection, be paid from the Federal Hospital
Insurance Trust Fund in amounts equal to 60 percent of the
hospital's reasonable charges for routine services furnished in the
accommodations occupied by the individual or in semi-private
accommodations (as defined in section 1861(v)(4) of the Social
Security Act [section 1395x(v)(4) of this title]) whichever is
less, plus 80 percent of the hospital's reasonable charges for
ancillary services. If separate charges for routine and ancillary
services are not made by the hospital, reimbursement may be based
on two-thirds of the hospital's reasonable charges for the services
received but not to exceed the charges which would have been made
if the patient had occupied semi-private accommodations (as so
defined). For purposes of the preceding provisions of this
paragraph, the term 'routine services' shall mean the regular room,
dietary, and nursing services, minor medical and surgical supplies
and the use of equipment and facilities for which a separate charge
is not customarily made; the term 'ancillary services' shall mean
those special services for which charges are customarily made in
addition to routine services.
"(2) Before applying paragraph (1), payments made under this
section shall be reduced to the extent provided for under section
1813 of the Social Security Act [section 1395e of this title] in
the case of benefits payable to providers of services under part A
of title XVIII of such Act [this part].
"(d) For the purposes of this section -
"(1) the 90-day period, referred to in subsection (b)(3)(A),
shall be reduced by the number of days of inpatient hospital
services furnished to such individual during the spell of
illness, referred to therein, and with respect to which he was
entitled to have payment made under part A of title XVIII of the
Social Security Act [this part];
"(2) the 20-day period, referred to in subsection (b)(3)(B)
shall be reduced by the number of days in excess of 70 days of
inpatient hospital services furnished during the spell of
illness, referred to therein, and with respect to which such
individual was entitled to have payment made under such part A
[this part];
"(3) the term 'spell of illness' shall have the meaning
assigned to it by subsection (a) of section 1861 of such Act
[section 1395x(a) of this title] except that the term 'inpatient
hospital services' as it appears in such subsection shall have
the meaning assigned to it by subsection (a) of this section."
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in title 26 section 220; title 38
sections 1725, 1729.
-End-
-CITE-
42 USC Sec. 1395d 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395d. Scope of benefits
-STATUTE-
(a) Entitlement to payment for inpatient hospital services,
post-hospital extended care services, home health services, and
hospice care
The benefits provided to an individual by the insurance program
under this part shall consist of entitlement to have payment made
on his behalf or, in the case of payments referred to in section
1395f(d)(2) of this title to him (subject to the provisions of this
part) for -
(1) inpatient hospital services or inpatient critical access
hospital services for up to 150 days during any spell of illness
minus 1 day for each day of such services in excess of 90
received during any preceding spell of illness (if such
individual was entitled to have payment for such services made
under this part unless he specifies in accordance with
regulations of the Secretary that he does not desire to have such
payment made);
(2)(A) post-hospital extended care services for up to 100 days
during any spell of illness, and (B) to the extent provided in
subsection (f) of this section, extended care services that are
not post-hospital extended care services;
(3) for individuals not enrolled in part B of this subchapter,
home health services, and for individuals so enrolled,
post-institutional home health services furnished during a home
health spell of illness for up to 100 visits during such spell of
illness; and
(4) in lieu of certain other benefits, hospice care with
respect to the individual during up to two periods of 90 days
each and an unlimited number of subsequent periods of 60 days
each with respect to which the individual makes an election under
subsection (d)(1) of this section.
(b) Services not covered
Payment under this part for services furnished an individual
during a spell of illness may not (subject to subsection (c) of
this section) be made for -
(1) inpatient hospital services furnished to him during such
spell after such services have been furnished to him for 150 days
during such spell minus 1 day for each day of inpatient hospital
services in excess of 90 received during any preceding spell of
illness (if such individual was entitled to have payment for such
services made under this part unless he specifies in accordance
with regulations of the Secretary that he does not desire to have
such payment made);
(2) post-hospital extended care services furnished to him
during such spell after such services have been furnished to him
for 100 days during such spell; or
(3) inpatient psychiatric hospital services furnished to him
after such services have been furnished to him for a total of 190
days during his lifetime.
Payment under this part for post-institutional home health services
furnished an individual during a home health spell of illness may
not be made for such services beginning after such services have
been furnished for a total of 100 visits during such spell.
(c) Inpatients of psychiatric hospitals
If an individual is an inpatient of a psychiatric hospital on the
first day of the first month for which he is entitled to benefits
under this part, the days on which he was an inpatient of such a
hospital in the 150-day period immediately before such first day
shall be included in determining the number of days limit under
subsection (b)(1) of this section insofar as such limit applies to
(1) inpatient psychiatric hospital services, or (2) inpatient
hospital services for an individual who is an inpatient primarily
for the diagnosis or treatment of mental illness (but shall not be
included in determining such number of days limit insofar as it
applies to other inpatient hospital services or in determining the
190-day limit under subsection (b)(3) of this section).
(d) Hospice care; election; waiver of rights; revocation; change of
election
(1) Payment under this part may be made for hospice care provided
with respect to an individual only during two periods of 90 days
each and an unlimited number of subsequent periods of 60 days each
during the individual's lifetime and only, with respect to each
such period, if the individual makes an election under this
paragraph to receive hospice care under this part provided by, or
under arrangements made by, a particular hospice program instead of
certain other benefits under this subchapter.
(2)(A) Except as provided in subparagraphs (B) and (C) and except
in such exceptional and unusual circumstances as the Secretary may
provide, if an individual makes such an election for a period with
respect to a particular hospice program, the individual shall be
deemed to have waived all rights to have payment made under this
subchapter with respect to -
(i) hospice care provided by another hospice program (other
than under arrangements made by the particular hospice program)
during the period, and
(ii) services furnished during the period that are determined
(in accordance with guidelines of the Secretary) to be -
(I) related to the treatment of the individual's condition
with respect to which a diagnosis of terminal illness has been
made or
(II) equivalent to (or duplicative of) hospice care;
except that clause (ii) shall not apply to physicians' services
furnished by the individual's attending physician (if not an
employee of the hospice program) or to services provided by (or
under arrangements made by) the hospice program.
(B) After an individual makes such an election with respect to a
90-day period or a subsequent 60-day period, the individual may
revoke the election during the period, in which case -
(i) the revocation shall act as a waiver of the right to have
payment made under this part for any hospice care benefits for
the remaining time in such period and (for purposes of subsection
(a)(4) of this section and subparagraph (A)) the individual shall
be deemed to have been provided such benefits during such entire
period, and
(ii) the individual may at any time after the revocation
execute a new election for a subsequent period, if the individual
otherwise is entitled to hospice care benefits with respect to
such a period.
(C) An individual may, once in each such period, change the
hospice program with respect to which the election is made and such
change shall not be considered a revocation of an election under
subparagraph (B).
(D) For purposes of this subchapter, an individual's election
with respect to a hospice program shall no longer be considered to
be in effect with respect to that hospice program after the date
the individual's revocation or change of election with respect to
that election takes effect.
(e) Services taken into account
For purposes of subsections (b) and (c) of this section,
inpatient hospital services, inpatient psychiatric hospital
services, and post-hospital extended care services shall be taken
into account only if payment is or would be, except for this
section or the failure to comply with the request and certification
requirements of or under section 1395f(a) of this title, made with
respect to such services under this part.
(f) Coverage of extended care services without regard to three-day
prior hospitalization requirement
(1) The Secretary shall provide for coverage, under clause (B) of
subsection (a)(2) of this section, of extended care services which
are not post-hospital extended care services at such time and for
so long as the Secretary determines, and under such terms and
conditions (described in paragraph (2)) as the Secretary finds
appropriate, that the inclusion of such services will not result in
any increase in the total of payments made under this subchapter
and will not alter the acute care nature of the benefit described
in subsection (a)(2) of this section.
(2) The Secretary may provide -
(A) for such limitations on the scope and extent of services
described in subsection (a)(2)(B) of this section and on the
categories of individuals who may be eligible to receive such
services, and
(B) notwithstanding sections 1395f, 1395x(v), and 1395ww of
this title, for such restrictions and alternatives on the amounts
and methods of payment for services described in such subsection,
as may be necessary to carry out paragraph (1).
(g) "Spell of illness" defined
For definitions of "spell of illness", and for definitions of
other terms used in this part, see section 1395x of this title.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1812, as added Pub. L.
89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 291; amended
Pub. L. 90-248, title I, Secs. 129(c)(2), 137(a), 138(a), 143(b),
146(a), Jan. 2, 1968, 81 Stat. 847, 853, 854, 857, 859; Pub. L.
96-499, title IX, Secs. 930(b)-(d), 931(a), Dec. 5, 1980, 94 Stat.
2631, 2633; Pub. L. 97-35, title XXI, Sec. 2121(a), Aug. 13, 1981,
95 Stat. 796; Pub. L. 97-248, title I, Secs. 122(b), 123, Sept. 3,
1982, 96 Stat. 356, 364; Pub. L. 97-448, title III, Sec. 309(b)(5),
Jan. 12, 1983, 96 Stat. 2409; Pub. L. 100-360, title I, Sec. 101,
July 1, 1988, 102 Stat. 684; Pub. L. 101-234, title I, Sec. 101(a),
Dec. 13, 1989, 103 Stat. 1979; Pub. L. 101-239, title VI, Sec.
6003(g)(3)(B)(i), Dec. 19, 1989, 103 Stat. 2152; Pub. L. 101-508,
title IV, Sec. 4006(a), Nov. 5, 1990, 104 Stat. 1388-43; Pub. L.
103-432, title I, Sec. 102(g)(1), Oct. 31, 1994, 108 Stat. 4404;
Pub. L. 105-33, title IV, Secs. 4201(c)(1), 4443(a), (b)(1),
4611(a), Aug. 5, 1997, 111 Stat. 373, 423, 472; Pub. L. 106-113,
div. B, Sec. 1000(a)(6) [title III, Sec. 321(k)(1)], Nov. 29, 1999,
113 Stat. 1536, 1501A-366.)
-REFTEXT-
REFERENCES IN TEXT
Part B of this subchapter, referred to in subsec. (a)(3), is
classified to section 1395j et seq. of this title.
-MISC1-
AMENDMENTS
1999 - Subsec. (b). Pub. L. 106-113 inserted "during" after "100
visits" in concluding provisions.
1997 - Subsec. (a)(1). Pub. L. 105-33, Sec. 4201(c)(1),
substituted "critical access" for "rural primary care".
Subsec. (a)(3). Pub. L. 105-33, Sec. 4611(a)(1), substituted "for
individuals not enrolled in part B of this subchapter, home health
services, and for individuals so enrolled, post-institutional home
health services furnished during a home health spell of illness for
up to 100 visits during such spell of illness" for "home health
services".
Subsec. (a)(4). Pub. L. 105-33, Sec. 4443(a), substituted "and an
unlimited number of subsequent periods of 60 days each" for ", a
subsequent period of 30 days, and a subsequent extension period".
Subsec. (b). Pub. L. 105-33, Sec. 4611(a)(2), inserted closing
provisions.
Subsec. (d)(1). Pub. L. 105-33, Sec. 4443(a), substituted "and an
unlimited number of subsequent periods of 60 days each" for ", a
subsequent period of 30 days, and a subsequent extension period".
Subsec. (d)(2)(B). Pub. L. 105-33, Sec. 4443(b)(1), substituted
"90-day period or a subsequent 60-day period" for "90- or 30-day
period or a subsequent extension period".
1994 - Subsec. (a)(1). Pub. L. 103-432 substituted "inpatient
hospital services or inpatient rural primary care hospital
services" for "inpatient hospital services" before "for up to 150
days" and "such services" for "inpatient hospital services" before
"in excess of 90" and struck out "and inpatient rural primary care
hospital services" after "such payment made)".
1990 - Subsec. (a)(4). Pub. L. 101-508, Sec. 4006(a)(1),
substituted "90 days each, a subsequent period of 30 days, and a
subsequent extension period" for "90 days each and one subsequent
period of 30 days".
Subsec. (d)(1). Pub. L. 101-508, Sec. 4006(a)(2)(A), substituted
"90 days each, a subsequent period of 30 days, and a subsequent
extension period during the individual's lifetime" for "90 days
each and one subsequent period of 30 days during the individual's
lifetime".
Subsec. (d)(2)(B). Pub. L. 101-508, Sec. 4006(a)(2)(B),
substituted "a 90- or 30-day period or a subsequent extension
period" for "a 90- or 30-day period".
1989 - Subsec. (a). Pub. L. 101-234 repealed Pub. L. 100-360,
Sec. 101(1), and provided that the provisions of law amended or
repealed by such section are restored or revived as if such section
had not been enacted, see 1988 Amendment note below.
Subsec. (a)(1). Pub. L. 101-239 inserted "and inpatient rural
primary care hospital services" before semicolon at end.
Subsecs. (b) to (d)(1), (2)(B), (e) to (g). Pub. L. 101-234
repealed Pub. L. 100-360, Sec. 101(2)-(6), and provided that the
provisions of law amended or repealed by such section are restored
or revived as if such section had not been enacted, see 1988
Amendment notes below.
1988 - Subsec. (a). Pub. L. 100-360, Sec. 101(1), struck out
former pars. (1) to (4) and added new pars. (1) to (4) which read
as follows:
"(1) inpatient hospital services;
"(2) extended care services for up to 150 days during any
calendar year;
"(3) home health services; and
"(4) in lieu of certain other benefits, hospice care with respect
to the individual during up to two periods of 90 days each, a
subsequent period of 30 days, and a subsequent extension period
with respect to which the individual makes an election under
subsection (d)(1) of this section."
Subsec. (b). Pub. L. 100-360, Sec. 101(2), amended subsec. (b)
generally, striking out par. (1) and renumbering and amending pars.
(2) and (3) as (1) and (2), respectively.
Subsec. (c). Pub. L. 100-360, Sec. 101(3), amended subsec. (c)
generally, substituting pars. (1) to (4) limiting periods for
inpatients of psychiatric hospitals for former single paragraph.
Subsec. (d)(1). Pub. L. 100-360, Sec. 101(4)(A), substituted ", a
subsequent period of 30 days, and a subsequent extension period"
for "and one subsequent period of 30 days".
Subsec. (d)(2)(B). Pub. L. 100-360, Sec. 101(4)(B), inserted "or
a subsequent extension period" after "30-day period" in
introductory provisions.
Subsec. (e). Pub. L. 100-360, Sec. 101(5), struck out
"post-hospital" before "extended care services".
Subsec. (f). Pub. L. 100-360, Sec. 101(6), struck out subsec. (f)
which provided coverage of extended care services without regard to
three-day prior hospitalization requirement.
Subsec. (g). Pub. L. 100-360, Sec. 101(6), struck out subsec. (g)
which cross-referenced section 1395x of this title for definitions
of "spell of illness" and other terms used in this part.
1983 - Subsec. (d)(2)(A). Pub. L. 97-448 substituted "or to
services" for "or to other than services" after "(if not an
employee of the hospice program)".
1982 - Subsec. (a)(2). Pub. L. 97-248, Sec. 123(a), redesignated
existing provisions as subpar. (A) and added subpar. (B).
Subsec. (a)(4). Pub. L. 97-248, Sec. 122(b)(1), added par. (4).
Subsec. (d). Pub. L. 97-248, Sec. 122(b)(2), added subsec. (d).
Subsecs. (f), (g). Pub. L. 97-248, Sec. 123(b), added subsec. (f)
and redesignated former subsec. (f) as (g).
1981 - Subsec. (a). Pub. L. 97-35 struck out par. (4) which
related to alcohol detoxification facility services.
1980 - Subsec. (a)(3). Pub. L. 96-499, Sec. 930(b), substituted
"home health services" for "post-hospital home health services for
up to 100 visits (during the one-year period described in section
1395x(n) of this title) after the beginning of one spell of illness
and before the beginning of the next".
Subsec. (a)(4). Pub. L. 96-499, Sec. 931(a), added par. (4).
Subsec. (d). Pub. L. 96-499, Sec. 930(c), struck out subsec. (d)
which authorized payment for post-hospital home health services
furnished an individual only during the one year period described
in section 1395x(n) of this title following his most recent
hospital discharge which met the requirements of such section and
only for the first 100 visits in such period.
Subsec. (e). Pub. L. 96-499, Sec. 930(d), substituted
"subsections (b) and (c)" for "subsections (b), (c), and (d)" and
"and post-hospital extended care services" for "post-hospital
extended care services, and post-hospital home health services".
1968 - Subsec. (a). Pub. L. 90-248, Sec. 143(b), inserted "or, in
the case of payments referred to in section 1395f(d)(2) of this
title to him" after "on his behalf" in text preceding par. (1).
Subsec. (a)(1). Pub. L. 90-248, Sec. 137(a)(1), increased the
maximum duration of benefits from 90 to 150 days minus 1 day for
each day of inpatient hospital services in excess of 90 received
during any preceding spell of illness (if such individual was
entitled to have payment for such services made under this part
unless he specifies that he does not desire to have such payment
made).
Subsec. (a)(4). Pub. L. 90-248, Sec. 129(c)(2), struck out par.
(4) which provided for payment for outpatient hospital diagnostic
services.
Subsec. (b)(1). Pub. L. 90-248, Sec. 137(a)(2), changed the
limitation on payments from 90 to 150 days minus 1 day for each day
of inpatient hospital services in excess of 90 received during any
preceding spell of illness (if such individual was entitled to have
payment for such services made under this part unless he specifies
that he does not desire to have such payment made).
Subsec. (c). Pub. L. 90-248, Sec. 138(a), increased the limit
from 90 to 150 days so that if an individual was an inpatient of a
psychiatric or tuberculosis hospital on the first day of the first
month for which he is entitled to benefits, the days he was an
inpatient in the 150-day period immediately before such first day
are included in determining the limit under subsec. (b)(1) insofar
as such limit applies to (1) inpatient psychiatric hospital
services and inpatient tuberculosis hospital services, or (2)
inpatient hospital services for an individual who is an inpatient
primarily for the diagnosis or treatment of mental illness or
tuberculosis (but are not included in determining such limit as it
applies to other inpatient hospital services or in determining the
190-day limit under subsec. (b)(3)).
Pub. L. 90-248, Sec. 146(a), provided that the limitation of
allowable days of inpatient hospital services will not apply to
services provided to an inpatient of a tuberculosis hospital.
EFFECTIVE DATE OF 1999 AMENDMENT
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec.
321(m)], Nov. 29, 1999, 113 Stat. 1536, 1501A-368, provided that:
"Except as otherwise provided, the amendments made by this section
[amending this section and sections 1395i, 1395i-4, 1395l, 1395m,
1395u, 1395w-3, 1395w-4, 1395w-21, 1395w-22, 1395w-24, 1395x,
1395y, 1395cc, 1395ss, 1395ww, 1395yy, and 1395fff of this title,
repealing section 1320b-5 of this title, and amending provisions
set out as notes under sections 1395f and 1395ww of this title]
shall take effect as if included in the enactment of BBA [Balanced
Budget Act of 1997, Pub. L. 105-33]."
EFFECTIVE DATE OF 1997 AMENDMENT
Amendment by section 4201(c)(1) of Pub. L. 105-33 applicable to
services furnished on or after Oct. 1, 1997, see section 4201(d) of
Pub. L. 105-33, set out as a note under section 1395f of this
title.
Section 4449 of title IV of Pub. L. 105-33 provided that: "Except
as otherwise provided in this chapter [chapter 4 (Secs. 4441-4449)
of subtitle E of title IV of Pub. L. 105-33, amending this section
and sections 1395f, 1395x, and 1395pp of this title and enacting
provisions set out as notes under section 1395f and 1395x of this
title], the amendments made by this chapter apply to benefits
provided on or after the date of the enactment of this chapter
[Aug. 5, 1997], regardless of whether or not an individual has made
an election under section 1812(d) of the Social Security Act (42
U.S.C. 1395d(d)) before such date."
Section 4611(f) of Pub. L. 105-33 provided that: "The amendments
made by this section [amending this section and sections 1395u,
1395x, and 1395ff of this title] apply to services furnished on or
after January 1, 1998. For purpose of applying such amendments, any
home health spell of illness that began, but not [sic] did not end,
before such date shall be considered to have begun as of such
date."
EFFECTIVE DATE OF 1994 AMENDMENT
Section 102(i) of Pub. L. 103-432 provided that: "The amendments
made by this section [amending this section and sections 1395e,
1395f, 1395i-4, 1395m, 1395x, and 1395ww of this title] shall take
effect on the date of the enactment of this Act [Oct. 31, 1994]."
EFFECTIVE DATE OF 1990 AMENDMENT
Section 4006(c) of Pub. L. 101-508 provided that: "The amendments
made by this section [amending this section and section 1395f of
this title] shall apply with respect to care and services furnished
on or after January 1, 1990."
EFFECTIVE DATE OF 1989 AMENDMENT
Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section
101(d) of Pub. L. 101-234, set out as a note under section 1395c of
this title.
EFFECTIVE DATE OF 1988 AMENDMENT
Section 104(a) of Pub. L. 100-360, as amended by Pub. L. 100-485,
title VI, Sec. 608(d)(3)(A), Oct. 13, 1988, 102 Stat. 2413,
provided that:
"(1) In general. - Except as provided in paragraph (2) and
subsection (b), the amendments made by this subtitle [subtitle A
(Secs. 101-104) of title I of Pub. L. 100-360, amending this
section and sections 1395c, 1395e, 1395f, 1395i-2, 1395k, 1395x,
1395cc, and 1395tt of this title] shall take effect on January 1,
1989, and shall apply -
"(A) to the inpatient hospital deductible for 1989 and
succeeding years,
"(B) to care and services furnished on or after January 1,
1989,
"(C) to premiums for January 1989 and succeeding months, and
"(D) to blood or blood cells furnished on or after January 1,
1989.
"(2) Elimination of post-hospital requirement for extended care
services. - The amendments made by this subtitle, insofar as they
eliminate the requirement (under section 1812(a)(2) of the Social
Security Act [subsec. (a)(2) of this section]) that extended care
services are only covered under title XVIII of such Act [this
subchapter] if they are post-hospital extended care services, shall
only apply to extended care services furnished pursuant to an
admission to a skilled nursing facility occurring on or after
January 1, 1989."
EFFECTIVE DATE OF 1983 AMENDMENT
Amendment by Pub. L. 97-448 effective as if originally included
as a part of this section as this section was amended by the Tax
Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248, see
section 309(c)(2) of Pub. L. 97-448, set out as a note under
section 426-1 of this title.
EFFECTIVE DATE OF 1982 AMENDMENT
Amendment by section 122(b) of Pub. L. 97-248 applicable to
hospice care provided on or after Nov. 1, 1983, see section
122(h)(1) of Pub. L. 97-248, as amended, set out as a note under
section 1395c of this title.
EFFECTIVE DATE OF 1981 AMENDMENT
Section 2121(i) of Pub. L. 97-35 provided that: "The amendments
made by this section [amending this section and sections 1320c-3,
1320c-4, 1320c-7, 1395f, and 1395x of this title] (other than by
subsection (h) [repealing provisions set out as a note under
section 1395ll of this title]) shall apply to services furnished in
detoxification facilities for inpatient stays beginning on or after
the tenth day after the date of the enactment of this Act [Aug. 13,
1981]."
EFFECTIVE DATE OF 1980 AMENDMENT
Amendment by section 930(b)-(d) of Pub. L. 96-499 effective with
respect to services furnished on or after July 1, 1981, see section
930(s)(1) of Pub. L. 96-499, set out as a note under section 1395x
of this title.
Section 931(e) of Pub. L. 96-499 provided that: "The amendments
made by subsections (a) through (d) of this section [amending this
section and sections 1395f and 1395x of this title] shall become
effective on April 1, 1981."
EFFECTIVE DATE OF 1968 AMENDMENT
Section 129(d) of Pub. L. 90-248 provided that: "The amendments
made by this section [amending this section and sections 426,
1395e, 1395f, 1395k, 1395l, 1395n, 1395x, and 1395cc of this title
and section 228s-2 of Title 45, Railroads] shall apply with respect
to services furnished after March 31, 1968, except that subsection
(c)(5) of such section [amending section 1395f of this title] shall
become effective with respect to services furnished after the date
of enactment of this Act [Jan. 2, 1968]."
Section 137(c) of Pub. L. 90-248 provided that: "The amendments
made by subsections (a) and (b) [amending this section and section
1395e of this title] shall apply with respect to services furnished
after December 31, 1967."
Section 138(b) of Pub. L. 90-248 provided that: "The amendments
made by subsection (a) [amending this section] shall apply with
respect to payment for services furnished after December 31, 1967."
Section 143(d) of Pub. L. 90-248 provided that: "The provisions
made by subsection (a) of this section [amending section 1395x of
this title] shall become effective as of July 1, 1966, and the
provisions made by subsections (b) and (c) of this section
[amending this section and section 1395f of this title] shall apply
to services furnished with respect to admissions occurring after
December 31, 1967, and to outpatient hospital diagnostic services
furnished after December 31, 1967, and before April 1, 1968."
Section 146(b) of Pub. L. 90-248 provided that: "The amendment
made by subsection (a) [amending this section] shall apply with
respect to payment for services furnished after December 31, 1967."
MEDPAC REPORT ON ACCESS TO, AND USE OF, HOSPICE BENEFIT
Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 323], Dec. 21,
2000, 114 Stat. 2763, 2763A-501, provided that:
"(a) In General. - The Medicare Payment Advisory Commission shall
conduct a study to examine the factors affecting the use of hospice
benefits under the medicare program under title XVIII of the Social
Security Act [this subchapter], including a delay in the time
(relative to death) of entry into a hospice program, and
differences in such use between urban and rural hospice programs
and based upon the presenting condition of the patient.
"(b) Report. - Not later than 18 months after the date of the
enactment of this Act [Dec. 21, 2000], the Commission shall submit
to Congress a report on the study conducted under subsection (a),
together with any recommendations for legislation that the
Commission deems appropriate."
TRANSITION
Section 4611(e) of Pub. L. 105-33 provided that:
"(1) In general. - Notwithstanding any provision of title XVIII
of the Social Security Act [this subchapter], the Secretary of
Health and Human Services shall establish a transition for the
aggregate amount of expenditures that are transferred from part A,
to part B, of title XVIII of the Social Security Act [this part and
part B of this subchapter], as a result of the amendments made by
this section [amending this section and sections 1395u, 1395x, and
1395ff of this title], during each of the years during the period
beginning with 1998 and ending with 2002 according to this
subsection. Under the transition for each such year, the Secretary
shall effect such transfer, between the trust funds under such
parts, as will result in only the proportion (specified in
paragraph (2)) of such aggregate expenditures for the year being
transferred from such part A to such part B.
"(2) Proportion specified. - The proportion specified in this
paragraph for -
"(A) 1998 is 1/6 ,
"(B) 1999 is 1/3 ,
"(C) 2000 is 1/2 ,
"(D) 2001 is 2/3 , and
"(E) 2002 is 5/6 .
"(3) Application in establishing monthly premiums for 1998
through 2003. -
"(A) In general. - For purposes only of computing the monthly
premium under section 1839 of the Social Security Act (42 U.S.C.
1395r), the monthly actuarial rate for enrollees age 65 and over
shall be computed as though any reference in paragraph (1) of
this subsection to 2002 were a reference to 2003 and as if the
following proportions were substituted for the proportions
specified in paragraph (2):
"(i) For 1998, 1/7 .
"(ii) For 1999, 2/7 .
"(iii) For 2000, 3/7 .
"(iv) For 2001, 4/7 .
"(v) For 2002, 5/7 .
"(vi) For 2003, 6/7 .
"(B) No impact on government contribution. - Subparagraph (A)
does not apply in determining the amount of the Government
contribution under section 1844 of the Social Security Act (42
U.S.C. 1395w)."
REPEAL OF 1988 EXPANSION OF MEDICARE PART A BENEFITS
For provisions repealing amendment by section 101 of Pub. L.
100-360, restoring or reviving this section as if section 101 of
Pub. L. 100-360 had not been enacted, and providing a transition
period for medicare beneficiaries with respect to inpatient
hospital services and extended care services provided on or after
Jan. 1, 1990, and providing an exception to such restoration for
certain hospice care, see section 101(a)-(b)(2) of Pub. L. 101-234,
set out as a note under section 1395e of this title.
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 1395e, 1395f, 1395w-23,
1395x, 1395eee, 1396b, 1396d, 1396r-8 of this title; title 10
section 1074j.
-End-
-CITE-
42 USC Sec. 1395e 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395e. Deductibles and coinsurance
-STATUTE-
(a) Inpatient hospital services; outpatient hospital diagnostic
services; blood; post-hospital extended care services
(1) The amount payable for inpatient hospital services or
inpatient critical access hospital services furnished an individual
during any spell of illness shall be reduced by a deduction equal
to the inpatient hospital deductible or, if less, the charges
imposed with respect to such individual for such services, except
that, if the customary charges for such services are greater than
the charges so imposed, such customary charges shall be considered
to be the charges so imposed. Such amount shall be further reduced
by a coinsurance amount equal to -
(A) one-fourth of the inpatient hospital deductible for each
day (before the 91st day) on which such individual is furnished
such services during such spell of illness after such services
have been furnished to him for 60 days during such spell; and
(B) one-half of the inpatient hospital deductible for each day
(before the day following the last day for which such individual
is entitled under section 1395d(a)(1) of this title to have
payment made on his behalf for inpatient hospital services or
inpatient critical access hospital services during such spell of
illness) on which such individual is furnished such services
during such spell of illness after such services have been
furnished to him for 90 days during such spell;
except that the reduction under this sentence for any day shall not
exceed the charges imposed for that day with respect to such
individual for such services (and for this purpose, if the
customary charges for such services are greater than the charges so
imposed, such customary charges shall be considered to be the
charges so imposed).
(2)(A) The amount payable to any provider of services under this
part for services furnished an individual shall be further reduced
by a deduction equal to the expenses incurred for the first three
pints of whole blood (or equivalent quantities of packed red blood
cells, as defined under regulations) furnished to the individual
during each calendar year, except that such deductible for such
blood shall in accordance with regulations be appropriately reduced
to the extent that there has been a replacement of such blood (or
equivalent quantities of packed red blood cells, as so defined);
and for such purposes blood (or equivalent quantities of packed red
blood cells, as so defined) furnished such individual shall be
deemed replaced when the institution or other person furnishing
such blood (or such equivalent quantities of packed red blood
cells, as so defined) is given one pint of blood for each pint of
blood (or equivalent quantities of packed red blood cells, as so
defined) furnished such individual with respect to which a
deduction is made under this sentence.
(B) The deductible under subparagraph (A) for blood or blood
cells furnished an individual in a year shall be reduced to the
extent that a deductible has been imposed under section 1395l(b) of
this title to blood or blood cells furnished the individual in the
year.
(3) The amount payable for post-hospital extended care services
furnished an individual during any spell of illness shall be
reduced by a coinsurance amount equal to one-eighth of the
inpatient hospital deductible for each day (before the 101st day)
on which he is furnished such services after such services have
been furnished to him for 20 days during such spell.
(4)(A) The amount payable for hospice care shall be reduced -
(i) in the case of drugs and biologicals provided on an
outpatient basis by (or under arrangements made by) the hospice
program, by a coinsurance amount equal to an amount (not to
exceed $5 per prescription) determined in accordance with a drug
copayment schedule (established by the hospice program) which is
related to, and approximates 5 percent of, the cost of the drug
or biological to the program, and
(ii) in the case of respite care provided by (or under
arrangements made by) the hospice program, by a coinsurance
amount equal to 5 percent of the amount estimated by the hospice
program (in accordance with regulations of the Secretary) to be
equal to the amount of payment under section 1395f(i) of this
title to that program for respite care;
except that the total of the coinsurance required under clause (ii)
for an individual may not exceed for a hospice coinsurance period
the inpatient hospital deductible applicable for the year in which
the period began. For purposes of this subparagraph, the term
"hospice coinsurance period" means, for an individual, a period of
consecutive days beginning with the first day for which an election
under section 1395d(d) of this title is in effect for the
individual and ending with the close of the first period of 14
consecutive days on each of which such an election is not in effect
for the individual.
(B) During the period of an election by an individual under
section 1395d(d)(1) of this title, no copayments or deductibles
other than those under subparagraph (A) shall apply with respect to
services furnished to such individual which constitute hospice
care, regardless of the setting in which such services are
furnished.
(b) Inpatient hospital deductible; application
(1) The inpatient hospital deductible for 1987 shall be $520. The
inpatient hospital deductible for any succeeding year shall be an
amount equal to the inpatient hospital deductible for the preceding
calendar year, changed by the Secretary's best estimate of the
payment-weighted average of the applicable percentage increases (as
defined in section 1395ww(b)(3)(B) of this title) which are applied
under section 1395ww(d)(3)(A) of this title for discharges in the
fiscal year that begins on October 1 of such preceding calendar
year, and adjusted to reflect changes in real case mix (determined
on the basis of the most recent case mix data available). Any
amount determined under the preceding sentence which is not a
multiple of $4 shall be rounded to the nearest multiple of $4 (or,
if it is midway between two multiples of $4, to the next higher
multiple of $4).
(2) The Secretary shall promulgate the inpatient hospital
deductible and all coinsurance amounts under this section between
September 1 and September 15 of the year preceding the year to
which they will apply.
(3) The inpatient hospital deductible for a year shall apply to -
(A) the deduction under the first sentence of subsection (a)(1)
of this section for the year in which the first day of inpatient
hospital services or inpatient critical access hospital services
occurs in a spell of illness, and
(B) to the coinsurance amounts under subsection (a) of this
section for inpatient hospital services, inpatient critical
access hospital services and post-hospital extended care services
furnished in that year.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1813, as added Pub. L.
89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 292; amended
Pub. L. 90-248, title I, Secs. 129(c)(3), (4), 135(a), 137(b), Jan.
2, 1968, 81 Stat. 847, 848, 852, 854; Pub. L. 97-35, title XXI,
Secs. 2131(a), 2132(a), Aug. 13, 1981, 95 Stat. 797; Pub. L.
97-248, title I, Sec. 122(e), Sept. 3, 1982, 96 Stat. 361; Pub. L.
99-272, title IX, Sec. 9125(a), Apr. 7, 1986, 100 Stat. 168; Pub.
L. 99-509, title IX, Sec. 9301(a), Oct. 21, 1986, 100 Stat. 1981;
Pub. L. 100-203, title IV, Sec. 4002(f)(3), Dec. 22, 1987, as added
Pub. L. 100-360, title IV, Sec. 411(b)(1)(H)(ii), July 1, 1988, 102
Stat. 769; Pub. L. 100-360, title I, Sec. 102, July 1, 1988, 102
Stat. 685; Pub. L. 101-234, title I, Sec. 101(a), Dec. 13, 1989,
103 Stat. 1979; Pub. L. 103-432, title I, Sec. 102(g)(2), (3), Oct.
31, 1994, 108 Stat. 4404; Pub. L. 105-33, title IV, Sec.
4201(c)(1), Aug. 5, 1997, 111 Stat. 373.)
-MISC1-
AMENDMENTS
1997 - Pub. L. 105-33 substituted "critical access" for "rural
primary care" wherever appearing.
1994 - Subsec. (a)(1). Pub. L. 103-432, Sec. 102(g)(2),
substituted "inpatient hospital services or inpatient rural primary
care hospital services" for "inpatient hospital services" in
introductory provisions and in subpar. (B).
Subsec. (b)(3)(A). Pub. L. 103-432, Sec. 102(g)(2), substituted
"inpatient hospital services or inpatient rural primary care
hospital services" for "inpatient hospital services".
Subsec. (b)(3)(B). Pub. L. 103-432, Sec. 102(g)(3), substituted
"inpatient hospital services, inpatient rural primary care hospital
services" for "inpatient hospital services".
1989 - Subsecs. (a)(1) to (3), (b)(3). Pub. L. 101-234 repealed
Pub. L. 100-360, Sec. 102, subject to an exception for blood
deduction, and provided that the provisions of law amended or
repealed by such section are restored or revived as if such section
had not been enacted, see 1988 Amendment notes below.
1988 - Subsec. (a)(1) to (3). Pub. L. 100-360, Sec. 102(1),
amended pars. (1) to (3) generally, revising and reorganizing
former pars. (1)(A), (B), (2), and (3), as par. (1), consisting of
subpars. (A) to (D), and pars. (2) and (3), each consisting of
subpars. (A) and (B).
Subsec. (b)(1). Pub. L. 100-360, Sec. 411(b)(1)(H)(ii), added
Pub. L. 100-203, Sec. 4002(f)(3), see 1987 Amendment note below.
Subsec. (b)(3). Pub. L. 100-360, Sec. 102(2), struck out par. (3)
which related to application of deductible.
1987 - Subsec. (b)(1). Pub. L. 100-203, Sec. 4002(f)(3), as added
by Pub. L. 100-360, Sec. 411(b)(1)(H)(ii), substituted "Secretary's
best estimate of the payment-weighted average of the applicable
percentage increases (as defined in section 1395ww(b)(3)(B) of this
title) which are applied" for "applicable percentage increase (as
defined in section 1395ww(b)(3)(B) of this title) which is
applied".
1986 - Subsec. (b). Pub. L. 99-509 amended subsec. (b) generally.
Prior to amendment, subsec. (b) read as follows:
"(1) The inpatient hospital deductible which shall be applicable
for the purposes of subsection (a) of this section shall be $40 in
the case of any spell of illness beginning before 1969.
"(2) The Secretary shall, between July 1 and September 15 of
1968, and of each year thereafter, determine and promulgate the
inpatient hospital deductible which shall be applicable for the
purposes of subsection (a) of this section in the case of any
inpatient hospital services or post-hospital extended care services
furnished during the succeeding calendar year. Such inpatient
hospital deductible shall be equal to $45 multiplied by the ratio
of (A) the current average per diem rate for inpatient hospital
services for the calendar year preceding the promulgation, to (B)
the current average per diem rate for such services for 1966. Any
amount determined under the preceding sentence which is not a
multiple of $4 shall be rounded to the nearest multiple of $4 (or,
if it is midway between two multiplies of $4, to the next higher
multiple of $4). The current average per diem rate for any year
shall be determined by the Secretary on the basis of the best
information available to him (at the time the determination is
made) as to the amounts paid under this part on account of
inpatient hospital services furnished during such year, by
hospitals which have agreements in effect under section 1395cc of
this title, to individuals who are entitled to hospital insurance
benefits under section 426 of this title, plus the amount which
would have been so paid but for subsection (a)(1) of this section."
Subsec. (b)(2). Pub. L. 99-272 substituted "September 15" for
"October 1".
1982 - Subsec. (a)(4). Pub. L. 97-248 added par. (4).
1981 - Subsec. (b)(2). Pub. L. 97-35 substituted "any inpatient
hospital services or post-hospital extended care services furnished
during the succeeding calendar year. Such inpatient hospital
deductible shall be equal to $45" for "any spell of illness
beginning during the succeeding calendar year. Such inpatient
hospital deductible shall be equal to $40".
1968 - Subsec. (a)(1). Pub. L. 90-248, Sec. 137(b), designated
existing provisions as subpar. (A) and added subpar. (B) and the
exception provision that the reduction for any day shall not exceed
the charges for that day.
Subsec. (a)(2). Pub. L. 90-248, Sec. 135(a), made the three pint
deductible applicable also to equivalent quantities of packed red
blood cells, as defined by the Secretary under regulations.
Subsec. (a)(2) to (4). Pub. L. 90-248, Sec. 129(c)(3), struck out
par. (2) which provided for reduction of amount payable for
outpatient hospital diagnostic services furnished an individual
during a diagnostic study, and redesignated pars. (3) and (4) as
(2) and (3), respectively.
Subsec. (b)(1), (2). Pub. L. 90-248, Sec. 129(c)(4)(A), (B),
struck out diagnostic studies from application of inpatient
hospital deductible.
EFFECTIVE DATE OF 1997 AMENDMENT
Amendment by Pub. L. 105-33 applicable to services furnished on
or after Oct. 1, 1997, see section 4201(d) of Pub. L. 105-33, set
out as a note under section 1395f of this title.
EFFECTIVE DATE OF 1989 AMENDMENT
Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section
101(d) of Pub. L. 101-234, set out as a note under section 1395c of
this title.
EFFECTIVE DATE OF 1988 AMENDMENT
Amendment by section 102 of Pub. L. 100-360 effective Jan. 1,
1989, except as otherwise provided, and applicable to inpatient
hospital deductible for 1989 and succeeding years, to care and
services furnished on or after Jan. 1, 1989, to premiums for
January 1989 and succeeding months, and to blood or blood cells
furnished on or after Jan. 1, 1989, see section 104(a) of Pub. L.
100-360, set out as a note under section 1395d of this title.
Section 411(b)(1)(H)(iii) of Pub. L. 100-360 provided that: "The
amendment made by clause (ii) [amending Pub. L. 100-203] shall
apply to the inpatient hospital deductible for years beginning with
1989."
EFFECTIVE DATE OF 1986 AMENDMENTS
Section 9301(b) of Pub. L. 99-509 provided that: "The amendment
made by subsection (a) [amending this section] shall apply to
inpatient hospital services and post-hospital extended care
services furnished on or after January 1, 1987, and to the monthly
premium (under part A of title XVIII of the Social Security Act
[this part]) for months beginning with January 1987."
Section 9125(b) of Pub. L. 99-272 provided that: "The amendment
made by this section [amending this section] shall apply to
calendar years after 1985."
EFFECTIVE DATE OF 1982 AMENDMENT
Amendment by Pub. L. 97-248 applicable to hospice care provided
on or after Nov. 1, 1983, see section 122(h)(1) of Pub. L. 97-248,
as amended, set out as a note under section 1395c of this title.
EFFECTIVE DATE OF 1981 AMENDMENT
Section 2131(b) of Pub. L. 97-35 provided that: "The amendment
made by subsection (a) [amending this section] is effective for
inpatient hospital services or post-hospital extended care services
furnished on or after January 1, 1982."
Section 2132(b) of Pub. L. 97-35 provided that: "The amendments
made by subsection (a) [amending this section] shall apply to
inpatient hospital services and post-hospital extended care
services furnished in calendar years beginning with calendar year
1982."
EFFECTIVE DATE OF 1968 AMENDMENT
Amendment by section 129(c)(3), (4) of Pub. L. 90-248 applicable
with respect to services furnished after Mar. 31, 1968, see section
129(d) of Pub. L. 90-248, set out as a note under section 1395d of
this title.
Section 135(d) of Pub. L. 90-248 provided that: "The amendments
made by this section [amending this section and sections 1395l and
1395cc of this title] shall apply with respect to payment for blood
(or packed red blood cells) furnished an individual after December
31, 1967."
Amendment by section 137(b) of Pub. L. 90-248 applicable with
respect to services furnished after Dec. 31, 1967, see section
137(c) of Pub. L. 90-248, set out as a note under section 1395d of
this title.
REPEAL OF 1988 EXPANSION OF MEDICARE PART A BENEFITS
Section 101(a)-(b)(2) of Pub. L. 101-234, as amended by Pub. L.
101-508, title IV, Sec. 4008(m)(1), Nov. 5, 1990, 104 Stat.
1388-53, provided that:
"(a) In General. -
"(1) General rule. - Except as provided in paragraph (2),
sections 101, 102, and 104(d) (other than paragraph (7)) of the
Medicare Catastrophic Coverage Act of 1988 (Public Law 100-360)
[amending this section and sections 1395c, 1395d, 1395f, 1395k,
1395x, 1395cc, and 1395tt of this title] (in this Act referred to
as 'MCCA') are repealed, and the provisions of law amended or
repealed by such sections are restored or revived as if such
section had not been enacted.
"(2) Exception for blood deduction. - The repeal of section
102(1) of MCCA [amending this section] (relating to deductibles
and coinsurance under part A) shall not apply, but only insofar
as such section amended paragraph (2) of section 1813(a) of the
Social Security Act [subsec. (a)(2) of this section] (relating to
a deduction for blood).
"(b) Transition Provisions for Medicare Beneficiaries. -
"(1) Inpatient hospital services and post-hospital extended
care services. - In applying sections 1812 and 1813 of the Social
Security Act [section 1395d of this title and this section], as
restored by subsection (a)(1), with respect to inpatient hospital
services and extended care services provided on or after January
1, 1990 -
"(A) no day before January 1, 1990, shall be counted in
determining the beginning (or period) of a spell of illness;
"(B) with respect to the limitation (other than the
limitation under section 1812(c) of such Act [section 1395d(c)
of this title]) on such services provided in a spell of
illness, days of such services before January 1, 1990, shall
not be counted, except that days of inpatient hospital services
before January 1, 1989, which were applied with respect to an
individual after receiving 90 days of services in a spell of
illness (commonly known as 'lifetime reserve days') shall be
counted;
"(C) the limitation of coverage of extended care services to
post-hospital extended care services shall not apply to an
individual receiving such services from a skilled nursing
facility during a continuous period beginning before (and
including) January 1, 1990, until the end of the period of 30
consecutive days in which the individual is not provided
inpatient hospital services or extended care services; and
"(D) the inpatient hospital deductible under section
1813(a)(1) of such Act [subsec. (a)(1) of this section] shall
not apply -
"(i) in the case of an individual who is receiving
inpatient hospital services during a continuous period
beginning before (and including) January 1, 1990, with
respect to the spell of illness beginning on such date, if
such a deductible was imposed on the individual for a period
of hospitalization during 1989;
"(ii) for a spell of illness beginning during January 1990,
if such a deductible was imposed on the individual for a
period of hospitalization that began in December 1989; and
"(iii) in the case of a spell of illness of an individual
that began before January 1, 1990.
"(2) Hospice care. - The restoration of section 1812(a)(4) of
the Social Security Act [section 1395d(a)(4) of this title],
effected by subsection (a)(1), shall not apply to hospice care
provided during the subsequent period (described in such section
as in effect on December 31, 1989) with respect to which an
election has been made before January 1, 1990."
[Section 4008(m)(1) of Pub. L. 101-508 provided that amendment by
that section to section 101(b)(1)(B) of Pub. L. 101-234, set out
above, is effective as if included in enactment of Medicare
Catastrophic Coverage Repeal Act of 1989, Pub. L. 101-234.]
HOLD HARMLESS PROVISIONS; APPLICATION OF SUBSECTION (A)(1) AND (2)
Section 104(b) of Pub. L. 100-360, as amended by Pub. L. 100-485,
title VI, Sec. 608(d)(3)(B), Oct. 13, 1988, 102 Stat. 2413; Pub. L.
101-234, title I, Sec. 101(b)(3), Dec. 13, 1989, 103 Stat. 1980,
provided that: "In the case of an individual for whom a spell of
illness (as defined in section 1861(a) of the Social Security Act
[section 1395x(a) of this title], as in effect on December 31,
1988) began before January 1, 1989, and had not yet ended as of
such date -
"(1)(A) section 1813(a)(1) of such Act [subsec. (a)(1) of this
section] (as amended by this subtitle [subtitle A (Secs. 101-104)
of title I of Pub. L. 100-360]) shall not apply to services
furnished during that spell of illness during 1989, and
"(B) if that individual begins a period of hospitalization (as
defined in such section) during 1989 after the end of that spell
of illness, the first period of hospitalization during 1989 that
begins after that spell of illness shall be considered to be (for
purposes of such section) the first period of hospitalization
that begins during that year; and
"(2) the amount of any deductible under section 1813(a)(2) of
such Act (as amended by this subtitle) shall be reduced during
that spell of illness during 1989 to the extent the deductible
under such section was applied during the spell of illness."
PROMULGATION OF NEW DEDUCTIBLE
Section 9301(c) of Pub. L. 99-509 directed Secretary of Health
and Human Services to provide, within 30 days after Oct. 21, 1986,
for publication of inpatient hospital deductible, coinsurance
amounts for inpatient hospital services and post-hospital extended
care services, and monthly part A premiums for 1987, as modified
under the amendment of this section made by subsection (a).
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 1395f, 1395l, 1395x,
1395cc, 1395ww, 1395eee, 1396d of this title; title 5 section 8904;
title 38 section 1710.
-End-
-CITE-
42 USC Sec. 1395f 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395f. Conditions of and limitations on payment for services
-STATUTE-
(a) Requirement of requests and certifications
Except as provided in subsections (d) and (g) of this section and
in section 1395mm of this title, payment for services furnished an
individual may be made only to providers of services which are
eligible therefor under section 1395cc of this title and only if -
(1) written request, signed by such individual, except in cases
in which the Secretary finds it impracticable for the individual
to do so, is filed for such payment in such form, in such manner,
and by such person or persons as the Secretary may by regulation
prescribe, no later than the close of the period of 3 calendar
years following the year in which such services are furnished
(deeming any services furnished in the last 3 calendar months of
any calendar year to have been furnished in the succeeding
calendar year) except that where the Secretary deems that
efficient administration so requires, such period may be reduced
to not less than 1 calendar year;
(2) a physician, or, in the case of services described in
subparagraph (B), a physician, or a nurse practitioner or
clinical nurse specialist who does not have a direct or indirect
employment relationship with the facility but is working in
collaboration with a physician, certifies (and recertifies, where
such services are furnished over a period of time, in such cases,
with such frequency, and accompanied by such supporting material,
appropriate to the case involved, as may be provided by
regulations, except that the first of such recertifications shall
be required in each case of inpatient hospital services not later
than the 20th day of such period) that -
(A) in the case of inpatient psychiatric hospital services,
such services are or were required to be given on an inpatient
basis, by or under the supervision of a physician, for the
psychiatric treatment of an individual; and (i) such treatment
can or could reasonably be expected to improve the condition
for which such treatment is or was necessary or (ii) inpatient
diagnostic study is or was medically required and such services
are or were necessary for such purposes;
(B) in the case of post-hospital extended care services, such
services are or were required to be given because the
individual needs or needed on a daily basis skilled nursing
care (provided directly by or requiring the supervision of
skilled nursing personnel) or other skilled rehabilitation
services, which as a practical matter can only be provided in a
skilled nursing facility on an inpatient basis, for any of the
conditions with respect to which he was receiving inpatient
hospital services (or services which would constitute inpatient
hospital services if the institution met the requirements of
paragraphs (6) and (9) of section 1395x(e) of this title) prior
to transfer to the skilled nursing facility or for a condition
requiring such extended care services which arose after such
transfer and while he was still in the facility for treatment
of the condition or conditions for which he was receiving such
inpatient hospital services;
(C) in the case of home health services, such services are or
were required because the individual is or was confined to his
home (except when receiving items and services referred to in
section 1395x(m)(7) of this title) and needs or needed skilled
nursing care (other than solely venipuncture for the purpose of
obtaining a blood sample) on an intermittent basis or physical
or speech therapy or, in the case of an individual who has been
furnished home health services based on such a need and who no
longer has such a need for such care or therapy, continues or
continued to need occupational therapy; a plan for furnishing
such services to such individual has been established and is
periodically reviewed by a physician; and such services are or
were furnished while the individual was under the care of a
physician; or
(D) in the case of inpatient hospital services in connection
with the care, treatment, filling, removal, or replacement of
teeth or structures directly supporting teeth, the individual,
because of his underlying medical condition and clinical status
or because of the severity of the dental procedure, requires
hospitalization in connection with the provision of such
services;
(3) with respect to inpatient hospital services (other than
inpatient psychiatric hospital services) which are furnished over
a period of time, a physician certifies that such services are
required to be given on an inpatient basis for such individual's
medical treatment, or that inpatient diagnostic study is
medically required and such services are necessary for such
purpose, except that (A) such certification shall be furnished
only in such cases, with such frequency, and accompanied by such
supporting material, appropriate to the cases involved, as may be
provided by regulations, and (B) the first such certification
required in accordance with clause (A) shall be furnished no
later than the 20th day of such period;
(4) in the case of inpatient psychiatric hospital services, the
services are those which the records of the hospital indicate
were furnished to the individual during periods when he was
receiving (A) intensive treatment services, (B) admission and
related services necessary for a diagnostic study, or (C)
equivalent services;
(5) with respect to inpatient hospital services furnished such
individual after the 20th day of a continuous period of such
services, there was not in effect, at the time of admission of
such individual to the hospital, a decision under section
1395cc(d) of this title (based on a finding that utilization
review of long-stay cases is not being made in such hospital);
(6) with respect to inpatient hospital services or
post-hospital extended care services furnished such individual
during a continuous period, a finding has not been made (by the
physician members of the committee or group, as described in
section 1395x(k)(4) of this title, including any finding made in
the course of a sample or other review of admissions to the
institution) pursuant to the system of utilization review that
further inpatient hospital services or further post-hospital
extended care services, as the case may be, are not medically
necessary; except that, if such a finding has been made, payment
may be made for such services furnished before the 4th day after
the day on which the hospital or skilled nursing facility, as the
case may be, received notice of such finding;
(7) in the case of hospice care provided an individual -
(A)(i) in the first 90-day period -
(I) the individual's attending physician (as defined in
section 1395x(dd)(3)(B) of this title), and
(II) the medical director (or physician member of the
interdisciplinary group described in section 1395x(dd)(2)(B)
of this title) of the hospice program providing (or arranging
for) the care,
each certify in writing at the beginning of the period, that
the individual is terminally ill (as defined in section
1395x(dd)(3)(A) of this title), and
(ii) in a subsequent 90- or 60-day period, the medical
director or physician described in clause (i)(II) recertifies
at the beginning of the period that the individual is
terminally ill;
(B) a written plan for providing hospice care with respect to
such individual has been established (before such care is
provided by, or under arrangements made by, that hospice
program) and is periodically reviewed by the individual's
attending physician and by the medical director (and the
interdisciplinary group described in section 1395x(dd)(2)(B) of
this title) of the hospice program; and
(C) such care is being or was provided pursuant to such plan
of care; and
(8) in the case of inpatient critical access hospital services,
a physician certifies that the individual may reasonably be
expected to be discharged or transferred to a hospital within 96
hours after admission to the critical access hospital.
To the extent provided by regulations, the certification and
recertification requirements of paragraph (2) shall be deemed
satisfied where, at a later date, a physician, nurse practitioner,
or clinical nurse specialist (as the case may be) makes
certification of the kind provided in subparagraph (A), (B), (C),
or (D) of paragraph (2) (whichever would have applied), but only
where such certification is accompanied by such medical and other
evidence as may be required by such regulations. With respect to
the physician certification required by paragraph (2) for home
health services furnished to any individual by a home health agency
(other than an agency which is a governmental entity) and with
respect to the establishment and review of a plan for such
services, the Secretary shall prescribe regulations which shall
become effective no later than July 1, 1981, and which prohibit a
physician who has a significant ownership interest in, or a
significant financial or contractual relationship with, such home
health agency from performing such certification and from
establishing or reviewing such plan, except that such prohibition
shall not apply with respect to a home health agency which is a
sole community home health agency (as determined by the Secretary).
For purposes of the preceding sentence, service by a physician as
an uncompensated officer or director of a home health agency shall
not constitute having a significant ownership interest in, or a
significant financial or contractual relationship with, such
agency. For purposes of paragraph (2)(C), an individual shall be
considered to be "confined to his home" if the individual has a
condition, due to an illness or injury, that restricts the ability
of the individual to leave his or her home except with the
assistance of another individual or the aid of a supportive device
(such as crutches, a cane, a wheelchair, or a walker), or if the
individual has a condition such that leaving his or her home is
medically contraindicated. While an individual does not have to be
bedridden to be considered "confined to his home", the condition of
the individual should be such that there exists a normal inability
to leave home, that leaving home requires a considerable and taxing
effort by the individual. The certification regarding terminal
illness of an individual under paragraph (7) shall be based on the
physician's or medical director's clinical judgment regarding the
normal course of the individual's illness. Any absence of an
individual from the home attributable to the need to receive health
care treatment, including regular absences for the purpose of
participating in therapeutic, psychosocial, or medical treatment in
an adult day-care program that is licensed or certified by a State,
or accredited, to furnish adult day-care services in the State
shall not disqualify an individual from being considered to be
"confined to his home". Any other absence of an individual from the
home shall not so disqualify an individual if the absence is of
infrequent or of relatively short duration. For purposes of the
preceding sentence, any absence for the purpose of attending a
religious service shall be deemed to be an absence of infrequent or
short duration.
(b) Amount paid to provider of services
The amount paid to any provider of services (other than a hospice
program providing hospice care, other than a critical access
hospital providing inpatient critical access hospital services, and
other than a home health agency with respect to durable medical
equipment) with respect to services for which payment may be made
under this part shall, subject to the provisions of sections 1395e
(!1) 1395ww, and 1395fff of this title, be -
(1) except as provided in paragraph (3), the lesser of (A) the
reasonable cost of such services, as determined under section
1395x(v) of this title and as further limited by section
1395rr(b)(2)(B) of this title, or (B) the customary charges with
respect to such services;
(2) if such services are furnished by a public provider of
services, or by another provider which demonstrates to the
satisfaction of the Secretary that a significant portion of its
patients are low-income (and requests that payment be made under
this paragraph), free of charge or at nominal charges to the
public, the amount determined on the basis of those items
(specified in regulations prescribed by the Secretary) included
in the determination of such reasonable cost which the Secretary
finds will provide fair compensation to such provider for such
services; or
(3) if some or all of the hospitals in a State have been
reimbursed for services (for which payment may be made under this
part) pursuant to a reimbursement system approved as a
demonstration project under section 402 of the Social Security
Amendments of 1967 or section 222 of the Social Security
Amendments of 1972, if the rate of increase in such hospitals in
their costs per hospital inpatient admission of individuals
entitled to benefits under this part over the duration of such
project was equal to or less than such rate of increase for
admissions of such individuals with respect to all hospitals in
the United States during such period, and if either the State has
legislative authority to operate such system and the State elects
to have reimbursement to such hospitals made in accordance with
this paragraph or the system is operated through a voluntary
agreement of hospitals and such hospitals elect to have
reimbursement to those hospitals made in accordance with this
paragraph, then the Secretary may provide for continuation of
reimbursement to such hospitals under such system until the
Secretary determines that -
(A) a third-party payor reimburses such a hospital on a basis
other than under such system, or
(B) the aggregate rate of increase from January 1, 1981, to
the most recent date for which annual data are available in
such hospitals in costs per hospital inpatient admission of
individuals entitled to benefits under this part is greater
than such rate of increase for admissions of such individuals
with respect to all hospitals in the United States for such
period.
In the case of any State which has had such a demonstration project
reimbursement system in continuous operation since July 1, 1977,
the Secretary shall provide under paragraph (3) for continuation of
reimbursement to hospitals in the State under such system until the
first day of the 37th month beginning after the date the Secretary
determines and notifies the Governor of the State that either of
the conditions described in subparagraph (A) or (B) of such
paragraph has occurred. If, by the end of such 36-month period, the
Secretary determines, based on evidence submitted by the Governor
of the State, that neither of the conditions described in
subparagraph (A) or (B) of paragraph (3) continues to apply, the
Secretary shall continue without interruption payment to hospitals
in the State under the State's system. If, by the end of such
36-month period, the Secretary determines, based on such evidence,
that either of the conditions described in subparagraph (A) or (B)
of such paragraph continues to apply, the Secretary shall (i)
collect any net excess reimbursement to hospitals in the State
during such 36-month period (basing such net excess reimbursement
on the net difference, if any, in the rate of increase in costs per
hospital inpatient admission under the State system compared to the
rate of increase in such costs with respect to all hospitals in the
United States over the 36-month period, as measured by including
the cumulative savings under the State system based on the
difference in the rate of increase in costs per hospital inpatient
admission under the State system as compared to the rate of
increase in such costs with respect to all hospitals in the United
States between January 1, 1981, and the date of the Secretary's
initial notice), and (ii) provide a reasonable period, not to
exceed 2 years, for transition from the State system to the
national payment system.
(c) No payments to Federal providers of services
Subject to section 1395qq of this title, no payment may be made
under this part (except under subsection (d) or subsection (h) of
this section) to any Federal provider of services, except a
provider of services which the Secretary determines is providing
services to the public generally as a community institution or
agency; and no such payment may be made to any provider of services
for any item or service which such provider is obligated by a law
of, or a contract with, the United States to render at public
expense.
(d) Payments for emergency hospital services
(1) Payments shall also be made to any hospital for inpatient
hospital services furnished in a calendar year, by the hospital or
under arrangements (as defined in section 1395x(w) of this title)
with it, to an individual entitled to hospital insurance benefits
under section 426 of this title even though such hospital does not
have an agreement in effect under this subchapter if (A) such
services were emergency services, (B) the Secretary would be
required to make such payment if the hospital had such an agreement
in effect and otherwise met the conditions of payment hereunder,
and (C) such hospital has elected to claim payments for all such
inpatient emergency services and for the emergency outpatient
services referred to in section 1395n(b) of this title furnished
during such year. Such payments shall be made only in the amounts
provided under subsection (b) of this section and then only if such
hospital agrees to comply, with respect to the emergency services
provided, with the provisions of section 1395cc(a) of this title.
(2) Payment may be made on the basis of an itemized bill to an
individual entitled to hospital insurance benefits under section
426 of this title for services described in paragraph (1) which are
emergency services if (A) payment cannot be made under paragraph
(1) solely because the hospital does not elect to claim such
payment, and (B) such individual files application (submitted
within such time and in such form and manner and by such person,
and containing and supported by such information as the Secretary
shall by regulations prescribe) for reimbursement.
(3) The amounts payable under the preceding paragraph with
respect to services described therein shall, subject to the
provisions of section 1395e of this title, be equal to 60 percent
of the hospital's reasonable charges for routine services furnished
in the accommodations occupied by the individual or in semiprivate
accommodations (as defined in section 1395x(v)(4) of this title),
whichever is less, plus 80 percent of the hospital's reasonable
charges for ancillary services. If separate charges for routine and
ancillary services are not made by the hospital, reimbursement may
be based on two-thirds of the hospital's reasonable charges for the
services received but not to exceed the charges which would have
been made if the patient had occupied semiprivate accommodations.
For purposes of the preceding provisions of this paragraph, the
term "routine services" shall mean the regular room, dietary, and
nursing services, minor medical and surgical supplies and the use
of equipment and facilities for which a separate charge is not
customarily made; the term "ancillary services" shall mean those
special services for which charges are customarily made in addition
to routine services.
(e) Payment for inpatient hospital services prior to notification
of noneligibility
Notwithstanding that an individual is not entitled to have
payment made under this part for inpatient hospital services
furnished by any hospital, payment shall be made to such hospital
(unless it elects not to receive such payment or, if payment has
already been made by or on behalf of such individual, fails to
refund such payment within the time specified by the Secretary) for
such services which are furnished to the individual prior to
notification to such hospital from the Secretary of his lack of
entitlement, if such payments are precluded only by reason of
section 1395d of this title and if such hospital complies with the
requirements of and regulations under this subchapter with respect
to such payments, has acted in good faith and without knowledge of
such lack of entitlement, and has acted reasonably in assuming
entitlement existed. Payment under the preceding sentence may not
be made for services furnished an individual pursuant to any
admission after the 6th elapsed day (not including as an elapsed
day Saturday, Sunday, or a legal holiday) after the day on which
such admission occurred.
(f) Payment for certain inpatient hospital services furnished
outside United States
(1) Payment shall be made for inpatient hospital services
furnished to an individual entitled to hospital insurance benefits
under section 426 of this title by a hospital located outside the
United States, or under arrangements (as defined in section
1395x(w) of this title) with it, if -
(A) such individual is a resident of the United States, and
(B) such hospital was closer to, or substantially more
accessible from, the residence of such individual than the
nearest hospital within the United States which was adequately
equipped to deal with, and was available for the treatment of,
such individual's illness or injury.
(2) Payment may also be made for emergency inpatient hospital
services furnished to an individual entitled to hospital insurance
benefits under section 426 of this title by a hospital located
outside the United States if -
(A) such individual was physically present -
(i) in a place within the United States; or
(ii) at a place within Canada while traveling without
unreasonable delay by the most direct route (as determined by
the Secretary) between Alaska and another State;
at the time the emergency which necessitated such inpatient
hospital services occurred, and
(B) such hospital was closer to, or substantially more
accessible from, such place than the nearest hospital within the
United States which was adequately equipped to deal with, and was
available for the treatment of, such individual's illness or
injury.
(3) Payment shall be made in the amount provided under subsection
(b) of this section to any hospital for the inpatient hospital
services described in paragraph (1) or (2) furnished to an
individual by the hospital or under arrangements (as defined in
section 1395x(w) of this title) with it if (A) the Secretary would
be required to make such payment if the hospital had an agreement
in effect under this subchapter and otherwise met the conditions of
payment hereunder, (B) such hospital elects to claim such payment,
and (C) such hospital agrees to comply, with respect to such
services, with the provisions of section 1395cc(a) of this title.
(4) Payment for the inpatient hospital services described in
paragraph (1) or (2) furnished to an individual entitled to
hospital insurance benefits under section 426 of this title may be
made on the basis of an itemized bill to such individual if (A)
payment for such services cannot be made under paragraph (3) solely
because the hospital does not elect to claim such payment, and (B)
such individual files application (submitted within such time and
in such form and manner and by such person, and continuing and
supported by such information as the Secretary shall by regulations
prescribe) for reimbursement. The amount payable with respect to
such services shall, subject to the provisions of section 1395e of
this title, be equal to the amount which would be payable under
subsection (d)(3) of this section.
(g) Payments to physicians for services rendered in teaching
hospitals
For purposes of services for which the reasonable cost thereof is
determined under section 1395x(v)(1)(D) of this title (or would be
if section 1395ww of this title did not apply), payment under this
part shall be made to such fund as may be designated by the
organized medical staff of the hospital in which such services were
furnished or, if such services were furnished in such hospital by
the faculty of a medical school, to such fund as may be designated
by such faculty, but only if -
(1) such hospital has an agreement with the Secretary under
section 1395cc of this title, and
(2) the Secretary has received written assurances that (A) such
payment will be used by such fund solely for the improvement of
care of hospital patients or for educational or charitable
purposes and (B) the individuals who were furnished such services
or any other persons will not be charged for such services (or if
charged, provision will be made for return of any moneys
incorrectly collected).
(h) Payment for specified hospital services provided in Department
of Veterans Affairs hospitals; amount of payment
(1) Payments shall also be made to any hospital operated by the
Department of Veterans Affairs for inpatient hospital services
furnished in a calendar year by the hospital, or under arrangements
(as defined in section 1395x(w) of this title) with it, to an
individual entitled to hospital benefits under section 426 of this
title even though the hospital is a Federal provider of services if
(A) the individual was not entitled to have the services furnished
to him free of charge by the hospital, (B) the individual was
admitted to the hospital in the reasonable belief on the part of
the admitting authorities that the individual was a person who was
entitled to have the services furnished to him free of charge, (C)
the authorities of the hospital, in admitting the individual, and
the individual, acted in good faith, and (D) the services were
furnished during a period ending with the close of the day on which
the authorities operating the hospital first became aware of the
fact that the individual was not entitled to have the services
furnished to him by the hospital free of charge, or (if later)
ending with the first day on which it was medically feasible to
remove the individual from the hospital by discharging him
therefrom or transferring him to a hospital which has in effect an
agreement under this subchapter.
(2) Payment for services described in paragraph (1) shall be in
an amount equal to the charge imposed by the Secretary of Veterans
Affairs for such services, or (if less) the amount that would be
payable for such services under subsection (b) of this section and
section 1395ww of this title (as estimated by the Secretary). Any
such payment shall be made to the entity to which payment for the
services involved would have been payable, if payment for such
services had been made by the individual receiving the services
involved (or by another private person acting on behalf of such
individual).
(i) Payment for hospice care
(1)(A) Subject to the limitation under paragraph (2) and the
provisions of section 1395e(a)(4) of this title and except as
otherwise provided in this paragraph, the amount paid to a hospice
program with respect to hospice care for which payment may be made
under this part shall be an amount equal to the costs which are
reasonable and related to the cost of providing hospice care or
which are based on such other tests of reasonableness as the
Secretary may prescribe in regulations (including those authorized
under section 1395x(v)(1)(A) of this title), except that no payment
may be made for bereavement counseling and no reimbursement may be
made for other counseling services (including nutritional and
dietary counseling) as separate services.
(B) Notwithstanding subparagraph (A), for hospice care furnished
on or after April 1, 1986, the daily rate of payment per day for
routine home care shall be $63.17 and the daily rate of payment for
other services included in hospice care shall be the daily rate of
payment recognized under subparagraph (A) as of July 1, 1985,
increased by $10.
(C)(i) With respect to routine home care and other services
included in hospice care furnished on or after January 1, 1990, and
on or before September 30, 1990, the payment rates for such care
and services shall be 120 percent of such rates in effect as of
September 30, 1989.
(ii) With respect to routine home care and other services
included in hospice care furnished during a subsequent fiscal year,
the payment rates for such care and services shall be the payment
rates in effect under this subparagraph during the previous fiscal
year increased by -
(I) for a fiscal year ending on or before September 30, 1993,
the market basket percentage increase (as defined in section
1395ww(b)(3)(B)(iii) of this title) for the fiscal year;
(II) for fiscal year 1994, the market basket percentage
increase for the fiscal year minus 2.0 percentage points;
(III) for fiscal year 1995, the market basket percentage
increase for the fiscal year minus 1.5 percentage points;
(IV) for fiscal year 1996, the market basket percentage
increase for the fiscal year minus 1.5 percentage points;
(V) for fiscal year 1997, the market basket percentage increase
for the fiscal year minus 0.5 percentage point;
(VI) for each of fiscal years 1998 through 2002, the market
basket percentage increase for the fiscal year involved minus 1.0
percentage points, plus, in the case of fiscal year 2001, 5.0
percentage points; and
(VII) for a subsequent fiscal year, the market basket
percentage increase for the fiscal year.
(2)(A) The amount of payment made under this part for hospice
care provided by (or under arrangements made by) a hospice program
for an accounting year may not exceed the "cap amount" for the year
(computed under subparagraph (B)) multiplied by the number of
medicare beneficiaries in the hospice program in that year
(determined under subparagraph (C)).
(B) For purposes of subparagraph (A), the "cap amount" for a year
is $6,500, increased or decreased, for accounting years that end
after October 1, 1984, by the same percentage as the percentage
increase or decrease, respectively, in the medical care expenditure
category of the Consumer Price Index for All Urban Consumers
(United States city average), published by the Bureau of Labor
Statistics, from March 1984 to the fifth month of the accounting
year.
(C) For purposes of subparagraph (A), the "number of medicare
beneficiaries" in a hospice program in an accounting year is equal
to the number of individuals who have made an election under
subsection (d) of this section with respect to the hospice program
and have been provided hospice care by (or under arrangements made
by) the hospice program under this part in the accounting year,
such number reduced to reflect the proportion of hospice care that
each such individual was provided in a previous or subsequent
accounting year or under a plan of care established by another
hospice program.
(D) A hospice program shall submit claims for payment for hospice
care furnished in an individual's home under this subchapter only
on the basis of the geographic location at which the service is
furnished, as determined by the Secretary.
(3) Hospice programs providing hospice care for which payment is
made under this subsection shall submit to the Secretary such data
with respect to the costs for providing such care for each fiscal
year, beginning with fiscal year 1999, as the Secretary determines
necessary.
(j) Elimination of lesser-of-cost-or-charges provision
(1) The lesser-of-cost-or-charges provisions (described in
paragraph (2)) will not apply in the case of services provided by a
class of provider of services if the Secretary determines and
certifies to Congress that the failure of such provisions to apply
to the services provided by that class of providers will not result
in any increase in the amount of payments made for those services
under this subchapter. Such change will take effect with respect to
services furnished, or cost reporting periods of providers, on or
after such date as the Secretary shall provide in the
certification. Such change for a class of provider shall be
discontinued if the Secretary determines and notifies Congress that
such change has resulted in an increase in the amount of payments
made under this subchapter for services provided by that class of
provider.
(2) The lesser-of-cost-or-charges provisions referred to in
paragraph (1) are as follows:
(A) Clause (B) of paragraph (1) and paragraph (2) of subsection
(b) of this section.
(B) Section 1395m(a)(1)(B) of this title.
(C) So much of subparagraph (A) of section 1395l(a)(2) of this
title as provides for payment other than of the reasonable cost
of such services, as determined under section 1395x(v) of this
title.
(D) Subclause (II) of clause (i) and clause (ii) of section
1395l(a)(2)(B) of this title.
(k) Payments to home health agencies for durable medical equipment
The amount paid to any home health agency with respect to durable
medical equipment for which payment may be made under this part
shall be the amount described in section 1395m(a)(1) of this title.
(l) Payment for inpatient critical access hospital services
The amount of payment under this part for inpatient critical
access hospital services is the reasonable costs of the critical
access hospital in providing such services.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1814, as added Pub. L.
89-87, title I, Sec. 102(a), July 30, 1965, 79 Stat. 294; amended
Pub. L. 90-248, title I, Secs. 126(a), 129(c)(5), (6)(A), 143(c),
Jan. 2, 1968, 81 Stat. 846, 848, 857; Pub. L. 92-603, title II,
Secs. 211(a), 226(c)(1), 227(b), 228(a), 233(a), 234(g)(1), 238(a),
247(a), 256(a), 278(a)(1)-(3), (b)(4), (17), 281(e), Oct. 30, 1972,
86 Stat. 1382, 1404, 1405, 1407, 1411, 1413, 1416, 1425, 1447,
1453, 1454, 1456; Pub. L. 93-233, Sec. 18(k)(1), (2), Dec. 31,
1973, 87 Stat. 970; Pub. L. 94-437, title IV, Sec. 401(a), Sept.
30, 1976, 90 Stat. 1408; Pub. L. 95-142, Sec. 23(a), (b), Oct. 25,
1977, 91 Stat. 1208; Pub. L. 95-292, Sec. 4(f), June 13, 1978, 92
Stat. 315; Pub. L. 96-499, title IX, Secs. 903(a), 930(e), (f),
931(b), 936(b), 941(a), (b), Dec. 5, 1980, 94 Stat. 2614, 2631,
2633, 2640, 2641; Pub. L. 97-35, title XXI, Secs. 2121(b),
2122(a)(1), Aug. 13, 1981, 95 Stat. 796; Pub. L. 97-248, title I,
Secs. 101(c)(1), 122(c)(1), (2), Sept. 3, 1982, 96 Stat. 335, 357,
358; Pub. L. 97-448, title III, Sec. 309(b)(7), Jan. 12, 1983, 96
Stat. 2409; Pub. L. 98-21, title VI, Secs. 601(d), 602(b), (c),
Apr. 20, 1983, 97 Stat. 152, 163; Pub. L. 98-90, Aug. 29, 1983, 97
Stat. 606; Pub. L. 98-369, div. B, title III, Secs. 2308(b)(2)(A),
2321(a), (f), 2335(a), 2336(a), (b), 2354(b)(1), (c)(1)(A), July
18, 1984, 98 Stat. 1074, 1084, 1085, 1090, 1091, 1100, 1102; Pub.
L. 98-617, Secs. 1(a), 3(a)(3), (b)(1), Nov. 8, 1984, 98 Stat.
3294, 3295; Pub. L. 99-272, title IX, Sec. 9123(b), Apr. 7, 1986,
100 Stat. 168; Pub. L. 100-203, title IV, Secs. 4008(b)(1),
4024(a), 4062(d)(1), Dec. 22, 1987, 101 Stat. 1330-55, 1330-73,
1330-108; Pub. L. 100-360, title I, Sec. 104(d)(2), 102 Stat. 688;
Pub. L. 101-234, title I, Sec. 101(a), Dec. 13, 1989, 103 Stat.
1979; Pub. L. 101-239, title VI, Secs. 6003(g)(3)(B)(ii), (iii),
6005(a), (b), 6028, Dec. 19, 1989, 103 Stat. 2152, 2160, 2161,
2168; Pub. L. 101-508, title IV, Secs. 4006(b), 4008(i)(3),
(m)(3)(A), Nov. 5, 1990, 104 Stat. 1388-43, 1388-51, 1388-53; Pub.
L. 102-54, Sec. 13(q)(3)(A)(iii), (iv), (B)(iv), June 13, 1991, 105
Stat. 279; Pub. L. 103-66, title XIII, Sec. 13504, Aug. 10, 1993,
107 Stat. 579; Pub. L. 103-432, title I, Secs. 102(a)(3), (d),
106(b)(1)(A), 110(d)(1), Oct. 31, 1994, 108 Stat. 4402, 4403, 4405,
4408; Pub. L. 105-33, title IV, Secs. 4201(c)(1), (3), 4441,
4442(a), 4443(b)(2), 4448, 4603(c)(1), 4615(a), Aug. 5, 1997, 111
Stat. 373, 422-424, 470, 475; Pub. L. 106-554, Sec. 1(a)(6) [title
III, Secs. 321(a), (e), 322(a)(1), title V, Sec. 507(a)(1)], Dec.
21, 2000, 114 Stat. 2763, 2763A-500, 2763A-501, 2763A-532.)
-REFTEXT-
REFERENCES IN TEXT
Section 402 of the Social Security Amendments of 1967, referred
to in subsec. (b)(3), means section 402 of Pub. L. 90-248, which
amended sections 1395b-1 and 1395ll of this title.
Section 222 of the Social Security Amendments of 1972, referred
to in subsec. (b)(3), means section 222 of Pub. L. 92-603, which
amended sections 1395b-1 and 1395ll of this title and enacted a
provision set out as a note under section 1395b-1 of this title.
-MISC1-
AMENDMENTS
2000 - Subsec. (a). Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec.
507(a)(1)(B)], inserted at end "Any absence of an individual from
the home attributable to the need to receive health care treatment,
including regular absences for the purpose of participating in
therapeutic, psychosocial, or medical treatment in an adult
day-care program that is licensed or certified by a State, or
accredited, to furnish adult day-care services in the State shall
not disqualify an individual from being considered to be 'confined
to his home'. Any other absence of an individual from the home
shall not so disqualify an individual if the absence is of
infrequent or of relatively short duration. For purposes of the
preceding sentence, any absence for the purpose of attending a
religious service shall be deemed to be an absence of infrequent or
short duration."
Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 507(a)(1)(A)], which
directed amendment of subsec. (a) by striking out in the last
sentence ", and that absences of the individual from home are
infrequent or of relatively short duration, or are attributable to
the need to receive medical treatment", was executed by striking
out that language after "taxing effort by the individual" in the
penultimate sentence, to reflect the probable intent of Congress
and the amendment by Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec.
322(a)(1)]. See note below.
Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 322(a)(1)],
inserted at end "The certification regarding terminal illness of an
individual under paragraph (7) shall be based on the physician's or
medical director's clinical judgment regarding the normal course of
the individual's illness."
Subsec. (a)(7)(A)(ii). Pub. L. 106-554, Sec. 1(a)(6) [title III,
Sec. 321(e)], substituted a semicolon for period at end.
Subsec. (i)(1)(C)(ii)(VI). Pub. L. 106-554, Sec. 1(a)(6) [title
III, Sec. 321(a)], inserted ", plus, in the case of fiscal year
2001, 5.0 percentage points" before semicolon.
1997 - Subsec. (a)(2)(C). Pub. L. 105-33, Sec. 4615(a), inserted
"(other than solely venipuncture for the purpose of obtaining a
blood sample)" after "skilled nursing care".
Subsec. (a)(7)(A)(i). Pub. L. 105-33, Secs. 4443(b)(2)(A), 4448,
in concluding provisions, substituted "at the beginning of the
period" for " not later than 2 days after hospice care is initiated
(or, if each certify verbally not later than 2 days after hospice
care is initiated, not later than 8 days after such care is
initiated)" and inserted "and" at end.
Subsec. (a)(7)(A)(ii). Pub. L. 105-33, Sec. 4443(b)(2)(B),
substituted "60-day" for "30-day" and substituted a period for ",
and" at end.
Subsec. (a)(7)(A)(iii). Pub. L. 105-33, Sec. 4443(b)(2)(C),
struck out cl. (iii) which read as follows: "in a subsequent
extension period, the medical director or physician described in
clause (i)(II) recertifies at the beginning of the period that the
individual is terminally ill;".
Subsec. (a)(8). Pub. L. 105-33, Sec. 4201(c)(1), (3)(A),
substituted "critical access" for "rural primary care" in two
places and "96 hours" for "72 hours".
Subsec. (b). Pub. L. 105-33, Sec. 4603(c)(1), substituted
"1395ww, and 1395fff of this title" for "and 1395ww of this title"
in introductory provisions.
Pub. L. 105-33, Sec. 4201(c)(1), substituted "critical access"
for "rural primary care" in two places in introductory provisions.
Subsec. (i)(1)(C)(ii)(V) to (VII). Pub. L. 105-33, Sec. 4441(a),
struck out "and" at end of subcl. (V), added subcl. (VI), and
redesignated former subcl. (VI) as (VII).
Subsec. (i)(2)(D). Pub. L. 105-33, Sec. 4442(a), added subpar.
(D).
Subsec. (i)(3). Pub. L. 105-33, Sec. 4441(b), added par. (3).
Subsec. (l). Pub. L. 105-33, Sec. 4201(c)(3)(B), amended heading
and text of subsec. (l) generally. Prior to amendment, text read as
follows:
"(1) The amount of payment under this part for inpatient rural
primary care hospital services -
"(A) in the case of the first 12-month cost reporting period
for which the facility operates as such a hospital, is the
reasonable costs of the facility in providing inpatient rural
primary care hospital services during such period, as such costs
are determined on a per diem basis, and
"(B) in the case of a later reporting period, is the per diem
payment amount established under this paragraph for the preceding
12-month cost reporting period, increased by the applicable
percentage increase under section 1395ww(b)(3)(B)(i) of this
title for that particular cost reporting period applicable to
hospitals located in a rural area.
The payment amounts otherwise determined under this paragraph shall
be reduced, to the extent necessary, to avoid duplication of any
payment made under section 1395i-4(a)(2) of this title (or under
section 4005(e) of the Omnibus Budget Reconciliation Act of 1987)
to cover the provision of inpatient rural primary care hospital
services.
"(2) The Secretary shall develop a prospective payment system for
determining payment amounts for inpatient rural primary care
hospital services under this part furnished on or after January 1,
1996."
1994 - Subsec. (a)(5). Pub. L. 103-432, Sec. 106(b)(1)(A), struck
out "and with respect to post-hospital extended care services
furnished after such day of a continuous period of such services as
may be prescribed in or pursuant to regulations" after "continuous
period of such services", "or skilled nursing facility, as the case
may be" after "such individual to the hospital", and "or facility"
after "made in such hospital".
Subsec. (a)(8). Pub. L. 103-432, Sec. 102(a)(3), substituted "the
individual may reasonably be expected to be discharged or
transferred to a hospital within 72 hours after admission to the
rural primary care hospital." for "such services were required to
be immediately furnished on a temporary, inpatient basis."
Subsec. (i)(1)(C)(i). Pub. L. 103-432, Sec. 110(d)(1),
substituted "September 30, 1990," for "September 30, 1990,,".
Subsec. (l)(2). Pub. L. 103-432, Sec. 102(d), substituted
"January 1, 1996" for "January 1, 1993".
1993 - Subsec. (i)(1)(C)(ii). Pub. L. 103-66 substituted
"increased by - " and subcls. (I) to (VI) for "increased by the
market basket percentage increase (as defined in section
1395ww(b)(3)(B)(iii) of this title) otherwise applicable to
discharges occurring in the fiscal year."
1991 - Subsec. (h). Pub. L. 102-54 substituted "Department of
Veterans Affairs" for "Veterans' Administration" in heading and
par. (1) and "Secretary of Veterans Affairs" for "Veterans'
Administration" in par. (2).
1990 - Subsec. (a)(7)(A)(iii). Pub. L. 101-508, Sec. 4006(b),
added cl. (iii).
Subsec. (b)(3). Pub. L. 101-508, Sec. 4008(i)(3), substituted
"January 1, 1981" for "October 1, 1983" in subpar. (B) substituted
"37th month" for "seventh month" in sentence following subpar. (B),
and inserted at end provisions setting forth procedures to be
followed by Secretary at end of 36-month period.
Subsec. (i)(1)(C)(i). Pub. L. 101-508, Sec. 4008(m)(3)(A),
substituted "on or after January 1, 1990, and on or before
September 30, 1990," for "during fiscal year 1990".
1989 - Subsec. (a). Pub. L. 101-239, Sec. 6028(2), substituted "a
physician, nurse practitioner, or clinical nurse specialist (as the
case may be) makes" for "a physician makes" in first sentence of
concluding provisions.
Subsec. (a)(2). Pub. L. 101-239, Sec. 6028(1), substituted "a
physician, or, in the case of services described in subparagraph
(B), a physician, or a nurse practitioner or clinical nurse
specialist who does not have a direct or indirect employment
relationship with the facility but is working in collaboration with
a physician," for "a physician" after "(2)".
Subsec. (a)(2)(B), (6). Pub. L. 101-234 repealed Pub. L. 100-360,
Sec. 104(d)(2)(A), (B), and provided that the provisions of law
amended or repealed by such section are restored or revived as if
such section had not been enacted, see 1988 Amendment notes below.
Subsec. (a)(7)(A)(i). Pub. L. 101-239, Sec. 6005(b), substituted
"certify in writing, not later than 2 days after hospice care is
initiated (or, if each certify verbally not later than 2 days after
hospice care is initiated, not later than 8 days after such care is
initiated)," for "certify, not later than two days after hospice
care is initiated," in concluding provisions.
Subsec. (a)(7)(A)(iii). Pub. L. 101-234 repealed Pub. L. 100-360,
Sec. 104(d)(2)(C), and provided that the provisions of law amended
or repealed by such section are restored or revived as if such
section had not been enacted, see 1988 Amendment note below.
Subsec. (a)(8). Pub. L. 101-239, Sec. 6003(g)(3)(B)(ii), added
par. (8).
Subsec. (b). Pub. L. 101-239, Sec. 6003(g)(3)(B)(iii)(I),
inserted ", other than a rural primary care hospital providing
inpatient rural primary care hospital services," after "providing
hospice care" in introductory provisions.
Subsec. (d)(3). Pub. L. 101-234 repealed Pub. L. 100-360, Sec.
104(d)(2)(D), and provided that the provisions of law amended or
repealed by such section are restored or revived as if such section
had not been enacted, see 1988 Amendment note below.
Subsec. (i)(1)(A). Pub. L. 101-239, Sec. 6005(a)(1), inserted
"and except as otherwise provided in this paragraph" after "section
1395e(a)(4) of this title".
Subsec. (i)(1)(C). Pub. L. 101-239, Sec. 6005(a)(2), added
subpar. (C) and struck out former subpar. (C) which read as
follows: "With respect to care and services furnished on or after
October 1, 1986, the Secretary shall, not less often than annually,
review and make appropriate adjustments to the payment rate for
routine home care and the payment rates for other services included
in hospice care based on the costs that are reasonable and related
to the costs of furnishing such care and services. The Secretary
shall report to Congress on October 1 each year on such review and
such adjustments and on the adequacy of the rates under this
paragraph to ensure participation by an adequate number of hospice
programs under this subchapter."
Subsec. (l). Pub. L. 101-239, Sec. 6003(g)(3)(B)(iii)(II), added
subsec. (l).
1988 - Subsec. (a)(2)(B). Pub. L. 100-360, Sec. 104(d)(2)(A),
(B), struck out "post-hospital" after "in the case of" and ", for
any of the conditions with respect to which he was receiving
inpatient hospital services (or services which would constitute
inpatient hospital services if the institution met the requirements
of paragraphs (6) and (9) of section 1395x(e) of this title) prior
to transfer to the skilled nursing facility or for a condition
requiring such extended care services which arose after such
transfer and while he was still in the facility for treatment of
the condition or conditions for which he was receiving such
inpatient hospital services" before semicolon at end.
Subsec. (a)(6). Pub. L. 100-360, Sec. 104(d)(2)(A), struck out
"post-hospital" before "extended care services" in two places.
Subsec. (a)(7)(A)(iii). Pub. L. 100-360, Sec. 104(d)(2)(C), added
cl. (iii) which read as follows: "in a subsequent extension period,
the medical director or physician described in clause (i)(II)
recertifies at the beginning of the period that the individual is
terminally ill;".
Subsec. (d)(3). Pub. L. 100-360, Sec. 104(d)(2)(D), substituted
"equal to 100 percent" for "equal to 60 percent" and "plus 100
percent" for "plus 80 percent" and struck out "two-thirds of" after
"based on".
1987 - Subsec. (a). Pub. L. 100-203, Sec. 4024(a), inserted two
sentences at end clarifying "confined to his home" for purposes of
par. (2)(C).
Subsec. (b)(3)(B). Pub. L. 100-203, Sec. 4008(b)(1), substituted
"aggregate rate of increase from October 1, 1983, to the most
recent date for which annual data are available" for "rate of
increase for the previous three-year period".
Subsec. (j)(2)(B). Pub. L. 100-203, Sec. 4062(d)(1)(A),
substituted "Section 1395m(a)(1)(B) of this title" for "Subsection
(k)(1)(B) of this section".
Subsec. (k). Pub. L. 100-203, Sec. 4062(d)(1)(B), substituted
"the amount described in section 1395m(a)(1) of this title." for a
dash and former pars. (1) and (2) which read as follows:
"(1) the lesser of -
"(A) the reasonable cost of such equipment, as determined under
section 1395x(v) of this title, or
"(B) the customary charges with respect to such equipment,
less the amount the home health agency may charge as described in
section 1395cc(a)(2)(A)(ii) of this title, but in no case may the
payment for such equipment exceed 80 percent of such reasonable
cost, or
"(2) if such equipment is furnished by a public home health
agency, or by another home health agency which demonstrates to the
satisfaction of the Secretary that a significant portion of its
patients are low-income (and requests that payment be made under
this paragraph), free of charge or at nominal charge to the public,
80 percent of the amount which the Secretary finds will provide
fair compensation to the home health agency."
1986 - Subsec. (i)(1)(B). Pub. L. 99-272, Sec. 9123(b)(1),
amended subpar. (B) generally. Prior to amendment, subpar. (B) read
as follows: "Notwithstanding subparagraph (A), the rate of payment
per day for routine home care furnished during fiscal year 1985
shall be $53.17."
Subsec. (i)(1)(C). Pub. L. 99-272, Sec. 9123(b)(2), substituted
"1986" for "1985".
1984 - Subsec. (a). Pub. L. 98-369, Sec. 2354(b)(1), as amended
by Pub. L. 98-617, Sec. 3(a)(3), in concluding provisions,
substituted "contractual" for "contractural".
Pub. L. 98-369, Sec. 2336(b), inserted before period at end of
third sentence ", except that such prohibition shall not apply with
respect to a home health agency which is a sole community home
health agency (as determined by the Secretary)".
Pub. L. 98-369, Sec. 2336(a), inserted sentence at end that for
purposes of the preceding sentence, service by a physician as an
uncompensated officer or director of a home health agency shall not
constitute having a significant ownership interest in, or a
significant financial or contractual relationship with, such
agency.
Pub. L. 98-369, Sec. 2335(a)(4), in concluding provisions,
substituted "or (D)" for "(D), or (E)".
Subsec. (a)(2)(B) to (E). Pub. L. 98-369, Sec. 2335(a)(1),
redesignated subpars. (C) to (E) as (B) to (D), respectively, and
struck out former subpar. (B) which provided that payment could be
made only if a physician certified, in the case of inpatient
tuberculosis hospital services, that such services were required to
be given on an inpatient basis, by or under the supervision of a
physician, for the treatment of an individual for tuberculosis; and
that such treatment could reasonably be expected to improve the
condition for which such treatment was necessary or render the
condition noncommunicable.
Subsec. (a)(3). Pub. L. 98-369, Sec. 2335(a)(2), struck out "and
inpatient tuberculosis hospital services" after "psychiatric
hospital services".
Subsec. (a)(5) to (8). Pub. L. 98-369, Sec. 2335(a)(3),
redesignated pars. (6) to (8) as (5) to (7), respectively, and
struck out former par. (5) which had provided that payment would be
made only if, in the case of inpatient tuberculosis hospital
services, the services were those which the records of the hospital
indicate were furnished to the individual during periods when he
was receiving treatment which could reasonably be expected to
improve his condition or render it noncommunicable.
Subsec. (b). Pub. L. 98-369, Sec. 2321(a)(1), inserted in
provisions preceding par. (1) "and other than a home health agency
with respect to durable medical equipment" after "hospice care".
Subsec. (b)(2). Pub. L. 98-369, Sec. 2308(b)(2)(A), inserted ",
or by another provider which demonstrates to the satisfaction of
the Secretary that a significant portion of its patients are
low-income (and requests that payment be made under this
paragraph),".
Subsec. (b)(3). Pub. L. 98-369, Sec. 2354(c)(1)(A), amended
directory language of Pub. L. 96-449, Sec. 903(a)(4), resulting in
no change in text. See 1980 Amendment note below.
Subsec. (i)(1). Pub. L. 98-617, Sec. 1(a), designated existing
provisions as subpar. (A) and added subpars. (B) and (C).
Subsec. (j)(2)(B) to (D). Pub. L. 98-369, Sec. 2321(f), added
subpar. (B) and redesignated former subpars. (B) and (C) as (C) and
(D), respectively.
Subsec. (k). Pub. L. 98-369, Sec. 2321(a)(2), added subsec. (k).
Subsec. (k)(2). Pub. L. 98-617, Sec. 3(b)(1), inserted ", or by
another home health agency which demonstrates to the satisfaction
of the Secretary that a significant portion of its patients are
low-income (and requests that payment be made under this
paragraph)," after "public home health agency" and "80 percent of"
before "the amount".
1983 - Subsec. (g). Pub. L. 98-21, Sec. 602(b), inserted "(or
would be if section 1395ww of this title did not apply)" after
"section 1395x(v)(1)(D) of this title".
Subsec. (h)(2). Pub. L. 98-21, Sec. 602(c), substituted "the
amount that would be payable for such services under subsection (b)
of this section and section 1395ww of this title" for "the
reasonable costs for such services".
Subsec. (i)(1). Pub. L. 97-448 inserted "made" before "for
bereavement counseling".
Subsec. (i)(2)(A). Pub. L. 98-90, Sec. 1(1), struck out "located
in a region (as defined by the Secretary)" after "a hospice
program" and "for the region" after " 'the cap amount' ".
Subsec. (i)(2)(B). Pub. L. 98-90, Sec. 1(2), amended subpar. (B)
generally, substituting provisions establishing a hospice
reimbursement cap amount of $6,500, indexed by the medical care
component of the Consumer Price Index, for provisions which had
established a cap of 40% of the estimated regional average medicare
expenditure per beneficiary in the regular medicare program during
the six months of life for persons dying of cancer.
Subsec. (j). Pub. L. 98-21, Sec. 601(d)(2), added subsec. (j) by
transferring and redesignating provisions formerly classified to
subsec. (d) of section 1395ww of this title.
Subsec. (j)(2)(A). Pub. L. 98-21, Sec. 601(d)(1), substituted
"subsection (b) of this section" for "section 1395f(b) of this
title".
1982 - Subsec. (a)(8). Pub. L. 97-248, Sec. 122(c)(1), added par.
(8).
Subsec. (b). Pub. L. 97-248, Sec. 101(c)(1), substituted
"sections 1395e and 1395ww" for "section 1395e" in provisions
preceding par. (1), and substituted "until the first day of the
seventh month beginning after the date the Secretary determines and
notifies the Governor of the State" for "until the Secretary
determines" in provisions following par. (3).
Pub. L. 97-248, Sec. 122(c)(2)(A), inserted "(other than a
hospice program providing hospice care)" after "The amount paid to
any provider of services".
Subsec. (i). Pub. L. 97-248, Sec. 122(c)(2)(B), added subsec.
(i).
1981 - Subsec. (a)(2)(D). Pub. L. 97-35, Sec. 2122(a)(1),
substituted "needs or needed skilled nursing care on an
intermittent basis or physical or speech therapy or, in the case of
an individual who has been furnished home health services based on
such a need and who no longer has such a need for such care or
therapy, continues or continued to need occupational therapy" for
"needed skilled nursing care on an intermittent basis, or physical,
occupational, or speech therapy".
Subsec. (a)(2)(F). Pub. L. 97-35, Sec. 2121(b), struck out
subpar. (F) which provided that in the case of alcohol
detoxification facility services, such services were required on an
inpatient basis (based upon an examination by such certifying
physician made prior to initiation of alcohol detoxification).
1980 - Subsec. (a). Pub. L. 96-499, Sec. 930(e), inserted
provision at end of subsec. (a) authorizing the Secretary to
prescribe regulations to prohibit significantly interested
physicians from performing the physician certification required by
par. (2) for home health services.
Subsec. (a)(2)(D). Pub. L. 96-499, Sec. 930(f), substituted "home
health services" for "post-hospital home health services" and
"physical, occupational, or speech" for "physical or speech" and
deleted ", for any of the conditions with respect to which he was
receiving inpatient hospital services (or services which would
constitute inpatient hospital services if the institution met the
requirements of paragraphs (6) and (9) of section 1395x(e) of this
title) or post-hospital extended care services" after "therapy".
Subsec. (a)(2)(E). Pub. L. 96-499, Sec. 936(b), inserted "or
because of the severity of the dental procedure" and substituted
"such services" for "such dental services".
Subsec. (a)(2)(F). Pub. L. 96-499, Sec. 931(b), added subpar.
(F).
Subsec. (b)(1). Pub. L. 96-499, Sec. 903(a)(1), inserted "except
as provided in paragraph (3),".
Subsec. (b)(3). Pub. L. 96-499, Sec. 903(a)(4), as amended by
Pub. L. 98-369, Sec. 2354(c)(1)(A), added par. (3).
Subsec. (c). Pub. L. 96-499, Sec. 941(b), substituted "subsection
(h)" for "subsection (j)".
Subsecs. (h) to (j). Pub. L. 96-499, Sec. 941(a), struck out
subsecs. (h) and (i) and redesignated subsec. (j) as (h).
1978 - Subsec. (b)(1). Pub. L. 95-292 inserted "and as further
limited by section 1395rr(b)(2)(B) of this title" after "section
1395x(v) of this title".
1977 - Subsec. (c). Pub. L. 95-142, Sec. 23(a), inserted
reference to subsec. (j) of this section.
Subsec. (j). Pub. L. 95-142, Sec. 23(b), added subsec. (j).
1976 - Subsec. (c). Pub. L. 94-437 substituted "Subject to
section 1395qq of this title, no payment" for "No payment".
1973 - Subsec. (a)(2)(E). Pub. L. 93-233, Sec. 18(k)(1),
substituted "the care, treatment, filling, removal, or replacement
of teeth or structures directly supporting teeth, the individual,
because of his underlying medical condition and clinical status,
requires hospitalization in connection with the provision of such
dental services" for "a dental procedure, the individual suffers
from impairments of such severity as to require hospitalization".
Subsec. (a), last sentence. Pub. L. 93-233, Sec. 18(k)(2),
inserted reference to subpar. (E) of par. (2).
1972 - Subsec. (a). Pub. L. 92-603, Secs. 226(c)(1), 227(b)(1),
inserted reference to subsec. (g) of this section and section
1395mm of this title in provisions preceding par. (1).
Subsec. (a)(1). Pub. L. 92-603, Sec. 281(e), placed a 3-year time
limitation on the time within which a written request for payment
is filed, with provision for reduction of the limit to 1 year.
Subsec. (a)(2)(C). Pub. L. 92-603, Secs. 234(g)(1), 247(a),
278(a)(1), substituted "because the individual needs or needed on a
daily basis skilled nursing care (provided directly by or requiring
the supervision of skilled nursing personnel) or other skilled
rehabilitation services, which as a practical matter can only be
provided in a skilled nursing facility on an inpatient basis," for
"on an inpatient basis because the individual needs or needed
skilled nursing care on a continuing basis", "skilled nursing
facility" for "extended care facility", and "paragraphs (6) and (9)
of section 1395x(e) of this title" for "paragraphs (6) and (8) of
section 1395x(e) of this title".
Subsec. (a)(2)(D). Pub. L. 92-603, Sec. 234(g)(1), substituted
reference to par. (9) of section 1395x(e) of this title for
reference to par. (8) of section 1395x(e) of this title.
Subsec. (a)(2)(E). Pub. L. 92-603, Sec. 256(a), added subpar.
(E).
Subsec. (a)(6). Pub. L. 92-603, Sec. 278(a)(2), substituted
"skilled nursing facility" for "extended care facility".
Subsec. (a)(7). Pub. L. 92-603, Secs. 238(a), 278(a)(3), inserted
", including any finding made in the course of a sample or other
review of admissions to the institution" after "as described in
section 1395x(k)(4) of this title" in the parenthetical provisions
covering the finding not made by the committee or group, and
substituted "skilled nursing facility" for "extended care
facility".
Subsec. (b). Pub. L. 92-603, Sec. 233(a), substituted pars. (1)
and (2) for provisions describing the amount payable as the
reasonable cost determined under section 1395x(v) of this title.
Subsec. (f). Pub. L. 92-603, Sec. 211(a), designated existing
provisions as par. (2), added pars. (1) and (3), and in par. (2) as
so redesignated inserted provisions covering individuals physically
present at a place within Canada while traveling without
unreasonable delay by the most direct route between Alaska and
another State.
Subsec. (g). Pub. L. 92-603, Sec. 227(b)(2), added subsec. (g).
Subsec. (h). Pub. L. 92-603, Secs. 228(a), 278(b)(4), (17), added
subsec. (h) and substituted "skilled nursing facility" for
"extended care facility".
Subsec. (i). Pub. L. 92-603, Sec. 228(a), added subsec. (i).
1968 - Subsec. (a). Pub. L. 90-248, Secs. 126(a)(5),
129(c)(5)(B), struck out references to former subpars. (E) and (F)
in last sentence.
Subsec. (a)(2)(A) to (E). Pub. L. 90-248, Sec. 126(a)(1), (2),
struck out subpar. (A) which provided that there be a physician's
certification of medical necessity for admissions to hospitals
other than psychiatric or tuberculosis institutions, and
redesignated subpars. (B) to (E) as (A) to (D), respectively.
Subsec. (a)(2)(F). Pub. L. 90-248, Sec. 129(c)(5)(A), struck out
subpar. (F) which provided that there be a physician's
certification for services furnished to outpatients.
Subsec. (a)(3) to (7). Pub. L. 90-248, Sec. 126(a)(3), (4), added
par. (3) and redesignated former pars. (3) to (6) as (4) to (7),
respectively.
Subsec. (d). Pub. L. 90-248, Sec. 129(c)(6)(A), struck out
reference to outpatient hospital diagnostic services from
provisions requiring payment for emergency hospital services.
Subsec. (d)(1) to (3). Pub. L. 90-248, Sec. 143(c), designated
existing provisions as par. (1), inserted "in a calendar year"
after "furnished" in first sentence of par. (1), added subpar. (C)
to par. (1), and added pars. (2) and (3).
EFFECTIVE DATE OF 2000 AMENDMENT
Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 321(b)], Dec. 21,
2000, 114 Stat. 2763, 2763A-500, provided that: "The amendment made
by subsection (a) [amending this section] shall apply to hospice
care furnished on or after April 1, 2001. In applying clause (ii)
of section 1814(i)(1)(C) of the Social Security Act (42 U.S.C.
1395f(i)(1)(C)) beginning with fiscal year 2002, the payment rates
in effect under such section during the period beginning on April
1, 2001, and ending on September 30, shall be treated as the
payment rates in effect during fiscal year 2001."
Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 322(a)(2)], Dec.
21, 2000, 114 Stat. 2763, 2763A-501, provided that: "The amendment
made by paragraph (1) [amending this section] shall apply to
certifications made on or after the date of the enactment of this
Act [Dec. 21, 2000]."
Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 507(a)(2)], Dec. 21,
2000, 114 Stat. 2763, 2763A-532, provided that: "The amendments
made by paragraph (1) [amending this section and section 1395n of
this title] shall apply to home health services furnished on or
after the date of the enactment of this Act [Dec. 21, 2000]."
EFFECTIVE DATE OF 1997 AMENDMENT
Section 4201(d) of Pub. L. 105-33 provided that: "The amendments
made by this section [amending this section and sections 1320a-7a,
1320a-7b, 1320b-4, 1320b-8, 1395d, 1395e, 1395h, 1395i-4, 1395k to
1395n, 1395u, 1395x, 1395y, 1395aa, 1395cc, 1395dd, and 1395ww of
this title] shall apply to services furnished on or after October
1, 1997."
Pub. L. 105-33, title IV, Sec. 4442(b), Aug. 5, 1997, 111 Stat.
423, as amended by Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title
III, Sec. 321(i)], Nov. 29, 1999, 113 Stat. 1536, 1501A-366,
provided that: "The amendment made by subsection (a) [amending this
section] applies to items and services furnished on or after
October 1, 1997."
Amendment by sections 4441, 4443(b)(2), and 4448 of Pub. L.
105-33 applicable to benefits provided on or after Aug. 5, 1997,
except as otherwise provided, see section 4449 of Pub. L. 105-33,
set out as a note under section 1395d of this title.
Amendment by section 4603(c)(1) of Pub. L. 105-33 applicable to
cost reporting periods beginning on or after Oct. 1, 1999, except
as otherwise provided, see section 4603(d) of Pub. L. 105-33, set
out as an Effective Date note under section 1395fff of this title.
Section 4615(b) of Pub. L. 105-33 provided that: "The amendments
made by subsection (a) [amending this section and section 1395n of
this title] apply to home health services furnished after the
6-month period beginning after the date of enactment of this Act
[Aug. 5, 1997]."
EFFECTIVE DATE OF 1994 AMENDMENT
Amendment by section 106(b)(1)(A) of Pub. L. 103-432 effective as
if included in the enactment of Pub. L. 100-203, see section
106(b)(2) of Pub. L. 103-432, set out as a note under section
1395cc of this title.
EFFECTIVE DATE OF 1990 AMENDMENT
Amendment by section 4006(b) of Pub. L. 101-508 applicable with
respect to care and services furnished on or after Jan. 1, 1990,
see section 4006(c) of Pub. L. 101-508, set out as a note under
section 1395d of this title.
EFFECTIVE DATE OF 1989 AMENDMENTS
Section 6005(c) of Pub. L. 101-239, as amended by Pub. L.
101-508, title IV, Sec. 4008(m)(3)(B), Nov. 5, 1990, 104 Stat.
1388-54, provided that: "The amendments made by subsections (a) and
(b) [amending this section] shall become effective with respect to
care and services furnished on or after January 1, 1990."
Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section
101(d) of Pub. L. 101-234, set out as a note under section 1395c of
this title.
EFFECTIVE DATE OF 1988 AMENDMENT
Amendment by Pub. L. 100-360 effective Jan. 1, 1989, except as
otherwise provided, and applicable to inpatient hospital deductible
for 1989 and succeeding years, to care and services furnished on or
after Jan. 1, 1989, to premiums for January 1989 and succeeding
months, and to blood or blood cells furnished on or after Jan. 1,
1989, see section 104(a) of Pub. L. 100-360, set out as a note
under section 1395d of this title.
EFFECTIVE DATE OF 1987 AMENDMENT
Section 4008(b)(2) of Pub. L. 100-203 provided that: "The
amendment made by paragraph (1) [amending this section] shall take
effect on the date of the enactment of this Act [Dec. 22, 1987]."
Section 4024(c) of Pub. L. 100-203 provided that: "The amendments
made by subsections (a) and (b) [amending this section and section
1395n of this title] shall apply to items and services provided on
or after January 1, 1988."
Section 4062(e) of Pub. L. 100-203, as amended by Pub. L.
101-508, title IV, Sec. 4152(h), Nov. 5, 1990, 104 Stat. 1388-80,
provided that: "The amendments made by this section [enacting
section 1395m of this title, amending this section and sections
1395k, 1395l, and 1395cc of this title, and repealing section
1395zz of this title] shall apply to covered items (other than
oxygen and oxygen equipment) furnished on or after January 1, 1989
and to oxygen and oxygen equipment furnished on or after June 1,
1989."
[Section 4152(h) of Pub. L. 101-508 provided that amendment by
that section to section 4062(e) of Pub. L. 100-203, set out above,
is effective as if included in enactment of Omnibus Budget
Reconciliation Act of 1987, Pub. L. 100-203.]
EFFECTIVE DATE OF 1984 AMENDMENTS
Section 1(b) of Pub. L. 98-617 provided that: "The amendments
made by this Act [probably means section 1 of Pub. L. 98-617,
amending this section] shall apply to routine home care and other
services included in hospice care furnished on or after October 1,
1984."
Section 3(c) of Pub. L. 98-617 provided that: "The amendments
made by this section [amending this section and sections 1395l,
1395n, 1395r, 1395u, 1395x, 1395rr, 1395ww, 1396a, and 1396b of
this title and amending provisions set out as notes under sections
1395h and 1395mm of this title] shall be effective as if they had
been originally included in the Deficit Reduction Act of 1984 [Pub.
L. 98-369]."
Section 2321(g) of Pub. L. 98-369 provided that: "The amendments
made by this section [enacting section 1395zz of this title and
amending this section and sections 1395l, 1395x, and 1395cc of this
title] shall apply to items and services furnished on or after the
date of the enactment of this Act [July 18, 1984]."
Section 2335(g) of Pub. L. 98-369 provided that: "The amendments
made by this section [amending this section and sections 1395x,
1395z, 1395cc, 1396a, and 1396d of this title] shall become
effective on the date of the enactment of this Act [July 18,
1984]."
Section 2336(c)(1) of Pub. L. 98-369 provided that: "The
amendments made by subsection (a) [amending this section and
section 1395n of this title] shall apply to certifications and
plans of care made or established on or after the date of the
enactment of this Act [July 18, 1984]."
Amendment by section 2354(b)(1) of Pub. L. 98-369 effective July
18, 1984, but not to be construed as changing or affecting any
right, liability, status, or interpretation which existed (under
the provisions of law involved) before that date, see section
2354(e)(1) of Pub. L. 98-369, set out as a note under section
1320a-1 of this title.
Amendment by section 2354(c)(1)(A) of Pub. L. 98-369 effective as
if originally included in Pub. L. 96-499, see section 2354(e)(2) of
Pub. L. 98-369, set out as a note under section 1320a-1 of this
title.
EFFECTIVE DATE OF 1983 AMENDMENTS
Amendment by Pub. L. 98-21 applicable to items and services
furnished by or under arrangement with a hospital beginning with
its first cost reporting period that begins on or after Oct. 1,
1983, any change in a hospital's cost reporting period made after
November 1982 to be recognized for such purposes only if the
Secretary finds good cause therefor, see section 604(a)(1) of Pub.
L. 98-21, set out as a note under section 1395ww of this title.
Amendment by Pub. L. 97-448 effective as if originally included
as a part of this section as this section was amended by the Tax
Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248, see
section 309(c)(2) of Pub. L. 97-448, set out as a note under
section 426-1 of this title.
EFFECTIVE DATE OF 1982 AMENDMENT
Amendment by section 122(c)(1), (2) of Pub. L. 97-248 applicable
to hospice care provided on or after Nov. 1, 1983, see section
122(h)(1) of Pub. L. 97-248, as amended, set out as a note under
section 1395c of this title.
EFFECTIVE DATE OF 1981 AMENDMENT
Amendment by section 2121(b) of Pub. L. 97-35 applicable to
services furnished in detoxification facilities for inpatient stays
beginning on or after the tenth day after Aug. 13, 1981, see
section 2121(i) of Pub. L. 97-35, set out as a note under section
1395d of this title.
Section 2122(b) of Pub. L. 97-35 provided that: "The amendments
made by this section [amending this section and section 1395n of
this title] shall apply to services furnished pursuant to plans of
treatment implemented after the third month beginning after the
date of the enactment of this Act [Aug. 13, 1981]."
EFFECTIVE DATE OF 1980 AMENDMENT
Amendment by section 930(e), (f) of Pub. L. 96-499 effective with
respect to services furnished on or after July 1, 1981, see section
930(s)(1) of Pub. L. 96-499, set out as a note under section 1395x
of this title.
Amendment by section 931(b) of Pub. L. 96-499 effective Apr. 1,
1981, see section 931(e) of Pub. L. 96-499, set out as a note under
section 1395d of this title.
Section 936(d) of Pub. L. 96-499 provided that: "The amendments
made by this section [amending this section and sections 1395x and
1395y of this title] shall apply with respect to services provided
on or after July 1, 1981."
Section 941(c) of Pub. L. 96-499 provided that: "The amendments
made by this section [amending this section] shall take effect on
January 1, 1981."
EFFECTIVE DATE OF 1978 AMENDMENT
Amendment by Pub. L. 95-292 effective with respect to services,
supplies, and equipment furnished after the third calendar month
beginning after June 13, 1978, except that provisions for the
implementation of an incentive reimbursement system for dialysis
services furnished in facilities and providers to become effective
with respect to a facility's or provider's first accounting period
beginning after the last day of the twelfth month following the
month of June 1978, and except that provisions for reimbursement
rates for home dialysis to become effective on Apr. 1, 1979, see
section 6 of Pub. L. 95-292, set out as a note under section 426 of
this title.
EFFECTIVE DATE OF 1977 AMENDMENT
Section 23(c) of Pub. L. 95-142 provided that: "The amendments
made by this section [amending this section] shall apply to
inpatient hospital services furnished on and after July 1, 1974."
EFFECTIVE DATE OF 1973 AMENDMENT
Section 18(z-3)(2) of Pub. L. 93-233 provided that: "The
amendments made by subsection (k) [amending this section and
section 1395y of this title] shall be effective with respect to
admissions subject to the provisions of section 1814(a)(2) of the
Social Security Act [subsec. (a)(2) of this section] which occur
after December 31, 1972."
EFFECTIVE DATE OF 1972 AMENDMENT
Section 211(d) of Pub. L. 92-603 provided that: "The amendments
made by this section [amending this section and sections 1395l,
1395u, 1395x, and 1395y of this title] shall apply to services
furnished with respect to admissions occurring after December 31,
1972."
Amendment by section 226(c)(1) of Pub. L. 92-603 effective with
respect to services provided on or after July 1, 1973, see section
226(f) of Pub. L. 92-603, set out as an Effective Date note under
section 1395mm of this title.
Amendment by section 227(b) of Pub. L. 92-603 applicable with
respect to accounting periods beginning after June 30, 1973, see
section 227(g) of Pub. L. 92-603, set out as a note under section
1395x of this title.
Section 228(b) of Pub. L. 92-603 provided that: "The amendment
made by subsection (a) [amending this section] and any regulations
adopted pursuant to such amendment shall apply with respect to
plans of care initiated on or after January 1, 1973, and with
respect to admission to skilled nursing facilities and home health
plans initiated on or after such date."
Section 233(f) of Pub. L. 92-603 provided that: "The amendments
made by subsections (a) and (b) [amending this section and section
1395l of this title] shall apply to services furnished by
hospitals, extended care facilities, and home health agencies in
accounting periods beginning after December 31, 1972. The
amendments made by subsections (c), (d), and (e) [amending sections
706, 709, and 1396b of this title] shall apply with respect to
services furnished by hospitals in accounting periods beginning
after December 31, 1972." See, also, section 16 of Pub. L. 93-233,
set out below.
Amendment by section 234(g)(1) of Pub. L. 92-603 applicable with
respect to providers of services for fiscal years beginning after
fifth month following October 1972, see section 234(i) of Pub. L.
92-603, set out as a note under section 1395x of this title.
Section 238(b) of Pub. L. 92-603 provided that: "The amendment
made by subsection (a) [amending this section] shall apply with
respect to services furnished after the second month following the
month in which this Act is enacted [October 1972]."
Section 247(c) of Pub. L. 92-603 provided that: "The amendments
made by this section [amending this section and section 1396d of
this title] shall be effective with respect to services furnished
after December 31, 1972."
Section 256(d) of Pub. L. 92-603 provided that: "The amendments
made by this section [amending this section and sections 1395x and
1395y of this title] shall apply with respect to admissions
occurring after the second month following the month in which this
Act is enacted [October 1972]."
Amendment by section 281(e) of Pub. L. 92-603 applicable in the
case of services furnished (or deemed to have been furnished) after
1970, see section 281(g) of Pub. L. 92-603, set out as a note under
section 1395gg of this title.
EFFECTIVE DATE OF 1968 AMENDMENT
Section 126(c) of Pub. L. 90-248 provided that: "The amendments
made by this section [amending this section and section 1395n of
this title] shall apply with respect to services furnished after
the date of the enactment of this Act [Jan. 2, 1968]."
Amendment by section 129(c)(5), (6)(A) of Pub. L. 90-248
applicable with respect to services furnished after Jan. 2, 1968,
see section 129(d) of Pub. L. 90-248, set out as a note under
section 1395d of this title.
Amendment by section 143(c) of Pub. L. 90-248 applicable with
respect to services furnished with respect to admissions occurring
after Dec. 31, 1967, and to outpatient hospital diagnostic services
furnished after Dec. 31, 1967, and before Apr. 1, 1968, see section
143(d) of Pub. L. 90-248, set out as a note under section 1395d of
this title.
STUDY AND REPORT ON EFFECT OF 2000 AMENDMENT
Pub. L. 106-554, Sec. 1(a)(6) [title V, Sec. 507(b)], Dec. 21,
2000, 114 Stat. 2763, 2763A-532, provided that:
"(1) In general. - The Comptroller General of the United States
shall conduct an evaluation of the effect of the amendment
[amending this section and section 1395n of this title] on the cost
of and access to home health services under the medicare program
under title XVIII of the Social Security Act [this subchapter].
"(2) Report. - Not later than 1 year after the date of the
enactment of this Act [Dec. 21, 2000], the Comptroller General
shall submit to Congress a report on the study conducted under
paragraph (1)."
STUDY AND REPORT ON PHYSICIAN CERTIFICATION REQUIREMENT FOR HOSPICE
BENEFITS
Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 322(b)], Dec. 21,
2000, 114 Stat. 2763, 2763A-501, provided that:
"(1) Study. - The Secretary of Health and Human Services shall
conduct a study to examine the appropriateness of the certification
regarding terminal illness of an individual under section
1814(a)(7) of the Social Security Act (42 U.S.C. 1395f(a)(7)) that
is required in order for such individual to receive hospice
benefits under the medicare program under title XVIII of such Act
[this subchapter]. In conducting such study, the Secretary shall
take into account the effect of the amendment made by subsection
(a) [amending this section].
"(2) Report. - Not later than 2 years after the date of the
enactment of this Act [Dec. 21, 2000], the Secretary of Health and
Human Services shall submit to Congress a report on the study
conducted under paragraph (1), together with any recommendations
for legislation that the Secretary deems appropriate."
TEMPORARY INCREASE IN PAYMENT FOR HOSPICE CARE
Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 321(c)], Dec. 21,
2000, 114 Stat. 2763, 2763A-501, provided that: "The provisions of
this section [amending this section and enacting provisions set out
as a note under this section] shall have no effect on the
application of section 131 of BBRA [Pub. L. 106-113, Sec.
1000(a)(6) [title I, Sec. 131], set out as a note below]."
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title I, Sec. 131],
Nov. 29, 1999, 113 Stat. 1536, 1501A-333, provided that:
"(a) Increase for Fiscal Years 2001 and 2002. - For purposes of
payments under section 1814(i)(1)(C) of the Social Security Act (42
U.S.C. 1395f(i)(1)(C)) for hospice care furnished during fiscal
years 2001 and 2002, the Secretary of Health and Human Services
shall increase the payment rate in effect (but for this section)
for -
"(1) fiscal year 2001, by 0.5 percent, and
"(2) fiscal year 2002, by 0.75 percent.
"(b) Additional Payment Not Built Into the Base. - The Secretary
of Health and Human Services shall not include any additional
payment made under this subsection (a) in updating the payment
rate, as increased by the applicable market basket percentage
increase for the fiscal year involved under section
1814(i)(1)(C)(ii) of that Act (42 U.S.C. 1395f(i)(1)(C)(ii))."
STUDY AND REPORT TO CONGRESS REGARDING MODIFICATION OF PAYMENT
RATES FOR HOSPICE CARE
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title I, Sec. 132],
Nov. 29, 1999, 113 Stat. 1536, 1501A-333, provided that:
"(a) Study. - The Comptroller General of the United States shall
conduct a study to determine the feasibility and advisability of
updating the payment rates and the cap amount determined with
respect to a fiscal year under section 1814(i) of the Social
Security Act (42 U.S.C. 1395f(i)) for routine home care and other
services included in hospice care. Such study shall examine the
cost factors used to determine such rates and such amount and shall
evaluate whether such factors should be modified, eliminated, or
supplemented with additional cost factors.
"(b) Report. - Not later than one year after the date of
enactment of this Act [Nov. 29, 1999], the Comptroller General of
the United States shall submit to Congress a report on the study
conducted under subsection (a), together with any recommendations
for legislation that the Comptroller General determines to be
appropriate as a result of such study."
STUDY OF METHODS TO COMPENSATE HOSPICES FOR HIGH-COST CARE
Section 6016 of Pub. L. 101-239 directed Secretary of Health and
Human Services to conduct a study of high-cost hospice care
provided to medicare beneficiaries under the medicare program,
evaluate the ability of hospice programs participating in the
medicare program to provide such high-cost care to such patients,
develop methods to compensate such programs for providing such
high-cost care, and submit, not later than Apr. 1, 1991, a report
to the Committee on Ways and Means of the House of Representatives
and the Committee on Finance of the Senate on the study, including
in the report any recommendations developed by the Secretary to
compensate hospice programs for providing high-cost hospice care to
medicare beneficiaries.
CONTINUATION OF BAD DEBT RECOGNITION FOR HOSPITAL SERVICES
Section 4008(c) of Pub. L. 100-203, as amended by Pub. L.
100-647, title VIII, Sec. 8402, Nov. 10, 1987, 102 Stat. 3798; Pub.
L. 101-239, title VI, Sec. 6023(a), Dec. 19, 1989, 103 Stat. 2167,
provided that: "In making payments to hospitals under title XVIII
of the Social Security Act [this subchapter], the Secretary of
Health and Human Services shall not make any change in the policy
in effect on August 1, 1987, with respect to payment under title
XVIII of the Social Security Act to providers of service for
reasonable costs relating to unrecovered costs associated with
unpaid deductible and coinsurance amounts incurred under such title
(including criteria for what constitutes a reasonable collection
effort, including criteria for indigency determination procedures,
for record keeping, and for determining whether to refer a claim to
an external collection agency). The Secretary may not require a
hospital to change its bad debt collection policy if a fiscal
intermediary, in accordance with the rules in effect as of August
1, 1987, with respect to criteria for indigency determination
procedures, record keeping, and determining whether to refer a
claim to an external collection agency, has accepted such policy
before that date, and the Secretary may not collect from the
hospital on the basis of an expectation of a change in the
hospital's collection policy."
[Section 6023(b) of Pub. L. 101-239 provided that: "The amendment
made by subsection (a) [amending section 4008(c) of Pub. L.
100-203, set out above] shall take effect as if included in the
enactment of the Omnibus Budget Reconciliation Act of 1987 [Pub. L.
100-203]."]
[Pub. L. 100-647, title VIII, Sec. 8402, Nov. 10, 1988, 102 Stat.
3798, provided that amendment of section 4008(c) of Pub. L.
100-203, set out above, by section 8402 of Pub. L. 100-647 is
effective as of date of enactment of Omnibus Budget Reconciliation
Act of 1987, Pub. L. 100-203, which was approved Dec. 22, 1987.]
PROVIDERS OF SERVICES TO CALCULATE AND REPORT
LESSER-OF-COST-OR-CHARGES DETERMINATIONS SEPARATELY WITH RESPECT TO
PAYMENTS UNDER PARTS A AND B OF THIS SUBCHAPTER; ISSUANCE OF
REGULATIONS
Section 2308(a) of Pub. L. 98-369 provided that: "The Secretary
of Health and Human Services shall issue regulations which require,
for purposes of title XVIII of the Social Security Act [this
subchapter], that providers of services calculate and report the
lesser-of-cost-or-charges determinations separately with respect to
payments for services under part A and services under part B of
such title (other than clinical diagnostic laboratory tests paid
under section 1833(h) [section 1395l(h) of this title]), and that
payment under such title be based upon such separate
determinations. Such regulations shall apply to cost reporting
periods beginning on or after October 1, 1984."
DETERMINATION OF NOMINAL CHARGES FOR APPLYING NOMINALITY TEST
Section 2308(b)(1) of Pub. L. 98-369 provided that: "For purposes
of applying the nominality test under sections 1814(b)(2) [subsec.
(b)(2) of this section] and 1833(a)(2)(B)(ii) [section
1395l(a)(2)(B)(ii) of this title] of the Social Security Act, the
Secretary shall, in addition to those rules for establishing
nominality which the Secretary determines to be appropriate,
provide that charges representing 60 percent or less of costs shall
be considered nominal. The charges used in making such
determinations shall be the charges actually billed to
charge-paying patients who are not entitled to benefits under
either part of such title [sections 1395c et seq., 1395j et seq. of
this title]. Such determination shall be made separately with
respect to payments for services under part A and services under
part B of such title (other than clinical diagnostic laboratory
tests paid under section 1833(h)), or on the basis of inpatient and
outpatient services, except that the determination need not be made
separately for home health services if the Secretary finds that
such separation is not appropriate."
REVISION OF REGULATIONS REGARDING ACCESS TO HOME HEALTH SERVICES
Section 2336(c)(2) of Pub. L. 98-369 provided that: "The
Secretary shall provide, not later than 90 days after the date of
the enactment of this Act [July 18, 1984], for such revision of
regulations as may be required to reflect the amendments made by
subsection (b) [amending this section and section 1395n of this
title]."
PROMULGATION OF REGULATIONS
Section 122(h)(2) of Pub. L. 97-248 provided that: "In order to
provide for the timely implementation of the amendments made by
this Act [probably means section 122 of Pub. L. 97-248, which
amended this section and sections 1395c to 1395e, 1395h, and 1395x
to 1395cc of this title and section 231f of Title 45, Railroads,
and enacted provisions set out as notes under this section and
sections 1395b-1 and 1395c of this title], the Secretary of Health
and Human Services shall, not later than September 1, 1983,
promulgate such final regulations as may be necessary to set forth
-
"(A) a description of the care included in 'hospice care' and
the standards for qualification of a 'hospice program', under
section 1861(dd) of the Social Security Act [section 1395x(dd) of
this title], and
"(B) the standards for payment for hospice care under part A of
title XVIII of such Act [this part], pursuant to section 1814(i)
of such Act [subsec. (i) of this section]."
STUDY AND REPORT RELATING TO THE REIMBURSEMENT METHOD AND BENEFIT
STRUCTURE FOR HOSPICE CARE; SUPERVISION OF REPORT BY COMPTROLLER
GENERAL
Section 122(j), formerly Sec. 122(i), of Pub. L. 97-248,
redesignated Sec. 122(i), by Pub. L. 97-448, title III, Sec.
309(a)(6), Jan. 12, 1983, 96 Stat. 2408, provided that:
"(1) The Secretary of Health and Human Services shall conduct a
study and, prior to January 1, 1986, report to the Congress on
whether or not the reimbursement method and benefit structure
(including copayments) for hospice care under title XVIII of the
Social Security Act [this subchapter] are fair and equitable and
promote the most efficient provision of hospice care. Such report
shall include the feasibility and advisability of providing for
prospective reimbursement for hospice care, an evaluation of the
inclusion of payment for outpatient drugs, an evaluation of the
need to alter the method of reimbursement for nutritional, dietary,
and bereavement counseling as hospice care, and any recommendations
for legislative changes in the hospice care reimbursement or
benefit structure.
"(2) The Comptroller General shall monitor and evaluate the study
and the preparation of the report under paragraph (1)."
WAIVER OF LIMITATIONS TO ALLOW PRE-EXISTING HOSPICES TO PARTICIPATE
AS A HOSPICE PROGRAM
Section 122(k), formerly Sec. 122(j), of Pub. L. 97-248, as
redesignated and amended by Pub. L. 97-448, title III, Sec.
309(a)(6), (7), Jan. 12, 1983, 96 Stat. 2408, provided that: "The
Secretary of Health and Human Services shall grant waivers of the
limitations imposed by section 1814(i)(2) of the Social Security
Act [subsec. (i)(2) of this section] (relating to the cap amount),
section 1861(dd)(1)(G) of such Act [section 1395x(dd)(1)(G) of this
title] (relating to the limitations on the frequency and number of
respite care days), and section 1861(dd)(2)(A)(iii) of such Act
[section 1395x(dd)(2)(A)(iii) of this title] (relating to the
aggregate limit on the number of days of inpatient care), as may be
necessary to allow any institution which commenced operations as a
hospice prior to January 1, 1975, to participate until October 1,
1986, in a viable manner as a hospice program under title XVIII of
the Social Security Act [this subchapter]."
MEDICARE PAYMENT BASIS FOR SERVICES PROVIDED BY AGENCIES AND
PROVIDERS; EFFECTIVE DATE
Section 16 of Pub. L. 93-233 provided that: "In the
administration of titles V, XVIII, and XIX of the Social Security
Act [subchapters V, XVIII, and XIX of this chapter], the amount
payable under such title to any provider of services on account of
services provided by such hospital, skilled nursing facility, or
home health agency shall be determined (for any period with respect
to which the amendments made by section 233 of Public Law 92-603
[this section and sections 706, 709, 1395l, and 1396b of this
title] would, except for the provisions of this section, be
applicable) in like manner as if the date contained in the first
and second sentences of subsection (f) of such section 233 [set out
as an Effective Date of 1972 Amendment note above] were December
31, 1973, rather than December 31, 1972."
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 426, 1320a-7a, 1395d,
1395e, 1395g, 1395l, 1395n, 1395w-23, 1395x, 1395y, 1395cc, 1395gg,
1395mm, 1395pp, 1395qq, 1395uu, 1395ww, 1395eee, 1395fff, 1395ggg
of this title; title 5 section 8904.
-FOOTNOTE-
(!1) So in original. Probably should be followed by a comma.
-End-
-CITE-
42 USC Sec. 1395g 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395g. Payments to providers of services
-STATUTE-
(a) Determination of amount
The Secretary shall periodically determine the amount which
should be paid under this part to each provider of services with
respect to the services furnished by it, and the provider of
services shall be paid, at such time or times as the Secretary
believes appropriate (but not less often than monthly) and prior to
audit or settlement by the General Accounting Office, from the
Federal Hospital Insurance Trust Fund, the amounts so determined,
with necessary adjustments on account of previously made
overpayments or underpayments; except that no such payments shall
be made to any provider unless it has furnished such information as
the Secretary may request in order to determine the amounts due
such provider under this part for the period with respect to which
the amounts are being paid or any prior period.
(b) Conditions
No payment shall be made to a provider of services which is a
hospital for or with respect to services furnished by it for any
period with respect to which it is deemed, under section
1395x(w)(2) of this title, to have in effect an arrangement with a
quality control and peer review organization for the conduct of
utilization review activities by such organization unless such
hospital has paid to such organization the amount due (as
determined pursuant to such section) to such organization for the
review activities conducted by it pursuant to such arrangements or
such hospital has provided assurances satisfactory to the Secretary
that such organization will promptly be paid the amount so due to
it from the proceeds of the payment claimed by the hospital.
Payment under this subchapter for utilization review activities
provided by a quality control and peer review organization pursuant
to an arrangement or deemed arrangement with a hospital under
section 1395x(w)(2) of this title shall be calculated without any
requirement that the reasonable cost of such activities be
apportioned among the patients of such hospital, if any, to whom
such activities were not applicable.
(c) Payments under assignment or power of attorney
No payment which may be made to a provider of services under this
subchapter for any service furnished to an individual shall be made
to any other person under an assignment or power of attorney; but
nothing in this subsection shall be construed (1) to prevent the
making of such a payment in accordance with an assignment from the
provider if such assignment is made to a governmental agency or
entity or is established by or pursuant to the order of a court of
competent jurisdiction, or (2) to preclude an agent of the provider
of services from receiving any such payment if (but only if) such
agent does so pursuant to an agency agreement under which the
compensation to be paid to the agent for his services for or in
connection with the billing or collection of payments due such
provider under this subchapter is unrelated (directly or
indirectly) to the amount of such payments or the billings
therefor, and is not dependent upon the actual collection of any
such payment.
(d) Accrual of interest on balance of excess or deficit not paid
Whenever a final determination is made that the amount of payment
made under this part to a provider of services was in excess of or
less than the amount of payment that is due, and payment of such
excess or deficit is not made (or effected by offset) within 30
days of the date of the determination, interest shall accrue on the
balance of such excess or deficit not paid or offset (to the extent
that the balance is owed by or owing to the provider) at a rate
determined in accordance with the regulations of the Secretary of
the Treasury applicable to charges for late payments.
(e) Periodic interim payments
(1) The Secretary shall provide payment under this part for
inpatient hospital services furnished by a subsection (d) hospital
(as defined in section 1395ww(d)(1)(B) of this title, and including
a distinct psychiatric or rehabilitation unit of such a hospital)
and a subsection (d) Puerto Rico hospital (as defined in section
1395ww(d)(9)(A) of this title) on a periodic interim payment basis
(rather than on the basis of bills actually submitted) in the
following cases:
(A) Upon the request of a hospital which is paid through an
agency or organization with an agreement with the Secretary under
section 1395h of this title, if the agency or organization, for
three consecutive calendar months, fails to meet the requirements
of subsection (c)(2) of such section and if the hospital meets
the requirements (in effect as of October 1, 1986) applicable to
payment on such a basis, until such time as the agency or
organization meets such requirements for three consecutive
calendar months.
(B) In the case of (!1) hospital that -
(i) has a disproportionate share adjustment percentage (as
established in clause (iv) of such section) of at least 5.1
percent (as computed for purposes of establishing the average
standardized amounts for discharges occurring during fiscal
year 1987), and
(ii) requests payment on such basis,
but only if the hospital was being paid for inpatient hospital
services on such a periodic interim payment basis as of June 30,
1987, and continues to meet the requirements (in effect as of
October 1, 1986) applicable to payment on such a basis.
(C) In the case of a hospital that -
(i) is located in a rural area,
(ii) has 100 or fewer beds, and
(iii) requests payment on such basis,
but only if the hospital was being paid for inpatient hospital
services on such a periodic interim payment basis as of June 30,
1987, and continues to meet the requirements (in effect as of
October 1, 1986) applicable to payment on such a basis.
(2) The Secretary shall provide (or continue to provide) for
payment on a periodic interim payment basis (under the standards
established under section 405.454(j) of title 42, Code of Federal
Regulations, as in effect on October 1, 1986) with respect to -
(A) inpatient hospital services of a hospital that is not a
subsection (d) hospital (as defined in section 1395ww(d)(1)(B) of
this title);
(B) a hospital which is receiving payment under a State
hospital reimbursement system under section 1395f(b)(3) or
1395ww(c) of this title, if payment on a periodic interim payment
basis is an integral part of such reimbursement system;
(C) extended care services; and
(D) hospice care;
if the provider of such services elects to receive, and qualifies
for, such payments.
(3) In the case of a subsection (d) hospital or a subsection (d)
Puerto Rico hospital (as defined for purposes of section 1395ww of
this title) which has significant cash flow problems resulting from
operations of its intermediary or from unusual circumstances of the
hospital's operation, the Secretary may make available appropriate
accelerated payments.
(4) A hospital created by the merger or consolidation of 2 or
more hospitals or hospital campuses shall be eligible to receive
periodic interim payment on the basis described in paragraph (1)(B)
if -
(A) at least one of the hospitals or campuses received periodic
interim payment on such basis prior to the merger or
consolidation; and
(B) the merging or consolidating hospitals or campuses would
each meet the requirement of paragraph (1)(B)(i) if such
hospitals or campuses were treated as independent hospitals for
purposes of this subchapter.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1815, as added Pub. L.
89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 297; amended
Pub. L. 94-182, title I, Sec. 112(a)(2), Dec. 31, 1975, 89 Stat.
1055; Pub. L. 95-142, Sec. 2(a)(2), Oct. 25, 1977, 91 Stat. 1175;
Pub. L. 96-473, Sec. 6(i), Oct. 19, 1980, 94 Stat. 2266; Pub. L.
97-248, title I, Secs. 117(a)(1), 148(b), Sept. 3, 1982, 96 Stat.
354, 394; Pub. L. 99-509, title IX, Sec. 9311(a)(1), Oct. 21, 1986,
100 Stat. 1996; Pub. L. 101-239, title VI, Sec. 6021(a), Dec. 19,
1989, 103 Stat. 2166; Pub. L. 105-33, title IV, Sec. 4603(b), Aug.
5, 1997, 111 Stat. 470.)
-MISC1-
AMENDMENTS
1997 - Subsec. (e)(2)(C) to (E). Pub. L. 105-33 inserted "and" at
end of subpar. (C), redesignated subpar. (E) as (D), and struck out
former subpar. (D) which read as follows: "home health services;
and".
1989 - Subsec. (e)(4). Pub. L. 101-239 added par. (4).
1986 - Subsec. (e). Pub. L. 99-509 added subsec. (e).
1982 - Subsec. (b). Pub. L. 97-248, Sec. 148(b), substituted
"quality control and peer review organization" for "Professional
Standards Review Organization" wherever appearing.
Subsec. (d). Pub. L. 97-248, Sec. 117(a)(1), added subsec. (d).
1980 - Subsec. (c). Pub. L. 96-473 substituted "for or in
connection with" for "for on in connection with".
1977 - Subsec. (c). Pub. L. 95-142 added subsec. (c).
1975 - Pub. L. 94-182 designated existing provisions as subsec.
(a) and added subsec. (b).
EFFECTIVE DATE OF 1997 AMENDMENT
Amendment by Pub. L. 105-33 applicable to cost reporting periods
beginning on or after Oct. 1, 1999, except as otherwise provided,
see section 4603(d) of Pub. L. 105-33, set out as an Effective Date
note under section 1395fff of this title.
EFFECTIVE DATE OF 1989 AMENDMENT
Section 6021(b) of Pub. L. 101-239 provided that: "The amendment
made by subsection (a) [amending this section] shall apply to
payments made for discharges occurring on or after the expiration
of the 30-day period that begins on the date of the enactment of
this Act [Dec. 19, 1989], regardless of the date of the merger or
consolidation involved."
EFFECTIVE DATE OF 1986 AMENDMENT
Section 9311(a)(2) of Pub. L. 99-509 provided that: "The
amendment made by paragraph (1) [amending this section] shall apply
to claims received on or after July 1, 1987."
EFFECTIVE DATE OF 1982 AMENDMENT
Section 117(b) of Pub. L. 97-248 provided that: "The amendments
made by subsection (a) [amending this section and section 1395l of
this title] apply to final determinations made on or after the date
of the enactment of this Act [Sept. 3, 1982]."
Amendment by section 148(b) of Pub. L. 97-248 effective with
respect to contracts entered into or renewed on or after Sept. 3,
1982, see section 149 of Pub. L. 97-248, set out as an Effective
Date note under section 1320c of this title.
EFFECTIVE DATE OF 1977 AMENDMENT
Section 2(a)(4) of Pub. L. 95-142 provided that: "The amendments
made by this subsection [amending this section and sections 1395u
and 1396a of this title] shall apply with respect to care and
services furnished on or after the date of the enactment of this
Act [Oct. 25, 1977]."
EFFECTIVE DATE OF 1975 AMENDMENT
Amendment by Pub. L. 94-182 effective with respect to utilization
review activities conducted on and after the first day of the first
month which begins more than 30 days after Dec. 31, 1975, see
section 112(d) of Pub. L. 94-182, set out as a note under section
1395x of this title.
TRANSITION
Section 9311(a)(3) of Pub. L. 99-509 provided that: "Upon the
request of a hospital which -
"(A) as of June 30, 1987, is receiving payments under part A of
title XVIII of such Act [this part] for inpatient hospital
services on a periodic interim payment basis,
"(B) requests continuation of payment on such basis, and
"(C) is paid through an agency or organization with an
agreement under section 1816 of such Act [section 1395h of this
title],
the Secretary of Health and Human Services shall continue payment
on such a basis until not earlier than the end of the first period
of three consecutive calendar months (beginning no earlier than
April 1987) during all of which the agency or organization has met
the requirements of section 1816(c)(2) of such Act (relating to
prompt payment of claims)."
DELAY IN PERIODIC INTERIM PAYMENTS
Section 120 of Pub. L. 97-248 provided that: "Notwithstanding
section 1815(a) of the Social Security Act [subsec. (a) of this
section], in the case of a hospital which is paid periodic interim
payments under such section, the Secretary of Health and Human
Services shall provide that -
"(1) with respect to the last 21 days for which such payments
would otherwise be made during fiscal year 1983, such payments
shall be deferred until fiscal year 1984; and
"(2) with respect to the last 21 days for which such payments
would otherwise be made during fiscal year 1984, such payments
shall be deferred until fiscal year 1985."
Pub. L. 96-499, title IX, Sec. 959, Dec. 5, 1980, 94 Stat. 2650,
provided for deferral of interim payments to be made during last
twenty-one days of fiscal year 1981 until fiscal year 1982, prior
to repeal by Pub. L. 97-35, title XXI, Sec. 2155, Aug. 13, 1981, 95
Stat. 802.
-FOOTNOTE-
(!1) So in original. Probably should be followed by "a".
-End-
-CITE-
42 USC Sec. 1395h 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395h. Use of public or private agencies or organizations to
facilitate payment to providers of services
-STATUTE-
(a) Authorization for agreement by Secretary for implementation;
scope of agreement
If any group or association of providers of services wishes to
have payments under this part to such providers made through a
national, State, or other public or private agency or organization
and nominates such agency or organization for this purpose, the
Secretary is authorized to enter into an agreement with such agency
or organization providing for the determination by such agency or
organization (subject to the provisions of section 1395oo of this
title and to such review by the Secretary as may be provided for by
the agreement) of the amount of the payments required pursuant to
this part to be made to such providers (and to providers assigned
to such agency or organization under subsection (e) of this
section), and for the making of such payments by such agency or
organization to such providers (and to providers assigned to such
agency or organization under subsection (e) of this section). Such
agreement may also include provision for the agency or organization
to do all or any part of the following: (1) to provide consultative
services to institutions or agencies to enable them to establish
and maintain fiscal records necessary for purposes of this part and
otherwise to qualify as hospitals, extended care facilities, or
home health agencies, and (2) with respect to the providers of
services which are to receive payments through it (A) to serve as a
center for, and communicate to providers, any information or
instructions furnished to it by the Secretary, and serve as a
channel of communication from providers to the Secretary; (B) to
make such audits of the records of providers as may be necessary to
insure that proper payments are made under this part; and (C) to
perform such other functions as are necessary to carry out this
subsection. As used in this subchapter and part B of subchapter XI
of this chapter, the term "fiscal intermediary" means an agency or
organization with a contract under this section.
(b) Prerequisites for agreement or renewal of agreement by
Secretary
The Secretary shall not enter into or renew an agreement with any
agency or organization under this section unless -
(1) he finds -
(A) after applying the standards, criteria, and procedures
developed under subsection (f) of this section, that to do so
is consistent with the effective and efficient administration
of this part, and
(B) that such agency or organization is willing and able to
assist the providers to which payments are made through it
under this part in the application of safeguards against
unnecessary utilization of services furnished by them to
individuals entitled to hospital insurance benefits under
section 426 of this title, and the agreement provides for such
assistance; and
(2) such agency or organization agrees -
(A) to furnish to the Secretary such of the information
acquired by it in carrying out its agreement under this
section, and
(B) to provide the Secretary with access to all such data,
information, and claims processing operations,
as the Secretary may find necessary in performing his functions
under this part.
(c) Terms and conditions of agreements; prompt payment of claims
(1) An agreement with any agency or organization under this
section may contain such terms and conditions as the Secretary
finds necessary or appropriate, may provide for advances of funds
to the agency or organization for the making of payments by it
under subsection (a) of this section, and shall provide for payment
of so much of the cost of administration of the agency or
organization as is determined by the Secretary to be necessary and
proper for carrying out the functions covered by the agreement. The
Secretary shall provide that in determining the necessary and
proper cost of administration, the Secretary shall, with respect to
each agreement, take into account the amount that is reasonable and
adequate to meet the costs which must be incurred by an efficiently
and economically operated agency or organization in carrying out
the terms of its agreement. The Secretary shall cause to have
published in the Federal Register, by not later than September 1
before each fiscal year, data, standards, and methodology to be
used to establish budgets for fiscal intermediaries under this
section for that fiscal year, and shall cause to be published in
the Federal Register for public comment, at least 90 days before
such data, standards, and methodology are published, the data,
standards, and methodology proposed to be used. The Secretary may
not require, as a condition of entering into or renewing an
agreement under this section or under section 1395hh of this title,
that a fiscal intermediary match data obtained other than in its
activities under this part with data used in the administration of
this part for purposes of identifying situations in which the
provisions of section 1395y(b) of this title may apply.
(2)(A) Each agreement under this section shall provide that
payment shall be issued, mailed, or otherwise transmitted with
respect to not less than 95 percent of all claims submitted under
this subchapter -
(i) which are clean claims, and
(ii) for which payment is not made on a periodic interim
payment basis,
within the applicable number of calendar days after the date on
which the claim is received.
(B) In this paragraph:
(i) The term "clean claim" means a claim that has no defect or
impropriety (including any lack of any required substantiating
documentation) or particular circumstance requiring special
treatment that prevents timely payment from being made on the
claim under this subchapter.
(ii) The term "applicable number of calendar days" means -
(I) with respect to claims received in the 12-month period
beginning October 1, 1986, 30 calendar days,
(II) with respect to claims received in the 12-month period
beginning October 1, 1987, 26 calendar days,
(III) with respect to claims received in the 12-month period
beginning October 1, 1988, 25 calendar days, and (!1)
(IV) with respect to claims received in the 12-month period
beginning October 1, 1989, and claims received in any
succeeding 12-month period ending on or before September 30,
1993, 24 calendar days.(!2)
(V) with respect to claims received in the 12-month period
beginning October 1, 1993, and claims received in any
succeeding 12-month period, 30 calendar days.
(C) If payment is not issued, mailed, or otherwise transmitted
within the applicable number of calendar days (as defined in clause
(ii) of subparagraph (B)) after a clean claim (as defined in clause
(i) of such subparagraph) is received from a hospital, critical
access hospital, skilled nursing facility, home health agency,
hospice program, comprehensive outpatient rehabilitation facility,
or rehabilitation agency that is not receiving payments on a
periodic interim payment basis with respect to such services,
interest shall be paid at the rate used for purposes of section
3902(a) of title 31 (relating to interest penalties for failure to
make prompt payments) for the period beginning on the day after the
required payment date and ending on the date on which payment is
made.
(3)(A) Each agreement under this section shall provide that no
payment shall be issued, mailed, or otherwise transmitted with
respect to any claim submitted under this subchapter within the
applicable number of calendar days after the date on which the
claim is received.
(B) In this paragraph, the term "applicable number of calendar
days" means -
(i) with respect to claims submitted electronically as
prescribed by the Secretary, 13 days, and
(ii) with respect to claims submitted otherwise, 26 days.
(d) Nomination of agency or organization; withdrawal
If the nomination of an agency or organization as provided in
this section is made by a group or association of providers of
services, it shall not be binding on members of the group or
association which notify the Secretary of their election to that
effect. Any provider may, upon such notice as may be specified in
the agreement under this section with an agency or organization,
withdraw its nomination to receive payments through such agency or
organization. Any provider which has withdrawn its nomination, and
any provider which has not made a nomination, may elect to receive
payments from any agency or organization which has entered into an
agreement with the Secretary under this section if the Secretary
and such agency or organization agree to it.
(e) Assignment or reassignment of provider of services; designation
of agency or organization to perform provider services and home
health agency functions
(1) Notwithstanding subsections (a) and (d) of this section, the
Secretary, after taking into consideration any preferences of
providers of services, may assign or reassign any provider of
services to any agency or organization which has entered into an
agreement with him under this section, if he determines, after
applying the standards, criteria, and procedures developed under
subsection (f) of this section, that such assignment or
reassignment would result in the more effective and efficient
administration of this part.
(2) Notwithstanding subsections (a) and (d) of this section, the
Secretary may (subject to the provisions of paragraph (4))
designate a national or regional agency or organization which has
entered into an agreement with him under this section to perform
functions under the agreement with respect to a class of providers
of services in the Nation or region (as the case may be), if he
determines, after applying the standards, criteria, and procedures
developed under subsection (f) of this section, that such
designation would result in more effective and efficient
administration of this part.
(3)(A) Before the Secretary makes an assignment or reassignment
under paragraph (1) of a provider of services to other than the
agency or organization nominated by the provider, he shall furnish
(i) the provider and such agency or organization with a full
explanation of the reasons for his determination as to the
efficiency and effectiveness of the agency or organization to
perform the functions required under this part with respect to the
provider, and (ii) such agency or organization with opportunity for
a hearing, and such determination shall be subject to judicial
review in accordance with chapter 7 of title 5.
(B) Before the Secretary makes a designation under paragraph (2)
with respect to a class of providers of services, he shall furnish
(i) such providers and the agencies and organizations adversely
affected by such designation with a full explanation of the reasons
for his determination as to the efficiency and effectiveness of
such agencies and organizations to perform the functions required
under this part with respect to such providers, and (ii) the
agencies and organizations adversely affected by such designation
with opportunity for a hearing, and such determination shall be
subject to judicial review in accordance with chapter 7 of title 5.
(4) Notwithstanding subsections (a) and (d) of this section and
paragraphs (1), (2), and (3) of this subsection, the Secretary
shall designate regional agencies or organizations which have
entered into an agreement with him under this section to perform
functions under such agreement with respect to home health agencies
(as defined in section 1395x(o) of this title) in the region,
except that in assigning such agencies to such designated regional
agencies or organizations the Secretary shall assign a home health
agency which is a subdivision of a hospital (and such agency and
hospital are affiliated or under common control) only if, after
applying such criteria relating to administrative efficiency and
effectiveness as he shall promulgate, he determines that such
assignment would result in the more effective and efficient
administration of this subchapter. By not later than July 1, 1987,
the Secretary shall limit the number of such regional agencies or
organizations to not more than ten.
(5) Notwithstanding any other provision of this subchapter, the
Secretary shall designate the agency or organization which has
entered into an agreement under this section to perform functions
under such an agreement with respect to each hospice program,
except that with respect to a hospice program which is a
subdivision of a provider of services (and such hospice program and
provider of services are under common control) due regard shall be
given to the agency or organization which performs the functions
under this section for the provider of services.
(f) Development of standards, criteria, and procedures by Secretary
for evaluation of agency or organization performance
(1) In order to determine whether the Secretary should enter
into, renew, or terminate an agreement under this section with an
agency or organization, whether the Secretary should assign or
reassign a provider of services to an agency or organization, and
whether the Secretary should designate an agency or organization to
perform services with respect to a class of providers of services,
the Secretary shall develop standards, criteria, and procedures to
evaluate such agency's or organization's (A) overall performance of
claims processing (including the agency's or organization's success
in recovering payments made under this subchapter for services for
which payment has been or could be made under a primary plan (as
defined in section 1395y(b)(2)(A) of this title)) and other related
functions required to be performed by such an agency or
organization under an agreement entered into under this section,
and (B) performance of such functions with respect to specific
providers of services, and the Secretary shall establish standards
and criteria with respect to the efficient and effective
administration of this part. No agency or organization shall be
found under such standards and criteria not to be efficient or
effective or to be less efficient or effective solely on the ground
that the agency or organization serves only providers located in a
single State.
(2) The standards and criteria established under paragraph (1)
shall include -
(A) with respect to claims for services furnished under this
part by any provider of services other than a hospital -
(i) whether such agency or organization is able to process 75
percent of reconsiderations within 60 days (except in the case
of fiscal year 1989, 66 percent of reconsiderations) and 90
percent of reconsiderations within 90 days, and
(ii) the extent to which such agency's or organization's
determinations are reversed on appeal; and
(B) with respect to applications for an exemption from or
exception or adjustment to the target amount applicable under
section 1395ww(b) of this title to a hospital that is not a
subsection (d) hospital (as defined in section 1395ww(d)(1)(B) of
this title) -
(i) if such agency or organization receives a completed
application, whether such agency or organization is able to
process such application not later than 75 days after the
application is filed, and
(ii) if such agency or organization receives an incomplete
application, whether such agency or organization is able to
return the application with instructions on how to complete the
application not later than 60 days after the application is
filed.
(g) Termination of agreement; procedures applicable
An agreement with the Secretary under this section may be
terminated -
(1) by the agency or organization which entered into such
agreement at such time and upon such notice to the Secretary, to
the public, and to the providers as may be provided in
regulations, or
(2) by the Secretary at such time and upon such notice to the
agency or organization, to the providers which have nominated it
for purposes of this section, and to the public, as may be
provided in regulations, but only if he finds, after applying the
standards, criteria, and procedures developed under subsection
(f) of this section and after reasonable notice and opportunity
for hearing to the agency or organization, that (A) the agency or
organization has failed substantially to carry out the agreement,
or (B) the continuation of some or all of the functions provided
for in the agreement with the agency or organization is
disadvantageous or is inconsistent with the efficient
administration of this part.
(h) Bonding requirement under agreement for officers and employees
of agency or organization
An agreement with an agency or organization under this section
may require any of its officers or employees certifying payments or
disbursing funds pursuant to the agreement, or otherwise
participating in carrying out the agreement, to give surety bond to
the United States in such amount as the Secretary may deem
appropriate.
(i) Liability of certifying and disbursing officers designated
under agreement for negligent, etc., payments
(1) No individual designated pursuant to an agreement under this
section as a certifying officer shall, in the absence of gross
negligence or intent to defraud the United States, be liable with
respect to any payments certified by him under this section.
(2) No disbursing officer shall, in the absence of gross
negligence or intent to defraud the United States, be liable with
respect to any payment by him under this section if it was based
upon a voucher signed by a certifying officer designated as
provided in paragraph (1) of this subsection.
(3) No such agency or organization shall be liable to the United
States for any payments referred to in paragraph (1) or (2).
(j) Denial of claim; notification and reconsideration
An agreement with an agency or organization under this section
shall require that, with respect to a claim for home health
services, extended care services, or post-hospital extended care
services submitted by a provider to such agency or organization
that is denied, such agency or organization -
(1) furnish the provider and the individual with respect to
whom the claim is made with a written explanation of the denial
and of the statutory or regulatory basis for the denial; and
(2) in the case of a request for reconsideration of a denial,
promptly notify such individual and the provider of the
disposition of such reconsideration.
(k) Annual reporting requirement on erroneous payment recovery
An agreement with an agency or organization under this section
shall require that such agency or organization submit an annual
report to the Secretary describing the steps taken to recover
payments made for items or services for which payment has been or
could be made under a primary plan (as defined in section
1395y(b)(2)(A) of this title).
(l) No authority for activities carried out under Medicare
Integrity Program
No agency or organization may carry out (or receive payment for
carrying out) any activity pursuant to an agreement under this
section to the extent that the activity is carried out pursuant to
a contract under the Medicare Integrity Program under section
1395ddd of this title.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1816, as added Pub. L.
89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 297; amended
Pub. L. 92-603, title II, Sec. 243(b), Oct. 30, 1972, 86 Stat.
1422; Pub. L. 95-142, Sec. 14(a), Oct. 25, 1977, 91 Stat. 1198;
Pub. L. 96-499, title IX, Sec. 930(o), Dec. 5, 1980, 94 Stat. 2632;
Pub. L. 97-248, title I, Sec. 122(c)(3), Sept. 3, 1982, 96 Stat.
359; Pub. L. 98-369, div. B, title III, Sec. 2326(b), (c)(1),
(d)(1), July 18, 1984, 98 Stat. 1087; Pub. L. 99-509, title IX,
Secs. 9311(b), 9352(a)(2), Oct. 21, 1986, 100 Stat. 1997, 2044;
Pub. L. 100-203, title IV, Secs. 4031(a)(1), 4032(a), (b),
4035(a)(1), 4085(d)(1), Dec. 22, 1987, 101 Stat. 1330-75 to
1330-78, 1330-130; Pub. L. 100-360, title II, Sec. 203(f), title
IV, Sec. 411(e)(1)(B), July 1, 1988, 102 Stat. 725, 775; Pub. L.
101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981; Pub.
L. 101-239, title VI, Secs. 6003(g)(3)(D)(vi), 6202(d)(1), Dec. 19,
1989, 103 Stat. 2153, 2234; Pub. L. 101-508, title IV, Sec.
4005(c)(1)(A), Nov. 5, 1990, 104 Stat. 1388-41; Pub. L. 103-66,
title XIII, Sec. 13568(a), (b), Aug. 10, 1993, 107 Stat. 608; Pub.
L. 103-432, title I, Secs. 110(d)(2), 151(b)(1)(A), (2)(A), Oct.
31, 1994, 108 Stat. 4408, 4433, 4434; Pub. L. 104-191, title II,
Sec. 202(b)(1), Aug. 21, 1996, 110 Stat. 1998; Pub. L. 105-33,
title IV, Sec. 4201(c)(1), Aug. 5, 1997, 111 Stat. 373.)
-REFTEXT-
REFERENCES IN TEXT
Part B of subchapter XI of this chapter, referred to in subsec.
(a), is classified to section 1320c et seq. of this title.
-MISC1-
AMENDMENTS
1997 - Subsec. (c)(2)(C). Pub. L. 105-33 substituted "critical
access" for "rural primary care".
1996 - Subsec. (l). Pub. L. 104-191 added subsec. (l).
1994 - Subsec. (f)(1)(A). Pub. L. 103-432, Sec. 151(b)(2)(A),
inserted "(including the agency's or organization's success in
recovering payments made under this subchapter for services for
which payment has been or could be made under a primary plan (as
defined in section 1395y(b)(2)(A) of this title))" after
"processing".
Subsec. (f)(2)(A)(ii). Pub. L. 103-432, Sec. 110(d)(2),
substituted "such agency's" for "such agency".
Subsec. (k). Pub. L. 103-432, Sec. 151(b)(1)(A), added subsec.
(k).
1993 - Subsec. (c)(2)(B)(ii)(IV), (V). Pub. L. 103-66, Sec.
13568(b), substituted "period ending on or before September 30,
1993" for "period" in subcl. (IV) and added subcl. (V).
Subsec. (c)(3)(B). Pub. L. 103-66, Sec. 13568(a), added cls. (i)
and (ii) and struck out former cls. (i) and (ii) which read as
follows:
"(i) with respect to claims received in the 3-month period
beginning July 1, 1988, 10 days, and
"(ii) with respect to claims received in the 12-month period
beginning October 1, 1988, 14 days."
1990 - Subsec. (f). Pub. L. 101-508 designated existing
provisions as par. (1), redesignated former pars. (1) and (2) as
subpars. (A) and (B), respectively, struck out "Such standards and
criteria" and all that follows, which was executed by striking out
"Such standards and criteria shall be published in the Federal
Register, and opportunity shall be provided for public comment
prior to implementation. Such standards and criteria shall include
with respect to claims for services furnished under this part by
any provider of services other than a hospital whether such agency
or organization is able to process 75 percent of reconsiderations
within 60 days (except in the case of the fiscal year 1989, 66
percent of reconsiderations) and 90 percent of reconsiderations
within 90 days and the extent to which its determinations are
reversed on appeal.", and added par. (2).
1989 - Subsec. (c)(1). Pub. L. 101-239, Sec. 6202(d)(1), inserted
at end "The Secretary may not require, as a condition of entering
into or renewing an agreement under this section or under section
1395hh of this title, that a fiscal intermediary match data
obtained other than in its activities under this part with data
used in the administration of this part for purposes of identifying
situations in which the provisions of section 1395y(b) of this
title may apply."
Subsec. (c)(2)(C). Pub. L. 101-239, Sec. 6003(g)(3)(D)(vi),
inserted "rural primary care hospital," after "hospital,".
Subsec. (k). Pub. L. 101-234 repealed Pub. L. 100-360, Sec.
203(f), and provided that the provisions of law amended or repealed
by such section are restored or revived as if such section had not
been enacted, see 1988 Amendment note below.
1988 - Subsec. (j)(2). Pub. L. 100-360, Sec. 411(e)(1)(B),
inserted "in the case of a request for reconsideration of a
denial," and substituted "the disposition" for "disposition".
Subsec. (k). Pub. L. 100-360, Sec. 203(f), added subsec. (k)
relating to use of regional intermediaries in administration of
benefits.
1987 - Subsec. (c)(1). Pub. L. 100-203, Sec. 4035(a)(1), inserted
at end "The Secretary shall cause to have published in the Federal
Register, by not later than September 1 before each fiscal year,
data, standards, and methodology to be used to establish budgets
for fiscal intermediaries under this section for that fiscal year,
and shall cause to be published in the Federal Register for public
comment, at least 90 days before such data, standards, and
methodology are published, the data, standards, and methodology
proposed to be used."
Subsec. (c)(2)(C). Pub. L. 100-203, Sec. 4085(d)(1), substituted
"hospice program, comprehensive outpatient rehabilitation facility,
or rehabilitation agency" for "or hospice program".
Subsec. (c)(3). Pub. L. 100-203, Sec. 4031(a)(1), added par. (3).
Subsec. (f). Pub. L. 100-203, Sec. 4023(b), inserted at end "Such
standards and criteria shall include with respect to claims for
services furnished under this part by any provider of services
other than a hospital whether such agency or organization is able
to process 75 percent of reconsiderations within 60 days (except in
the case of the fiscal year 1989, 66 percent of reconsiderations)
and 90 percent of reconsiderations within 90 days and the extent to
which its determinations are reversed on appeal."
Subsec. (j). Pub. L. 100-203, Sec. 4032(a), added subsec. (j).
1986 - Subsec. (a). Pub. L. 99-509, Sec. 9352(a)(2), inserted at
end "As used in this subchapter and part B of subchapter XI of this
chapter, the term 'fiscal intermediary' means an agency or
organization with a contract under this section."
Subsec. (c). Pub. L. 99-509, Sec. 9311(b), designated existing
provisions as par. (1) and added par. (2).
1984 - Subsec. (c). Pub. L. 98-369, Sec. 2326(d)(1), inserted
provision that the Secretary, in determining the necessary and
proper cost of administration with respect to each agreement, take
into account the amount that is reasonable and adequate to meet the
costs which must be incurred by an efficiently and economically
operated agency or organization in carrying out the terms of its
agreement.
Subsec. (e)(4). Pub. L. 98-369, Sec. 2326(b), inserted provision
that not later than July 1, 1987, the Secretary limit the number of
regional agencies or organizations to not more than ten.
Subsec. (f). Pub. L. 98-369, Sec. 2326(c)(1), struck out in cl.
(2) ", by regulation," after "Secretary shall establish" and
inserted provision that the standards and criteria be published in
the Federal Register and an opportunity be provided for public
comment prior to implementation.
1982 - Subsec. (e)(5). Pub. L. 97-248 added par. (5).
1980 - Subsec. (e)(2). Pub. L. 96-499, Sec. 930(o)(1), inserted
"(subject to the provisions of paragraph (4))".
Subsec. (e)(4). Pub. L. 96-499, Sec. 930(o)(2), added par. (4).
1977 - Subsec. (a). Pub. L. 95-142, Sec. 14(a)(1), inserted
provisions relating to applicability to providers assigned to the
agency or organization under subsec. (e) of this section.
Subsec. (b). Pub. L. 95-142, Sec. 14(a)(2), substituted
provisions setting forth criteria for agreements by the Secretary
or renewal of such agreements with agencies or organizations, for
provisions setting forth criteria for agreements by the Secretary
with agencies or organizations.
Subsecs. (e), (f). Pub. L. 95-142, Sec. 14(a)(4), (5), added
subsecs. (e) and (f). Former subsecs. (e) and (f) redesignated (g)
and (h), respectively.
Subsec. (g). Pub. L. 95-142, Sec. 14(a)(3), (4), redesignated
former subsec. (e) as (g) and inserted provisions relating to
applicability of standards, etc., developed under subsec. (f) of
this section. Former subsec. (g) redesignated (i).
Subsecs. (h), (i). Pub. L. 95-142, Sec. 14(a)(4), redesignated
former subsecs. (f) and (g) as (h) and (i), respectively.
1972 - Subsec. (a). Pub. L. 92-603 inserted reference to
provisions of section 1395oo of this title.
EFFECTIVE DATE OF 1997 AMENDMENT
Amendment by Pub. L. 105-33 applicable to services furnished on
or after Oct. 1, 1997, see section 4201(d) of Pub. L. 105-33, set
out as a note under section 1395f of this title.
EFFECTIVE DATE OF 1994 AMENDMENT
Section 151(b)(4) of Pub. L. 103-432 provided that: "The
amendments made by paragraphs (1) and (2) [amending this section
and section 1395u of this title] shall apply to contracts with
fiscal intermediaries and carriers under title XVIII of the Social
Security Act [this subchapter] for contract years beginning with
1995."
EFFECTIVE DATE OF 1993 AMENDMENT
Section 13568(c) of Pub. L. 103-66 provided that: "The amendments
made by this section [amending this section and section 1395u of
this title] shall apply to claims received on or after October 1,
1993."
EFFECTIVE DATE OF 1989 AMENDMENTS
Section 6202(d)(3) of Pub. L. 101-239 provided that: "The
amendments made by this subsection [amending this section and
section 1395u of this title] shall apply to agreements and
contracts entered into or renewed on or after the date of the
enactment of this Act [Dec. 19, 1989]."
Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section
201(c) of Pub. L. 101-234, set out as a note under section 1320a-7a
of this title.
EFFECTIVE DATE OF 1988 AMENDMENT
Amendment by section 203(f) of Pub. L. 100-360 applicable to
items and services furnished on or after Jan. 1, 1990, see section
203(g) of Pub. L. 100-360, set out as a note under section 1320c-3
of this title.
Except as specifically provided in section 411 of Pub. L.
100-360, amendment by section 411(e)(1)(B) of Pub. L. 100-360, as
it relates to a provision in the Omnibus Budget Reconciliation Act
of 1987, Pub. L. 100-203, effective as if included in the enactment
of that provision in Pub. L. 100-203, see section 411(a) of Pub. L.
100-360, set out as a Reference to OBRA; Effective Date note under
section 106 of Title 1, General Provisions.
EFFECTIVE DATE OF 1987 AMENDMENT
Section 4031(a)(3)(A) of Pub. L. 100-203 provided that: "The
amendments made by paragraphs (1) and (2) [amending this section
and section 1395u of this title] shall apply to claims received on
or after July 1, 1988."
Section 4032(c)(1) of Pub. L. 100-203, as amended by Pub. L.
100-360, title IV, Sec. 411(e)(1)(C), July 1, 1988, 102 Stat. 775,
provided that:
"(A) The amendment made by subsection (a) [amending this section]
shall apply with respect to claims received on or after January 1,
1988.
"(B) The amendment made by subsection (b) [amending this section]
shall apply with respect to reconsiderations requested on or after
October 1, 1988."
Section 4035(a)(3) of Pub. L. 100-203 provided that: "The
amendments made by this section [amending this section and sections
1395u and 1395hh of this title] shall take effect on the date of
the enactment of this Act [Dec. 22, 1987] and shall apply to
budgets for fiscal years beginning with fiscal year 1989."
Section 4085(d)(2) of Pub. L. 100-203 provided that:
"(A) The amendment made by paragraph (1) [amending this section]
shall apply to claims received on or after the date of enactment of
this Act [Dec. 22, 1987].
"(B) The Secretary of Health and Human Services shall provide for
such timely amendments to agreements under section 1816 [this
section], and regulations, to such extent as may be necessary to
implement the amendment made by paragraph (1)."
EFFECTIVE DATE OF 1986 AMENDMENT
Section 9311(d) of Pub. L. 99-509 provided that:
"(1) Except as provided in paragraph (2), the amendments made by
subsections (b) and (c) [amending this section and section 1395u of
this title] shall apply to claims received on or after November 1,
1986.
"(2) Sections 1816(c)(2)(C)) [sic] and 1842(c)(2)(C) of the
Social Security Act [subsec. (c)(2)(C) of this section and section
1395u(c)(2)(C) of this title], as added by such amendments, shall
apply to claims received on or after April 1, 1987.
"(3) The Secretary of Health and Human Services shall provide for
such timely amendments to agreements under section 1816 of the
Social Security Act [this section] and contracts under section 1842
of such Act [section 1395u of this title], and regulations, to such
extent as may be necessary to implement the provisions of this Act
on a timely basis."
Amendment by section 9352(a)(2) of Pub. L. 99-509 to be
implemented by Secretary of Health and Human Services not later
than 6 months after Oct. 21, 1986, see section 9352(c)(1) of Pub.
L. 99-509, set out as a note under section 1320c-2 of this title.
EFFECTIVE DATE OF 1984 AMENDMENT
Section 2326(d)(3) of Pub. L. 98-369 provided that: "The
amendments made by this subsection [amending this section and
section 1395u of this title] shall apply to agreements and
contracts entered into or renewed after September 30, 1984."
EFFECTIVE DATE OF 1982 AMENDMENT
Amendment by Pub. L. 97-248 applicable to hospice care provided
on or after Nov. 1, 1983, see section 122(h)(1) of Pub. L. 97-248,
as amended, set out as a note under section 1395c of this title.
EFFECTIVE DATE OF 1980 AMENDMENT
Amendment by Pub. L. 96-499 effective Dec. 5, 1980, see section
930(s)(1) of Pub. L. 96-499, set out as a note under section 1395x
of this title.
EFFECTIVE DATE OF 1977 AMENDMENT
Section 14(c), (d) of Pub. L. 95-142 provided that:
"(c) The amendment made by paragraphs (2) and (3) of subsection
(a) [amending this section] to the extent that they require
application of standards, criteria, and procedures developed under
section 1816(f) of the Social Security Act [subsec. (f) of this
section] shall apply to the entering into, renewal, or termination
of agreements on and after October 1, 1978.
"(d) Except as provided in subsection (c), the amendment made by
subsection (a)(2) [amending this section] shall apply to agreements
entered into or renewed on or after the date of enactment of this
Act [Oct. 25, 1977]."
EFFECTIVE DATE OF 1972 AMENDMENT
Amendment by Pub. L. 92-603 applicable with respect to cost
reports of providers of services for accounting periods ending on
or after June 30, 1973, see section 243(c) of Pub. L. 92-603, set
out as an Effective Date note under section 1395oo of this title.
ADVISORY COMMITTEE ON MEDICARE HOME HEALTH CLAIMS
Section 427 of Pub. L. 100-360, which provided that the
Administrator of the Health Care Financing Administration was to
establish an advisory committee to be known as the Advisory
Committee on Medicare Home Health Claims to study the reasons for
the increase in the denial of claims for home health services
during 1986 and 1987, the ramifications of such increase, and the
need to reform the process involved in such denials, was repealed
by Pub. L. 101-234, title III, Sec. 301(a), Dec. 13, 1989, 103
Stat. 1985.
AMENDMENTS TO AGREEMENTS AND CONTRACTS NECESSARY TO IMPLEMENT
SECTION 4031(A) OF PUB. L. 100-203
Section 4031(a)(3)(B) of Pub. L. 100-203 provided that: "The
Secretary of Health and Human Services shall provide for such
timely amendments to agreements under section 1816 of the Social
Security Act [this section] and contracts under section 1842 of
such Act [section 1395u of this title], and regulations, to such
extent as may be necessary to implement the provisions of this
subsection [amending this section and section 1395u of this title]
on a timely basis."
PROHIBITION OF POLICIES OTHER THAN AS PROVIDED BY SECTION 4031 OF
PUB. L. 100-203 INTENDED TO SLOW DOWN MEDICARE PAYMENTS; BUDGET
CONSIDERATIONS
Section 4031(b), (c) of Pub. L. 100-203 provided that:
"(b) Prohibition of Other Policies Intended to Slow Down Medicare
Payments. - Notwithstanding any other provision of law, except as
specifically provided in this section [amending this section and
section 1395u of this title and enacting provisions set out as
notes under this section], the Secretary of Health and Human
Services is not authorized to issue, after the date of the
enactment of this Act [Dec. 22, 1987], and before October 1, 1990,
any final regulation, instruction, or other policy change which is
primarily intended to have the effect of slowing down claims
processing, or delaying payment of claims, under title XVIII of the
Social Security Act [this subchapter].
"(c) Budget Considerations. - For purposes of section 202 of the
Balanced Budget and Emergency Deficit Control Reaffirmation Act of
1987 [2 U.S.C. 909], this section is a necessary (but secondary)
result of a significant policy change."
AMENDMENTS TO AGREEMENTS AND CONTRACTS NECESSARY TO IMPLEMENT
SECTION 4032(A), (B) OF PUB. L. 100-203
Section 4032(c)(2) provided that: "The Secretary of Health and
Human Services shall provide for such timely amendments to
agreements under section 1816 [this section] and contracts under
section 1842 of the Social Security Act [section 1395u of this
title], and regulations, to such extent as may be necessary to
implement the amendments made by subsections (a) and (b) [amending
this section] on a timely basis."
REPLACEMENT OF AGENCY, ORGANIZATION, OR CARRIER PROCESSING MEDICARE
CLAIMS; NUMBER OF AGREEMENTS AND CONTRACTS AUTHORIZED FOR FISCAL
YEARS 1985 THROUGH 1993
Section 2326(a) of Pub. L. 98-369, as amended by Pub. L. 98-617,
Sec. 3(a)(2), Nov. 8, 1984, 98 Stat. 3295; Pub. L. 99-509, title
IX, Sec. 9321(b), Oct. 21, 1986, 100 Stat. 2016; Pub. L. 101-239,
title VI, Sec. 6215(a), Dec. 19, 1989, 103 Stat. 2252; Pub. L.
103-432, title I, Sec. 159(a), Oct. 31, 1994, 108 Stat. 4443,
provided that: "During each fiscal year (beginning with fiscal year
1985 and ending with fiscal year 1993), the Secretary of Health and
Human Services may enter into not more than two agreements under
section 1816 of the Social Security Act [this section], and not
more than two contracts under section 1842 of such Act [section
1395u of this title], on the basis of competitive bidding, without
regard to the nominating process under section 1816(a) of such Act
or cost reimbursement provisions under sections 1816(c) or 1842(c)
of such Act during the term of the agreement. Such procedure may be
used only for the purpose of replacing an agency or organization or
carrier which over a 2-year period of time has been in the lowest
20th percentile of agencies and organizations or carriers having
agreements or contracts under the respective section, as measured
by the Secretary's cost and performance criteria. In addition,
beginning with fiscal year 1990 and any subsequent fiscal year the
Secretary may enter into such additional agreements and contracts
without regard to such cost reimbursement provisions if the fiscal
intermediary or carrier involved and the Secretary agree to waive
such provisions, but the Secretary may not take any action that has
the effect of requiring that the intermediary or carrier agree to
waive such provisions, including requiring such a waiver as a
condition for entering into or renewing such an agreement or
contract. Any agency or organization or carrier selected on the
basis of competitive bidding must perform all of the duties listed
in section 1816(a) of such Act, or the duties listed in paragraphs
(1) through (4) of section 1842(a) of such Act, as the case may be,
and must be a health insuring organization (as determined by the
Secretary)."
[Section 159(b) of Pub. L. 103-432 provided that: "The amendment
made by subsection (a) [amending section 2326(a) of Pub. L. 98-369,
set out above] shall apply beginning with fiscal year 1994."]
[Section 6215(b) of Pub. L. 101-239 provided that: "The
amendments made by subsection (a) [amending section 2326(a) of Pub.
L. 98-369, set out above] shall apply beginning with fiscal year
1990."]
AUDIT AND MEDICAL CLAIMS REVIEW
Section 118 of Pub. L. 97-248, as amended by Pub. L. 99-272,
title IX, Sec. 9216(a), Apr. 7, 1986, 100 Stat. 180, provided that:
"In addition to any funds otherwise provided for payments to
intermediaries and carriers under agreements entered into under
sections 1816 and 1842 of the Social Security Act [this section and
section 1395u of this title], there are transferred from the
Federal Hospital Insurance Trust Fund and the Federal Supplementary
Medical Insurance Fund in such proportions as the Secretary of
Health and Human Services determines to be appropriate, an
additional $45,000,000 for each of fiscal years 1983, 1984, and
1985, and $105,000,000 for each of fiscal years 1986, 1987, and
1988 for payments to such intermediaries and carriers under such
agreements to be used exclusively for purposes of carrying out
provider cost audits, of reviewing medical necessity, and of
recovering third-party liability payments, consistent with the
provisions of sections 1816 and 1842 of the Social Security Act."
[Section 9216(b) of Pub. L. 99-272 provided that: "The amendments
made by subsection (a) [amending section 118 of Pub. L. 97-248, set
out above] shall apply to fiscal years beginning with fiscal year
1986."]
DEVELOPMENTAL DATE FOR STANDARDS, CRITERIA, AND PROCEDURES PURSUANT
TO SUBSEC. (F) OF THIS SECTION
Section 14(b) of Pub. L. 95-142 directed the Secretary of Health,
Education, and Welfare to develop the standards, criteria, and
procedures described in subsection (f) of section 1816 of the
Social Security Act [subsec. (f) of this section] (as added by
subsection (a)(5)) not later than Oct. 1, 1978.
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 1320a-3, 1320c-2,
1320c-3, 1395g, 1395u, 1395w-27, 1395cc-2, 1395ff, 1395hh, 1395mm,
1395oo, 1395pp, 1395ddd of this title.
-FOOTNOTE-
(!1) So in original. The word "and" probably should not appear.
(!2) So in original. The period probably should be ", and".
-End-
-CITE-
42 USC Sec. 1395i 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395i. Federal Hospital Insurance Trust Fund
-STATUTE-
(a) Creation; deposits; transfers from Treasury
There is hereby created on the books of the Treasury of the
United States a trust fund to be known as the "Federal Hospital
Insurance Trust Fund" (hereinafter in this section referred to as
the "Trust Fund"). The Trust Fund shall consist of such gifts and
bequests as may be made as provided in section 401(i)(1) of this
title, and such amounts as may be deposited in, or appropriated to,
such fund as provided in this part. There are hereby appropriated
to the Trust Fund for the fiscal year ending June 30, 1966, and for
each fiscal year thereafter, out of any moneys in the Treasury not
otherwise appropriated, amounts equivalent to 100 per centum of -
(1) the taxes imposed by sections 3101(b) and 3111(b) of the
Internal Revenue Code of 1986 with respect to wages reported to
the Secretary of the Treasury or his delegate pursuant to
subtitle F of such Code after December 31, 1965, as determined by
the Secretary of the Treasury by applying the applicable rates of
tax under such sections to such wages, which wages shall be
certified by the Commissioner of Social Security on the basis of
records of wages established and maintained by the Commissioner
of Social Security in accordance with such reports; and
(2) the taxes imposed by section 1401(b) of the Internal
Revenue Code of 1986 with respect to self-employment income
reported to the Secretary of the Treasury or his delegate on tax
returns under subtitle F of such Code, as determined by the
Secretary of the Treasury by applying the applicable rate of tax
under such section to such self-employment income, which
self-employment income shall be certified by the Commissioner of
Social Security on the basis of records of self-employment
established and maintained by the Commissioner of Social Security
in accordance with such returns.
The amounts appropriated by the preceding sentence shall be
transferred from time to time from the general fund in the Treasury
to the Trust Fund, such amounts to be determined on the basis of
estimates by the Secretary of the Treasury of the taxes, specified
in the preceding sentence, paid to or deposited into the Treasury;
and proper adjustments shall be made in amounts subsequently
transferred to the extent prior estimates were in excess of or were
less than the taxes specified in such sentence.
(b) Board of Trustees; composition; meetings; duties
With respect to the Trust Fund, there is hereby created a body to
be known as the Board of Trustees of the Trust Fund (hereinafter in
this section referred to as the "Board of Trustees") composed of
the Commissioner of Social Security, the Secretary of the Treasury,
the Secretary of Labor, and the Secretary of Health and Human
Services, all ex officio, and of two members of the public (both of
whom may not be from the same political party), who shall be
nominated by the President for a term of four years and subject to
confirmation by the Senate. A member of the Board of Trustees
serving as a member of the public and nominated and confirmed to
fill a vacancy occurring during a term shall be nominated and
confirmed only for the remainder of such term. An individual
nominated and confirmed as a member of the public may serve in such
position after the expiration of such member's term until the
earlier of the time at which the member's successor takes office or
the time at which a report of the Board is first issued under
paragraph (2) after the expiration of the member's term. The
Secretary of the Treasury shall be the Managing Trustee of the
Board of Trustees (hereinafter in this section referred to as the
"Managing Trustee"). The Administrator of the Health Care Financing
Administration shall serve as the Secretary of the Board of
Trustees. The Board of Trustees shall meet not less frequently than
once each calendar year. It shall be the duty of the Board of
Trustees to -
(1) Hold the Trust Fund;
(2) Report to the Congress not later than the first day of
April of each year on the operation and status of the Trust Fund
during the preceding fiscal year and on its expected operation
and status during the current fiscal year and the next 2 fiscal
years;
(3) Report immediately to the Congress whenever the Board is of
the opinion that the amount of the Trust Fund is unduly small;
and
(4) Review the general policies followed in managing the Trust
Fund, and recommend changes in such policies, including necessary
changes in the provisions of law which govern the way in which
the Trust Fund is to be managed.
The report provided for in paragraph (2) shall include a statement
of the assets of, and the disbursements made from, the Trust Fund
during the preceding fiscal year, an estimate of the expected
income to, and disbursements to be made from, the Trust Fund during
the current fiscal year and each of the next 2 fiscal years, and a
statement of the actuarial status of the Trust Fund. Such report
shall also include an actuarial opinion by the Chief Actuarial
Officer of the Health Care Financing Administration certifying that
the techniques and methodologies used are generally accepted within
the actuarial profession and that the assumptions and cost
estimates used are reasonable. Such report shall be printed as a
House document of the session of the Congress to which the report
is made. A person serving on the Board of Trustees shall not be
considered to be a fiduciary and shall not be personally liable for
actions taken in such capacity with respect to the Trust Fund.
(c) Investment of Trust Fund by Managing Trustee
It shall be the duty of the Managing Trustee to invest such
portion of the Trust Fund as is not, in his judgment, required to
meet current withdrawals. Such investments may be made only in
interest-bearing obligations of the United States or in obligations
guaranteed as to both principal and interest by the United States.
For such purpose such obligations may be acquired (1) on original
issue at the issue price, or (2) by purchase of outstanding
obligations at the market price. The purposes for which obligations
of the United States may be issued under chapter 31 of title 31 are
hereby extended to authorize the issuance at par of public-debt
obligations for purchase by the Trust Fund. Such obligations issued
for purchase by the Trust Fund shall have maturities fixed with due
regard for the needs of the Trust Fund and shall bear interest at a
rate equal to the average market yield (computed by the Managing
Trustee on the basis of market quotations as of the end of the
calendar month next preceding the date of such issue) on all
marketable interest-bearing obligations of the United States then
forming a part of the public debt which are not due or callable
until after the expiration of 4 years from the end of such calendar
month; except that where such average market yield is not a
multiple of one-eighth of 1 per centum, the rate of interest on
such obligations shall be the multiple of one-eighth of 1 per
centum nearest such market yield. The Managing Trustee may purchase
other interest-bearing obligations of the United States or
obligations guaranteed as to both principal and interest by the
United States, on original issue or at the market price, only where
he determines that the purchase of such other obligations is in the
public interest.
(d) Authority of Managing Trustee to sell obligations
Any obligations acquired by the Trust Fund (except public-debt
obligations issued exclusively to the Trust Fund) may be sold by
the Managing Trustee at the market price, and such public-debt
obligations may be redeemed at par plus accrued interest.
(e) Interest on and proceeds from sale or redemption of obligations
The interest on, and the proceeds from the sale or redemption of,
any obligations held in the Trust Fund shall be credited to and
form a part of the Trust Fund.
(f) Payment of estimated taxes
(1) The Managing Trustee is directed to pay from time to time
from the Trust Fund into the Treasury the amount estimated by him
as taxes imposed under section 3101(b) which are subject to refund
under section 6413(c) of the Internal Revenue Code of 1986 with
respect to wages paid after December 31, 1965. Such taxes shall be
determined on the basis of the records of wages established and
maintained by the Commissioner of Social Security in accordance
with the wages reported to the Secretary of the Treasury or his
delegate pursuant to subtitle F of the Internal Revenue Code of
1986, and the Commissioner of Social Security shall furnish the
Managing Trustee such information as may be required by the
Managing Trustee for such purpose. The payments by the Managing
Trustee shall be covered into the Treasury as repayments to the
account for refunding internal revenue collections.
(2) Repayments made under paragraph (1) shall not be available
for expenditures but shall be carried to the surplus fund of the
Treasury. If it subsequently appears that the estimates under such
paragraph in any particular period were too high or too low,
appropriate adjustments shall be made by the Managing Trustee in
future payments.
(g) Transfers from other Funds
There shall be transferred periodically (but not less often than
once each fiscal year) to the Trust Fund from the Federal Old-Age
and Survivors Insurance Trust Fund and from the Federal Disability
Insurance Trust Fund amounts equivalent to the amounts not
previously so transferred which the Secretary of Health and Human
Services shall have certified as overpayments (other than amounts
so certified to the Railroad Retirement Board) pursuant to section
1395gg(b) of this title. There shall be transferred periodically
(but not less often than once each fiscal year) to the Trust Fund
from the Railroad Retirement Account amounts equivalent to the
amounts not previously so transferred which the Secretary of Health
and Human Services shall have certified as overpayments to the
Railroad Retirement Board pursuant to section 1395gg(b) of this
title.
(h) Payments from Trust Fund amounts certified by Secretary
The Managing Trustee shall also pay from time to time from the
Trust Fund such amounts as the Secretary of Health and Human
Services certifies are necessary to make the payments provided for
by this part, and the payments with respect to administrative
expenses in accordance with section 401(g)(1) of this title.
(i) Payment of travel expenses for travel within United States;
reconsideration interviews and proceedings before administrative
law judges
There are authorized to be made available for expenditure out of
the Trust Fund such amounts as are required to pay travel expenses,
either on an actual cost or commuted basis, to parties, their
representatives, and all reasonably necessary witnesses for travel
within the United States (as defined in section 410(i) of this
title) to attend reconsideration interviews and proceedings before
administrative law judges with respect to any determination under
this subchapter. The amount available under the preceding sentence
for payment for air travel by any person shall not exceed the coach
fare for air travel between the points involved unless the use of
first-class accommodations is required (as determined under
regulations of the Secretary) because of such person's health
condition or the unavailability of alternative accommodations; and
the amount available for payment for other travel by any person
shall not exceed the cost of travel (between the points involved)
by the most economical and expeditious means of transportation
appropriate to such person's health condition, as specified in such
regulations. The amount available for payment under this subsection
for travel by a representative to attend an administrative
proceeding before an administrative law judge or other adjudicator
shall not exceed the maximum amount allowable under this subsection
for such travel originating within the geographic area of the
office having jurisdiction over such proceeding.
(j) Loans from other Funds; interest; repayment; report to Congress
(1) If at any time prior to January 1988 the Managing Trustee
determines that borrowing authorized under this subsection is
appropriate in order to best meet the need for financing the
benefit payments from the Federal Hospital Insurance Trust Fund,
the Managing Trustee may, subject to paragraph (5), borrow such
amounts as he determines to be appropriate from either the Federal
Old-Age and Survivors Insurance Trust Fund or the Federal
Disability Insurance Trust Fund for transfer to and deposit in the
Federal Hospital Insurance Trust Fund.
(2) In any case where a loan has been made to the Federal
Hospital Insurance Trust Fund under paragraph (1), there shall be
transferred on the last day of each month after such loan is made,
from such Trust Fund to the lending Trust Fund, the total interest
accrued to such day with respect to the unrepaid balance of such
loan at a rate equal to the rate which the lending Trust Fund would
earn on the amount involved if the loan were an investment under
subsection (c) of this section (even if such an investment would
earn interest at a rate different than the rate earned by
investments redeemed by the lending fund in order to make the
loan).
(3)(A) If in any month after a loan has been made to the Federal
Hospital Insurance Trust Fund under paragraph (1), the Managing
Trustee determines that the assets of such Trust Fund are
sufficient to permit repayment of all or part of any loans made to
such Fund under paragraph (1), he shall make such repayments as he
determines to be appropriate.
(B)(i) If on the last day of any year after a loan has been made
under paragraph (1) by the Federal Old-Age and Survivors Insurance
Trust Fund or the Federal Disability Insurance Trust Fund to the
Federal Hospital Insurance Trust Fund, the Managing Trustee
determines that the Hospital Insurance Trust Fund ratio exceeds 15
percent, he shall transfer from such Trust Fund to the lending
trust fund an amount that -
(I) together with any amounts transferred to another lending
trust fund under this paragraph for such year, will reduce the
Hospital Insurance Trust Fund ratio to 15 percent; and
(II) does not exceed the outstanding balance of such loan.
(ii) Amounts required to be transferred under clause (i) shall be
transferred on the last day of the first month of the year
succeeding the year in which the determination described in clause
(i) is made.
(iii) For purposes of this subparagraph, the term "Hospital
Insurance Trust Fund ratio" means, with respect to any calendar
year, the ratio of -
(I) the balance in the Federal Hospital Insurance Trust Fund,
as of the last day of such calendar year; to
(II) the amount estimated by the Secretary to be the total
amount to be paid from the Federal Hospital Insurance Trust Fund
during the calendar year following such calendar year (other than
payments of interest on, and repayments of, loans from the
Federal Old-Age and Survivors Insurance Trust Fund and the
Federal Disability Insurance Trust Fund under paragraph (1)), and
reducing the amount of any transfer to the Railroad Retirement
Account by the amount of any transfers into such Trust Fund from
the Railroad Retirement Account.
(C)(i) The full amount of all loans made under paragraph (1)
(whether made before or after January 1, 1983) shall be repaid at
the earliest feasible date and in any event no later than December
31, 1989.
(ii) For the period after December 31, 1987 and before January 1,
1990, the Managing Trustee shall transfer each month from the
Federal Hospital Insurance Trust Fund to any Trust Fund that is
owed any amount by the Federal Hospital Insurance Trust Fund on a
loan made under paragraph (1), an amount not less than an amount
equal to (I) the amount owed to such Trust Fund by the Federal
Hospital Insurance Trust Fund at the beginning of such month (plus
the interest accrued on the outstanding balance of such loan during
such month), divided by (II) the number of months elapsing after
the preceding month and before January 1990. The Managing Trustee
may, during this period, transfer larger amounts than prescribed by
the preceding sentence.
(4) The Board of Trustees shall make a timely report to the
Congress of any amounts transferred (including interest payments)
under this subsection.
(5)(A) No amounts may be loaned by the Federal Old-Age and
Survivors Insurance Trust Fund or the Federal Disability Insurance
Trust Fund under paragraph (1) during any month if the OASDI trust
fund ratio for such month is less than 10 percent.
(B) For purposes of this paragraph, the term "OASDI trust fund
ratio" means, with respect to any month, the ratio of -
(i) the combined balance in the Federal Old-Age and Survivors
Insurance Trust Fund and the Federal Disability Insurance Trust
Fund, reduced by the outstanding amount of any loan (including
interest thereon) theretofore made to either such Trust Fund from
the Federal Hospital Insurance Trust Fund under section 401(l) of
this title, as of the last day of the second month preceding such
month, to
(ii) the amount obtained by multiplying by twelve the total
amount which (as estimated by the Secretary) will be paid from
the Federal Old-Age and Survivors Insurance Trust Fund and the
Federal Disability Insurance Trust Fund during the month for
which such ratio is to be determined for all purposes authorized
by section 401 of this title (other than payments of interest on,
or repayments of, loans from the Federal Hospital Insurance Trust
Fund under section 401(l) of this title), but excluding any
transfer payments between such trust funds and reducing the
amount of any transfers to the Railroad Retirement Account by the
amount of any transfers into either such trust fund from that
Account.
(k) Health Care Fraud and Abuse Control Account
(1) Establishment
There is hereby established in the Trust Fund an expenditure
account to be known as the "Health Care Fraud and Abuse Control
Account" (in this subsection referred to as the "Account").
(2) Appropriated amounts to Trust Fund
(A) In general
There are hereby appropriated to the Trust Fund -
(i) such gifts and bequests as may be made as provided in
subparagraph (B);
(ii) such amounts as may be deposited in the Trust Fund as
provided in sections 242(b) and 249(c) of the Health
Insurance Portability and Accountability Act of 1996, and
subchapter XI of this chapter; and
(iii) such amounts as are transferred to the Trust Fund
under subparagraph (C).
(B) Authorization to accept gifts
The Trust Fund is authorized to accept on behalf of the
United States money gifts and bequests made unconditionally to
the Trust Fund, for the benefit of the Account or any activity
financed through the Account.
(C) Transfer of amounts
The Managing Trustee shall transfer to the Trust Fund, under
rules similar to the rules in section 9601 of the Internal
Revenue Code of 1986, an amount equal to the sum of the
following:
(i) Criminal fines recovered in cases involving a Federal
health care offense (as defined in section 24(a) of title
18).
(ii) Civil monetary penalties and assessments imposed in
health care cases, including amounts recovered under this
subchapter and subchapters XI and XIX of this chapter, and
chapter 38 of title 31 (except as otherwise provided by law).
(iii) Amounts resulting from the forfeiture of property by
reason of a Federal health care offense.
(iv) Penalties and damages obtained and otherwise
creditable to miscellaneous receipts of the general fund of
the Treasury obtained under sections 3729 through 3733 of
title 31 (known as the False Claims Act), in cases involving
claims related to the provision of health care items and
services (other than funds awarded to a relator, for
restitution or otherwise authorized by law).
(D) Application
Nothing in subparagraph (C)(iii) shall be construed to limit
the availability of recoveries and forfeitures obtained under
title I of the Employee Retirement Income Security Act of 1974
[29 U.S.C. 1001 et seq.] for the purpose of providing equitable
or remedial relief for employee welfare benefit plans, and for
participants and beneficiaries under such plans, as authorized
under such title.
(3) Appropriated amounts to Account for fraud and abuse control
program, etc.
(A) Departments of Health and Human Services and Justice
(i) In general
There are hereby appropriated to the Account from the Trust
Fund such sums as the Secretary and the Attorney General
certify are necessary to carry out the purposes described in
subparagraph (C), to be available without further
appropriation, in an amount not to exceed -
(I) for fiscal year 1997, $104,000,000,(!1)
(II) for each of the fiscal years 1998 through 2003, the
limit for the preceding fiscal year, increased by 15
percent; and
(III) for each fiscal year after fiscal year 2003, the
limit for fiscal year 2003.
(ii) Medicare and medicaid activities
For each fiscal year, of the amount appropriated in clause
(i), the following amounts shall be available only for the
purposes of the activities of the Office of the Inspector
General of the Department of Health and Human Services with
respect to the Medicare and medicaid programs -
(I) for fiscal year 1997, not less than $60,000,000 and
not more than $70,000,000;
(II) for fiscal year 1998, not less than $80,000,000 and
not more than $90,000,000;
(III) for fiscal year 1999, not less than $90,000,000 and
not more than $100,000,000;
(IV) for fiscal year 2000, not less than $110,000,000 and
not more than $120,000,000;
(V) for fiscal year 2001, not less than $120,000,000 and
not more than $130,000,000;
(VI) for fiscal year 2002, not less than $140,000,000 and
not more than $150,000,000; and
(VII) for each fiscal year after fiscal year 2002, not
less than $150,000,000 and not more than $160,000,000.
(B) Federal Bureau of Investigation
There are hereby appropriated from the general fund of the
United States Treasury and hereby appropriated to the Account
for transfer to the Federal Bureau of Investigation to carry
out the purposes described in subparagraph (C), to be available
without further appropriation -
(i) for fiscal year 1997, $47,000,000;
(ii) for fiscal year 1998, $56,000,000;
(iii) for fiscal year 1999, $66,000,000;
(iv) for fiscal year 2000, $76,000,000;
(v) for fiscal year 2001, $88,000,000;
(vi) for fiscal year 2002, $101,000,000; and
(vii) for each fiscal year after fiscal year 2002,
$114,000,000.
(C) Use of funds
The purposes described in this subparagraph are to cover the
costs (including equipment, salaries and benefits, and travel
and training) of the administration and operation of the health
care fraud and abuse control program established under section
1320a-7c(a) of this title, including the costs of -
(i) prosecuting health care matters (through criminal,
civil, and administrative proceedings);
(ii) investigations;
(iii) financial and performance audits of health care
programs and operations;
(iv) inspections and other evaluations; and
(v) provider and consumer education regarding compliance
with the provisions of subchapter XI of this chapter.
(4) Appropriated amounts to Account for Medicare Integrity
Program
(A) In general
There are hereby appropriated to the Account from the Trust
Fund for each fiscal year such amounts as are necessary to
carry out the Medicare Integrity Program under section 1395ddd
of this title, subject to subparagraph (B) and to be available
without further appropriation.
(B) Amounts specified
The amount appropriated under subparagraph (A) for a fiscal
year is as follows:
(i) For fiscal year 1997, such amount shall be not less
than $430,000,000 and not more than $440,000,000.
(ii) For fiscal year 1998, such amount shall be not less
than $490,000,000 and not more than $500,000,000.
(iii) For fiscal year 1999, such amount shall be not less
than $550,000,000 and not more than $560,000,000.
(iv) For fiscal year 2000, such amount shall be not less
than $620,000,000 and not more than $630,000,000.
(v) For fiscal year 2001, such amount shall be not less
than $670,000,000 and not more than $680,000,000.
(vi) For fiscal year 2002, such amount shall be not less
than $690,000,000 and not more than $700,000,000.
(vii) For each fiscal year after fiscal year 2002, such
amount shall be not less than $710,000,000 and not more than
$720,000,000.
(5) Annual report
Not later than January 1, the Secretary and the Attorney
General shall submit jointly a report to Congress which
identifies -
(A) the amounts appropriated to the Trust Fund for the
previous fiscal year under paragraph (2)(A) and the source of
such amounts; and
(B) the amounts appropriated from the Trust Fund for such
year under paragraph (3) and the justification for the
expenditure of such amounts.
(6) GAO report
Not later than June 1, 1998, and January 1 of 2000, 2002, and
2004, the Comptroller General of the United States shall submit a
report to Congress which -
(A) identifies -
(i) the amounts appropriated to the Trust Fund for the
previous two fiscal years under paragraph (2)(A) and the
source of such amounts; and
(ii) the amounts appropriated from the Trust Fund for such
fiscal years under paragraph (3) and the justification for
the expenditure of such amounts;
(B) identifies any expenditures from the Trust Fund with
respect to activities not involving the Medicare program under
this subchapter;
(C) identifies any savings to the Trust Fund, and any other
savings, resulting from expenditures from the Trust Fund; and
(D) analyzes such other aspects of the operation of the Trust
Fund as the Comptroller General of the United States considers
appropriate.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1817, as added Pub. L.
89-97, title I, Sec. 102(a), July 30, 1965, 79 Stat. 299; amended
Pub. L. 90-248, title I, Sec. 169(a), Jan. 2, 1968, 81 Stat. 875;
Pub. L. 92-603, title I, Sec. 132(d), Oct. 30, 1972, 86 Stat. 1361;
Pub. L. 95-292, Sec. 5, June 13, 1978, 92 Stat. 315; Pub. L.
96-265, title III, Sec. 310(c), June 9, 1980, 94 Stat. 460; Pub. L.
97-123, Sec. 1(b), Dec. 29, 1981, 95 Stat. 1659; Pub. L. 98-21,
title I, Secs. 141(b), 142(b)(1), (2)(A), (3), (4), 154(b), title
III, Sec. 341(b), Apr. 20, 1983, 97 Stat. 98, 100, 101, 107, 135;
Pub. L. 98-369, div. B, title III, Secs. 2337(a), 2354(b)(2), title
VI, Sec. 2663(j)(2)(F)(i), July 18, 1984, 98 Stat. 1091, 1100,
1170; Pub. L. 99-272, title IX, Sec. 9213(b), Apr. 7, 1986, 100
Stat. 180; Pub. L. 99-514, Sec. 2, Oct. 22, 1986, 100 Stat. 2095;
Pub. L. 100-360, title II, Sec. 212(c)(3), July 1, 1988, 102 Stat.
741; Pub. L. 100-647, title VIII, Sec. 8005(a), Nov. 10, 1988, 102
Stat. 3781; Pub. L. 101-234, title II, Sec. 202(a), Dec. 13, 1989,
103 Stat. 1981; Pub. L. 101-508, title V, Sec. 5106(c), Nov. 5,
1990, 104 Stat. 1388-268; Pub. L. 103-296, title I, Sec. 108(c)(1),
Aug. 15, 1994, 108 Stat. 1485; Pub. L. 104-191, title II, Sec.
201(b), Aug. 21, 1996, 110 Stat. 1993; Pub. L. 105-33, title IV,
Sec. 4318, Aug. 5, 1997, 111 Stat. 392; Pub. L. 106-113, div. B,
Sec. 1000(a)(6) [title III, Sec. 321(j)(1)], Nov. 29, 1999, 113
Stat. 1536, 1501A-366.)
-REFTEXT-
REFERENCES IN TEXT
The Internal Revenue Code of 1986, referred to in subsecs.
(a)(1), (2), (f)(1), and (k)(2)(C), is classified generally to
Title 26, Internal Revenue Code. Subtitle F of such Code appears at
section 6001 et seq. of Title 26.
Sections 242(b) and 249(b) of the Health Insurance Portability
and Accountability Act of 1996, referred to in subsec.
(k)(2)(A)(ii), are sections 242(b) and 249(b) of Pub. L. 104-191,
which are set out as notes under this section.
The Employee Retirement Income Security Act of 1974, referred to
in subsec. (k)(2)(D), is Pub. L. 93-406, Sept. 2, 1974, 88 Stat.
832, as amended. Title I of the Act is classified generally to
subchapter I (Sec. 1001 et seq.) of chapter 18 of Title 29, Labor.
For complete classification of this Act to the Code, see Short
Title note set out under section 1001 of Title 29 and Tables.
-MISC1-
AMENDMENTS
1999 - Subsec. (k)(2)(C)(i). Pub. L. 106-113 substituted "section
24(a)" for "section 982(a)(6)(B)".
1997 - Subsec. (k)(6). Pub. L. 105-33 inserted "June 1, 1998,
and" after "Not later than" in introductory provisions.
1996 - Subsec. (k). Pub. L. 104-191 added subsec. (k).
1994 - Subsec. (a). Pub. L. 103-296, Sec. 108(c)(1)(A),
substituted "Commissioner of Social Security" for "Secretary of
Health and Human Services" wherever appearing.
Subsec. (b). Pub. L. 103-296, Sec. 108(c)(1)(B), inserted "the
Commissioner of Social Security," after "composed of" in
introductory provisions.
Subsec. (f)(1). Pub. L. 103-296, Sec. 108(c)(1)(C), substituted
"Commissioner of Social Security" for "Secretary of Health and
Human Services" in two places.
1990 - Subsec. (i). Pub. L. 101-508 inserted at end "The amount
available for payment under this subsection for travel by a
representative to attend an administrative proceeding before an
administrative law judge or other adjudicator shall not exceed the
maximum amount allowable under this subsection for such travel
originating within the geographic area of the office having
jurisdiction over such proceeding."
1989 - Subsec. (b). Pub. L. 101-234 repealed Pub. L. 100-360,
Sec. 212(c)(3), and provided that the provisions of law amended or
repealed by such section are restored or revised as if such section
had not been enacted, see 1988 Amendment note below.
1988 - Subsec. (b). Pub. L. 100-647 inserted after first sentence
"A member of the Board of Trustees serving as a member of the
public and nominated and confirmed to fill a vacancy occurring
during a term shall be nominated and confirmed only for the
remainder of such term. An individual nominated and confirmed as a
member of the public may serve in such position after the
expiration of such member's term until the earlier of the time at
which the member's successor takes office or the time at which a
report of the Board is first issued under paragraph (2) after the
expiration of the member's term."
Pub. L. 100-360 inserted after sixth sentence "Such report shall
also identify (and treat separately) those outlays from the Trust
Fund which are also outlays from the Medicare Catastrophic Coverage
Account created under section 1395t-2 of this title and those
outlays for which there are amounts transferred into the Federal
Hospital Insurance Catastrophic Coverage Reserve Fund."
1986 - Subsec. (a)(1), (2). Pub. L. 99-514 substituted "Internal
Revenue Code of 1986" for "Internal Revenue Code of 1954".
Subsec. (b). Pub. L. 99-272 struck out provision at end of
penultimate sentence that certification shall not refer to economic
assumptions underlying Trustee's report.
Subsec. (f)(1). Pub. L. 99-514 substituted "Internal Revenue Code
of 1986" for "Internal Revenue Code of 1954" wherever appearing.
1984 - Subsec. (a). Pub. L. 98-369, Sec. 2337(a), in provisions
following par. (2) substituted "from time to time" for "monthly on
the first day of each calendar month", "paid to or deposited into
the Treasury" for "to be paid to or deposited into the Treasury
during such month", and struck out provision that all amounts
transferred to the Trust Fund under the preceding sentence had to
be invested by the Managing Trustee in the same manner and to the
same extent as the other assets of the Trust Fund, and the Trust
Fund had to pay interest to the general fund on the amount so
transferred on the first day of any month at a rate (calculated on
a daily basis, and applied against the difference between the
amount so transferred on such first day and the amount which would
have been transferred to the Trust Fund up to that day under the
procedures in effect on January 1, 1983) equal to the rate earned
by the investments of the Trust Fund in the same month under
subsec. (c).
Subsec. (a)(1), (2). Pub. L. 98-369, Sec. 2663(j)(2)(F)(i),
substituted "Health and Human Services" for "Health, Education, and
Welfare" wherever appearing.
Subsec. (c). Pub. L. 98-369, Sec. 2354(b)(2), substituted "under
chapter 31 of title 31" for "under the Second Liberty Bond Act, as
amended".
Subsecs. (f)(1), (g), (h). Pub. L. 98-369, Sec. 2663(j)(2)(F)(i),
substituted "Health and Human Services" for "Health, Education, and
Welfare" wherever appearing.
1983 - Subsec. (a). Pub. L. 98-21, Sec. 141(b)(1)(A), in
provisions following par. (2) substituted "monthly on the first day
of each calendar month" for "from time to time", substituted "to be
paid to or deposited into the Treasury during such month" for "paid
to or deposited into the Treasury", and inserted provision that all
amounts transferred to the Trust Fund under existing provisions
shall be invested by the Managing Trustee in the same manner and to
the same extent as the other assets of the Trust Fund; and the
Trust Fund shall pay interest to the general fund on the amount so
transferred on the first day of any month at a rate (calculated on
a daily basis, and applied against the difference between the
amount so transferred on such first day and the amount which would
have been transferred to the Trust Fund up to that day under the
procedures in effect on Jan. 1, 1983) equal to the rate earned by
the investments of the Trust Fund in the same month under
subsection (c).
Subsec. (b). Pub. L. 98-21, Sec. 341(b)(1), substituted in
provisions preceding par. (1) "Secretary of Health and Human
Services, all ex officio, and of two members of the public (both of
whom may not be from the same political party), who shall be
nominated by the President for a term of four years and subject to
confirmation by the Senate" for "Secretary of Health, Education,
and Welfare, all ex officio".
Pub. L. 98-21, Sec. 154(b), inserted at end provision that the
report referred to in par. (2) shall also include an actuarial
opinion by the Chief Actuarial Officer of the Health Care Financing
Administration certifying that the techniques and methodologies
used are generally accepted within the actuarial profession and
that the assumptions and cost estimates used are reasonable and
provided further that the certification shall not refer to economic
assumptions underlying the Trustee's report.
Pub. L. 98-21, Sec. 341(b)(2), inserted at end provision that a
person serving on the Board of Trustees shall not be considered to
be a fiduciary and shall not be personally liable for actions taken
in such capacity with respect to the Trust Fund.
Subsec. (j)(1). Pub. L. 98-21, Sec. 142(b)(1), substituted
reference to January 1988 for reference to January 1983 and
inserted ", subject to paragraph (5)," after "may".
Subsec. (j)(2). Pub. L. 98-21, Sec. 142(b)(2)(A), substituted "on
the last day of each month after such loan is made" for "from time
to time", substituted "the total interest accrued to such day" for
"interest", and inserted "(even if such an investment would earn
interest at a rate different than the rate earned by investments
redeemed by the lending fund in order to make the loan)".
Subsec. (j)(3)(A). Pub. L. 98-21, Sec. 142(b)(3), designated
existing provisions as subpar. (A) and added subpars. (B) and (C).
Subsec. (j)(5). Pub. L. 98-21, Sec. 142(b)(4), added par. (5).
1981 - Subsec. (j). Pub. L. 97-123 added subsec. (j).
1980 - Subsec. (i). Pub. L. 96-265 added subsec. (i).
1978 - Subsec. (b). Pub. L. 95-292 substituted "Administrator of
the Health Care Financing Administration" for "Commissioner of
Social Security" in provisions preceding par. (1).
1972 - Subsec. (a). Pub. L. 92-603 inserted "such gifts and
bequests as may be made as provided in section 401(i)(1) of this
title, and" after "consist of" and before "such amounts" in
provisions preceding par. (1).
1968 - Subsec. (b)(2). Pub. L. 90-248 substituted "April" for
"March".
EFFECTIVE DATE OF 1999 AMENDMENT
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec.
321(j)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-366, provided
that: "The amendment made by this subsection [amending this
section] shall take effect as if included in the amendment made by
section 201 of the Health Insurance Portability and Accountability
Act of 1996 (Public Law 104-191; 110 Stat. 1992)."
EFFECTIVE DATE OF 1994 AMENDMENT
Amendment by Pub. L. 103-296 effective Mar. 31, 1995, see section
110(a) of Pub. L. 103-296, set out as a note under section 401 of
this title.
EFFECTIVE DATE OF 1990 AMENDMENT
Amendment by Pub. L. 101-508 applicable with respect to
determinations made on or after July 1, 1991, and to reimbursement
for travel expenses incurred on or after Apr. 1, 1991, see section
5106(d) of Pub. L. 101-508, set out as a note under section 401 of
this title.
EFFECTIVE DATE OF 1989 AMENDMENT
Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section
202(b) of Pub. L. 100-234, set out as a note under section 401 of
this title.
EFFECTIVE DATE OF 1988 AMENDMENT
Amendment by Pub. L. 100-647 applicable to members of Board of
Trustees of Federal Hospital Insurance Trust Fund serving on such
Board as members of the public on or after Nov. 10, 1988, see
section 8005(b) of Pub. L. 100-647, set out as a note under section
401 of this title.
EFFECTIVE DATE OF 1984 AMENDMENT
Section 2337(b) of Pub. L. 98-369 provided that: "The amendments
made by subsection (a) [amending this section] shall become
effective on the first day of the month following the month in
which this Act is enacted [July 1984]."
Amendment by section 2354(b)(2) of Pub. L. 98-369 effective July
18, 1984, but not to be construed as changing or affecting any
right, liability, status, or interpretation which existed (under
the provisions of law involved) before that date, see section
2354(e)(1) of Pub. L. 98-369, set out as a note under section
1320a-1 of this title.
Amendment by section 2663(j)(2)(F)(i) of Pub. L. 98-369 effective
July 18, 1984, but not to be construed as changing or affecting any
right, liability, status, or interpretation which existed (under
the provisions of law involved) before that date, see section
2664(b) of Pub. L. 98-369, set out as a note under section 401 of
this title.
EFFECTIVE DATE OF 1983 AMENDMENT
Amendment by section 141(b) of Pub. L. 98-21 effective on first
day of month following April 1983, see section 141(c) of Pub. L.
98-21, set out as a note under section 401 of this title.
Section 142(b)(2)(B) of Pub. L. 98-21 provided that: "The
amendment made by this paragraph [amending this section] shall
apply with respect to months beginning more than 30 days after the
date of enactment of this Act [Apr. 20, 1983]."
Amendment by sections 154(b) and 341(b) of Pub. L. 98-21
effective Apr. 20, 1983, see sections 154(e) and 341(d) of Pub. L.
98-21, set out as notes under section 401 of this title.
EFFECTIVE DATE OF 1981 AMENDMENT
Amendment by Pub. L. 97-123 effective Dec. 29, 1981, see section
1(c) of Pub. L. 97-123, set out as a note under section 401 of this
title.
EFFECTIVE DATE OF 1978 AMENDMENT
Amendment by Pub. L. 95-292 effective with respect to services,
supplies, and equipment furnished after the third calendar month
beginning after June 13, 1978, except that provisions for the
implementation of an incentive reimbursement system for dialysis
services furnished in facilities and providers to become effective
with respect to a facility's or provider's first accounting period
beginning after the last day of the twelfth month following the
month of June 1978, and except that provisions for reimbursement
rates for home dialysis to become effective on Apr. 1, 1979, see
section 6 of Pub. L. 95-292, set out as a note under section 426 of
this title.
EFFECTIVE DATE OF 1972 AMENDMENT
Amendment by Pub. L. 92-603 applicable with respect to gifts and
bequests received after Oct. 30, 1972, see section 132(f) of Pub.
L. 92-603, set out as a note under section 401 of this title.
TERMINATION OF REPORTING REQUIREMENTS
For termination, effective May 15, 2000, of provisions of law
requiring submittal to Congress of any annual, semiannual, or other
regular periodic report listed in House Document No. 103-7 (in
which certain reporting requirements under subsec. (b)(2) of this
section are listed in item 7 on page 143), see section 3003 of Pub.
L. 104-66, as amended, and section 1(a)(4) [div. A, Sec. 1402(1)]
of Pub. L. 106-554, set out as notes under section 1113 of Title
31, Money and Finance.
CRIMINAL FINES DEPOSITED IN FEDERAL HOSPITAL INSURANCE TRUST FUND
Section 242(b) of Pub. L. 104-191 provided that: "The Secretary
of the Treasury shall deposit into the Federal Hospital Insurance
Trust Fund pursuant to section 1817(k)(2)(C) of the Social Security
Act (42 U.S.C. 1395i) an amount equal to the criminal fines imposed
under section 1347 of title 18, United States Code (relating to
health care fraud)."
PROPERTY FORFEITED DEPOSITED IN FEDERAL HOSPITAL INSURANCE TRUST
FUND
Section 249(c) of Pub. L. 104-191 provided that:
"(1) In general. - After the payment of the costs of asset
forfeiture has been made and after all restoration payments (if
any) have been made, and notwithstanding any other provision of
law, the Secretary of the Treasury shall deposit into the Federal
Hospital Insurance Trust Fund pursuant to section 1817(k)(2)(C) of
the Social Security Act [subsec. (k)(2)(C) of this section], as
added by section 301(b), an amount equal to the net amount realized
from the forfeiture of property by reason of a Federal health care
offense pursuant to section 982(a)(6) of title 18, United States
Code.
"(2) Costs of asset forfeiture. - For purposes of paragraph (1),
the term 'payment of the costs of asset forfeiture' means -
"(A) the payment, at the discretion of the Attorney General, of
any expenses necessary to seize, detain, inventory, safeguard,
maintain, advertise, sell, or dispose of property under seizure,
detention, or forfeited, or of any other necessary expenses
incident to the seizure, detention, forfeiture, or disposal of
such property, including payment for -
"(i) contract services;
"(ii) the employment of outside contractors to operate and
manage properties or provide other specialized services
necessary to dispose of such properties in an effort to
maximize the return from such properties; and
"(iii) reimbursement of any Federal, State, or local agency
for any expenditures made to perform the functions described in
this subparagraph;
"(B) at the discretion of the Attorney General, the payment of
awards for information or assistance leading to a civil or
criminal forfeiture involving any Federal agency participating in
the Health Care Fraud and Abuse Control Account;
"(C) the compromise and payment of valid liens and mortgages
against property that has been forfeited, subject to the
discretion of the Attorney General to determine the validity of
any such lien or mortgage and the amount of payment to be made,
and the employment of attorneys and other personnel skilled in
State real estate law as necessary;
"(D) payment authorized in connection with remission or
mitigation procedures relating to property forfeited; and
"(E) the payment of State and local property taxes on forfeited
real property that accrued between the date of the violation
giving rise to the forfeiture and the date of the forfeiture
order.
"(3) Restoration payment. - Notwithstanding any other provision
of law, if the Federal health care offense referred to in paragraph
(1) resulted in a loss to an employee welfare benefit plan within
the meaning of section 3(1) of the Employee Retirement Income
Security Act of 1974 [29 U.S.C. 1002(1)], the Secretary of the
Treasury shall transfer to such employee welfare benefit plan, from
the amount realized from the forfeiture of property referred to in
paragraph (1), an amount equal to such loss. For purposes of
paragraph (1), the term 'restoration payment' means the amount
transferred to an employee welfare benefit plan pursuant to this
paragraph."
DUE DATE FOR 1983 REPORT ON OPERATION AND STATUS OF TRUST FUND
Notwithstanding subsec. (b)(2) of this section, the annual report
of the Board of Trustees of the Trust Fund required for calendar
year 1983 under this section may be filed at any time not later
than forty-five days after Apr. 20, 1983, see section 154(d) of
Pub. L. 98-21, set out as a note under section 401 of this title.
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 401, 417, 426a, 429, 910,
1320a-7a, 1320b-12, 1395b-1, 1395i-1, 1395gg, 1395vv, 1395yy,
1395ggg, 1396m of this title.
-FOOTNOTE-
(!1) So in original. The comma probably should be a semicolon.
-End-
-CITE-
42 USC Sec. 1395i-1 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395i-1. Authorization of appropriations
-STATUTE-
There are authorized to be appropriated to the Federal Hospital
Insurance Trust Fund (established by section 1395i of this title)
from time to time such sums as the Secretary deems necessary for
any fiscal year, on account of -
(1) payments made or to be made during such fiscal year from
such Trust Fund under this part with respect to individuals who
are qualified railroad retirement beneficiaries (as defined in
section 426(c) of this title) and who are not, and upon filing
application for monthly insurance benefits under section 402 of
this title would not be, entitled to such benefits if service as
an employee (as defined in the Railroad Retirement Act of 1937
[45 U.S.C. 228a et seq.]) after December 31, 1936, had been
included in the term "employment" as defined in this chapter,
(2) the additional administrative expenses resulting or
expected to result therefrom, and
(3) any loss of interest to such Trust Fund resulting from the
payment of such amounts,
in order to place such Trust Fund in the same position at the end
of such fiscal year in which it would have been if the individuals
described in paragraph (1) had not been entitled to benefits under
this part.
-SOURCE-
(Pub. L. 89-97, title I, Sec. 111(d), July 30, 1965, 79 Stat. 343.)
-REFTEXT-
REFERENCES IN TEXT
The Railroad Retirement Act of 1937, referred to in text, is act
Aug. 29, 1935, ch. 812, 49 Stat. 867, as amended generally by act
June 24, 1937, ch. 382, part I, 50 Stat. 307, and which was
classified principally to subchapter III (Sec. 228a et seq.) of
chapter 9 of Title 45, Railroads. The Railroad Retirement Act of
1937 was amended generally and redesignated the Railroad Retirement
Act of 1974 by Pub. L. 93-445, title I, Oct. 16, 1974, 88 Stat.
1305. The Railroad Retirement Act of 1974 is classified generally
to subchapter IV (Sec. 231 et seq.) of chapter 9 of title 45. For
complete classification of these Acts to the Code, see Tables.
-COD-
CODIFICATION
Section was enacted as part of the Social Security Amendments of
1965 and also as part of the Health Insurance for the Aged Act, and
not as part of the Social Security Act which comprises this
chapter.
-MISC1-
EFFECTIVE DATE
Section 111(e) of Pub. L. 89-97 provided that:
"(1) The amendments made by the preceding provisions of this
section [enacting this section and section 228s-2 of Title 45,
Railroads, and amending section 1395kk of this title and sections
1401, 3101, 3111, 3201, 3211, and 3221 of Title 26, Internal
Revenue Code, and section 228e of Title 45] shall apply to the
calendar year 1966 or to any subsequent calendar year, but only if
the requirement in paragraph (2) has been met with respect to such
calendar year.
"(2) The requirement referred to in paragraph (1) shall be deemed
to have been met with respect to any calendar year if, as of the
October 1 immediately preceding such calendar year, the Railroad
Retirement Tax Act [section 3101 et seq. of Title 26] provides that
the maximum amount of monthly compensation taxable under such Act
during all months of such calendar year will be an amount equal to
one-twelfth of the maximum wages which the Federal Insurance
Contributions Act [section 3201 et seq. of Title 26] provides may
be counted for such calendar year."
-End-
-CITE-
42 USC Sec. 1395i-1a 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395i-1a. Repealed. Pub. L. 101-234, title I, Sec. 102(a),
Dec. 13, 1989, 103 Stat. 1980
-MISC1-
Section, act Aug. 14, 1935, ch. 531, title XVIII, Sec. 1817A, as
added July 1, 1988, Pub. L. 100-360, title I, Sec. 112(a), 102
Stat. 698, provided for establishment and operation of Federal
Hospital Insurance Catastrophic Coverage Reserve Fund.
EFFECTIVE DATE OF REPEAL
Repeal effective Jan. 1, 1990, see section 102(d)(1) of Pub. L.
101-234, set out as a note under section 59B of Title 26, Internal
Revenue Code.
ADJUSTMENTS FOR INTEREST LOST DUE TO DELAY OF TRANSFERS TO RESERVE
FUND DURING 1989
Section 112(b) of Pub. L. 100-360, which directed Secretary of
the Treasury, in July of 1990, to calculate interest lost to
Federal Hospital Insurance Catastrophic Coverage Reserve Fund due
to lag between outlays (attributable to amendments made by Pub. L.
100-360) from Federal Hospital Insurance Trust Fund during 1989 and
transfers made to such Reserve Fund to cover such outlays, and
provided that appropriations under subsection (a)(2) of this
section include amount so calculated, was repealed by Pub. L.
101-234, title I, Sec. 102(a), Dec. 13, 1989, 103 Stat. 1980.
-End-
-CITE-
42 USC Sec. 1395i-2 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395i-2. Hospital insurance benefits for uninsured elderly
individuals not otherwise eligible
-STATUTE-
(a) Individuals eligible to enroll
Every individual who -
(1) has attained the age of 65,
(2) is enrolled under part B of this subchapter,
(3) is a resident of the United States, and is either (A) a
citizen or (B) an alien lawfully admitted for permanent residence
who has resided in the United States continuously during the 5
years immediately preceding the month in which he applies for
enrollment under this section, and
(4) is not otherwise entitled to benefits under this part,
shall be eligible to enroll in the insurance program established by
this part.
(b) Time, manner, and form of enrollment
An individual may enroll under this section only in such manner
and form as may be prescribed in regulations, and only during an
enrollment period prescribed in or under this section.
(c) Period of enrollment; scope of coverage
The provisions of section 1395p of this title (except subsection
(f) thereof), section 1395q of this title, subsection (b) of
section 1395r of this title, and subsections (f) and (h) of section
1395s of this title shall apply to persons authorized to enroll
under this section except that -
(1) individuals who meet the conditions of subsection (a)(1),
(3), and (4) of this section on or before the last day of the
seventh month after October 1972 may enroll under this part and
(if not already so enrolled) may also enroll under part B of this
subchapter during an initial general enrollment period which
shall begin on the first day of the second month which begins
after October 30, 1972, and shall end on the last day of the
tenth month after October 1972;
(2) in the case of an individual who first meets the conditions
of eligibility under this section on or after the first day of
the eighth month after October 1972, the initial enrollment
period shall begin on the first day of the third month before the
month in which he first becomes eligible and shall end 7 months
later;
(3) in the case of an individual who enrolls pursuant to
paragraph (1) of this subsection, entitlement to benefits shall
begin on -
(A) the first day of the second month after the month in
which he enrolls,
(B) July 1, 1973, or
(C) the first day of the first month in which he meets the
requirements of subsection (a) of this section,
whichever is the latest;
(4) an individual's entitlement under this section shall
terminate with the month before the first month in which he
becomes eligible for hospital insurance benefits under section
426 of this title or section 426a of this title; and upon such
termination, such individual shall be deemed, solely for purposes
of hospital insurance entitlement, to have filed in such first
month the application required to establish such entitlement;
(5) termination of coverage for supplementary medical insurance
shall result in simultaneous termination of hospital insurance
benefits for uninsured individuals who are not otherwise entitled
to benefits under this chapter;
(6) any percent increase effected under section 1395r(b) of
this title in an individual's monthly premium may not exceed 10
percent and shall only apply to premiums paid during a period
equal to twice the number of months in the full 12-month periods
described in that section and shall be subject to reduction in
accordance with subsection (d)(6) of this section;
(7) an individual who meets the conditions of subsection (a) of
this section may enroll under this part during a special
enrollment period that includes any month during any part of
which the individual is enrolled under section 1395mm of this
title with an eligible organization and ending with the last day
of the 8th consecutive month in which the individual is at no
time so enrolled;
(8) in the case of an individual who enrolls during a special
enrollment period under paragraph (7) -
(A) in any month of the special enrollment period in which
the individual is at any time enrolled under section 1395mm of
this title with an eligible organization or in the first month
following such a month, the coverage period shall begin on the
first day of the month in which the individual so enrolls (or,
at the option of the individual, on the first day of any of the
following three months), or
(B) in any other month of the special enrollment period, the
coverage period shall begin on the first day of the month
following the month in which the individual so enrolls; and
(9) in applying the provisions of section 1395r(b) of this
title, there shall not be taken into account months for which the
individual can demonstrate that the individual was enrolled under
section 1395mm of this title with an eligible organization.
(d) Monthly premiums
(1) The Secretary shall, during September of each year (beginning
with 1988), estimate the monthly actuarial rate for months in the
succeeding year. Such actuarial rate shall be one-twelfth of the
amount which the Secretary estimates (on an average, per capita
basis) is equal to 100 percent of the benefits and administrative
costs which will be payable from the Federal Hospital Insurance
Trust Fund for services performed and related administrative costs
incurred in the succeeding year with respect to individuals age 65
and over who will be entitled to benefits under this part during
that year.
(2) The Secretary shall, during September of each year (!1)
determine and promulgate the dollar amount which shall be
applicable for premiums for months occurring in the following year.
Subject to paragraphs (4) and (5), the amount of an individual's
monthly premium under this section shall be equal to the monthly
actuarial rate determined under paragraph (1) for that following
year. Any amount determined under the preceding sentence which is
not a multiple of $1 shall be rounded to the nearest multiple of $1
(or, if it is a multiple of 50 cents but not a multiple of $1, to
the next higher multiple of $1).
(3) Whenever the Secretary promulgates the dollar amount which
shall be applicable as the monthly premium under this section, he
shall, at the time such promulgation is announced, issue a public
statement setting forth the actuarial assumptions and bases
employed by him in arriving at the amount of an adequate actuarial
rate for individuals 65 and older as provided in paragraph (1).
(4)(A) In the case of an individual described in subparagraph
(B), the monthly premium for a month shall be reduced by the
applicable reduction percent specified in the following table:
The applicable
reduction
For a month in: percent is:
1994 25 percent
1995 30 percent
1996 35 percent
1997 40 percent
1998 or subsequent year 45 percent.
(B) An individual described in this subparagraph with respect to
a month is an individual who establishes to the satisfaction of the
Secretary that, as of the last day of the previous month, the
individual -
(i) had at least 30 quarters of coverage under subchapter II of
this chapter;
(ii) was married (and had been married for the previous 1-year
period) to an individual who had at least 30 quarters of coverage
under such subchapter;
(iii) had been married to an individual for a period of at
least 1 year (at the time of such individual's death) if at such
time the individual had at least 30 quarters of coverage under
such subchapter; or
(iv) is divorced from an individual and had been married to the
individual for a period of at least 10 years (at the time of the
divorce) if at such time the individual had at least 30 quarters
of coverage under such subchapter.
(5)(A) The amount of the monthly premium shall be zero in the
case of an individual who is a person described in subparagraph (B)
for a month, if -
(i) the individual's premium under this section for the month
is not (and will not be) paid for, in whole or in part, by a
State (under subchapter XIX of this chapter or otherwise), a
political subdivision of a State, or an agency or instrumentality
of one or more States or political subdivisions thereof; and
(ii) in each of 84 months before such month, the individual was
enrolled in this part under this section and the payment of the
individual's premium under this section for the month was not
paid for, in whole or in part, by a State (under subchapter XIX
of this chapter or otherwise), a political subdivision of a
State, or an agency or instrumentality of one or more States or
political subdivisions thereof.
(B) A person described in this subparagraph for a month is a
person who establishes to the satisfaction of the Secretary that,
as of the last day of the previous month -
(i)(I) the person was receiving cash benefits under a qualified
State or local government retirement system (as defined in
subparagraph (C)) on the basis of the person's employment in one
or more positions covered under any such system, and (II) the
person would have at least 40 quarters of coverage under
subchapter II of this chapter if remuneration for medicare
qualified government employment (as defined in paragraph (1) of
section 410(p) of this title, but determined without regard to
paragraph (3) of such section) paid to such person were treated
as wages paid to such person and credited for purposes of
determining quarters of coverage under section 413 of this title;
(ii)(I) the person was married (and had been married for the
previous 1-year period) to an individual who is described in
clause (i), or (II) the person met the requirement of clause
(i)(II) and was married (and had been married for the previous
1-year period) to an individual described in clause (i)(I);
(iii) the person had been married to an individual for a period
of at least 1 year (at the time of such individual's death) if
(I) the individual was described in clause (i) at the time of the
individual's death, or (II) the person met the requirement of
clause (i)(II) and the individual was described in clause (i)(I)
at the time of the individual's death; or
(iv) the person is divorced from an individual and had been
married to the individual for a period of at least 10 years (at
the time of the divorce) if (I) the individual was described in
clause (i) at the time of the divorce, or (II) the person met the
requirement of clause (i)(II) and the individual was described in
clause (i)(I) at the time of the divorce.
(C) For purposes of subparagraph (B)(i)(I), the term "qualified
State or local government retirement system" means a retirement
system that -
(i) is established or maintained by a State or political
subdivision thereof, or an agency or instrumentality of one or
more States or political subdivisions thereof;
(ii) covers positions of some or all employees of such a State,
subdivision, agency, or instrumentality; and
(iii) does not adjust cash retirement benefits based on
eligibility for a reduction in premium under this paragraph.
(6)(A) In the case where a State, a political subdivision of a
State, or an agency or instrumentality of a State or political
subdivision thereof determines to pay, for the life of each
individual, the monthly premiums due under paragraph (1) on behalf
of each of the individuals in a qualified State or local government
retiree group who meets the conditions of subsection (a) of this
section, the amount of any increase otherwise applicable under
section 1395r(b) of this title (as applied and modified by
subsection (c)(6) of this section) with respect to the monthly
premium for benefits under this part for an individual who is a
member of such group shall be reduced by the total amount of taxes
paid under section 3101(b) of the Internal Revenue Code of 1986 by
such individual and under section 3111(b) by the employers of such
individual on behalf of such individual with respect to employment
(as defined in section 3121(b) of such Code).
(B) For purposes of this paragraph, the term "qualified State or
local government retiree group" means all of the individuals who
retire prior to a specified date that is before January 1, 2002,
from employment in one or more occupations or other broad classes
of employees of -
(i) the State;
(ii) a political subdivision of the State; or
(iii) an agency or instrumentality of the State or political
subdivision of the State.
(e) Contract or other arrangement for payment of monthly premiums
Payment of the monthly premiums on behalf of any individual who
meets the conditions of subsection (a) of this section may be made
by any public or private agency or organization under a contract or
other arrangement entered into between it and the Secretary if the
Secretary determines that payment of such premiums under such
contract or arrangement is administratively feasible.
(f) Deposit of amounts into Treasury
Amounts paid to the Secretary for coverage under this section
shall be deposited in the Treasury to the credit of the Federal
Hospital Insurance Trust Fund.
(g) Buy-in under this part for qualified medicare beneficiaries
(1) The Secretary shall, at the request of a State made after
1989, enter into a modification of an agreement entered into with
the State pursuant to section 1395v(a) of this title under which
the agreement provides for enrollment in the program established by
this part of qualified medicare beneficiaries (as defined in
section 1396d(p)(1) of this title).
(2)(A) Except as provided in subparagraph (B), the provisions of
subsections (c), (d), (e), and (f) of section 1395v of this title
shall apply to qualified medicare beneficiaries enrolled, pursuant
to such agreement, in the program established by this part in the
same manner and to the same extent as they apply to qualified
medicare beneficiaries enrolled, pursuant to such agreement, in
part B of this subchapter.
(B) For purposes of this subsection, section 1395v(d)(1) of this
title shall be applied by substituting "section 1395i-2 of this
title" for "section 1395r of this title" and "subsection (c)(6)
(with reference to subsection (b) of section 1395r of this title)"
for "subsection (b).".(!2)
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1818, as added Pub. L.
92-603, title II, Sec. 202, Oct. 30, 1972, 86 Stat. 1374; amended
Pub. L. 98-21, title VI, Sec. 606(a)(3)(D), (b), Apr. 20, 1983, 97
Stat. 170, 171; Pub. L. 98-369, div. B, title III, Secs. 2315(e),
2354(b)(3), (4), July 18, 1984, 98 Stat. 1080, 1100; Pub. L.
99-272, title IX, Sec. 9124(a), Apr. 7, 1986, 100 Stat. 168; Pub.
L. 100-203, title IV, Sec. 4009(j)(9), Dec. 22, 1987, as added Pub.
L. 100-360, title IV, Sec. 411(b)(8)(D), July 1, 1988, 102 Stat.
772; Pub. L. 100-360, title I, Sec. 103, July 1, 1988, 102 Stat.
687; Pub. L. 100-485, title VI, Sec. 608(d)(2), Oct. 13, 1988, 102
Stat. 2413; Pub. L. 101-239, title VI, Secs. 6012(a)(1), 6013(a),
Dec. 19, 1989, 103 Stat. 2161, 2163; Pub. L. 101-508, title IV,
Sec. 4008(g)(1), (m)(3)(D), Nov. 5, 1990, 104 Stat. 1388-45,
1388-54; Pub. L. 103-66, title XIII, Sec. 13508(a), Aug. 10, 1993,
107 Stat. 579; Pub. L. 105-33, title IV, Sec. 4453(a), Aug. 5,
1997, 111 Stat. 425; Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec.
331(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A-502.)
-REFTEXT-
REFERENCES IN TEXT
Part B of this subchapter, referred to in subsecs. (a)(2),
(c)(1), and (g)(2)(A), is classified to section 1395j et seq. of
this title.
The Internal Revenue Code of 1986, referred to in subsec.
(d)(6)(A), is classified generally to Title 26, Internal Revenue
Code.
-MISC1-
AMENDMENTS
2000 - Subsec. (c)(6). Pub. L. 106-554, Sec. 1(a)(6) [title III,
Sec. 331(a)(1)], inserted "and shall be subject to reduction in
accordance with subsection (d)(6) of this section" before
semicolon.
Subsec. (d)(6). Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec.
331(a)(2)], added par. (6).
1997 - Subsec. (d)(2). Pub. L. 105-33, Sec. 4453(a)(1),
substituted "paragraphs (4) and (5)" for "paragraph (4)".
Subsec. (d)(5). Pub. L. 105-33, Sec. 4453(a)(2), added par. (5).
1993 - Subsec. (d)(2). Pub. L. 103-66, Sec. 13508(a)(1),
substituted "Subject to paragraph (4), the amount of an
individual's monthly premium under this section" for "Such amount".
Subsec. (d)(4). Pub. L. 103-66, Sec. 13508(a)(2), added par. (4).
1990 - Subsec. (c)(7) to (9). Pub. L. 101-508, Sec. 4008(g)(1),
added pars. (7) to (9).
Subsec. (g)(2)(B). Pub. L. 101-508, Sec. 4008(m)(3)(D),
substituted " 'subsection (c)(6)" for " 'subsection (c)".
1989 - Pub. L. 101-239, Sec. 6012(a)(1), inserted "elderly" after
"uninsured" in section catchline.
Subsec. (g). Pub. L. 101-239, Sec. 6013(a), added subsec. (g).
1988 - Subsec. (c)(4) to (7). Pub. L. 100-360, Sec. 411(b)(8)(D),
added Pub. L. 100-203, Sec. 4009(j)(9), see 1987 Amendment note
below.
Subsec. (d). Pub. L. 100-360, Sec. 103, amended subsec. (d)
generally. Prior to amendment, subsec. (d) read as follows:
"(1) The monthly premium of each individual for each month in his
coverage period before July 1974 shall be $33.
"(2) The Secretary shall, during the next to last calendar
quarter of each year determine and promulgate the dollar amount
(whether or not such dollar amount was applicable for premiums for
any prior month) which shall be applicable for premiums for months
occurring in the following calendar year. Such amount shall be
equal to $33, multiplied by the ratio of (A) the inpatient hospital
deductible for that following calendar year, as promulgated under
section 1395e(b)(2) of this title, to (B) such deductible
promulgated for 1973. Any amount determined under the preceding
sentence which is not a multiple of $1 shall be rounded to the
nearest multiple of $1, or, if a multiple of 50 cents but not a
multiple of $1, to the next higher multiple of $1."
Subsec. (d)(1). Pub. L. 100-485 substituted "during that year"
for "during that entire year".
1987 - Subsec. (c)(4) to (7). Pub. L. 100-203, Sec. 4009(j)(9),
as added by Pub. L. 100-360, Sec. 411(b)(8)(D), redesignated pars.
(5) to (7) as (4) to (6), respectively, and struck out former par.
(4) which read as follows: "termination of coverage under this
section by the filing of notice that the individual no longer
wishes to participate in the hospital insurance program shall take
effect at the close of the month following the month in which such
notice is filed;".
1986 - Subsec. (c)(7). Pub. L. 99-272 added par. (7).
1984 - Subsec. (c). Pub. L. 98-369, Sec. 2315(e), substituted
"subsection (b) of section 1395r of this title" for "subsection (a)
of section 1395r of this title".
Subsec. (c)(1). Pub. L. 98-369, Sec. 2354(b)(3), substituted
"October 1972" for "the month in which this Act is enacted".
Subsec. (d)(2). Pub. L. 98-369, Sec. 2354(b)(4), substituted ",
if a multiple of 50 cents but not a multiple of $1," for "if midway
between multiples of $1".
1983 - Subsec. (c). Pub. L. 98-21, Sec. 606(a)(3)(D), substituted
"subsection (a) of section 1395r" for "subsection (c) of section
1395r".
Subsec. (d)(2). Pub. L. 98-21, Sec. 606(b), substituted "during
the next to last calendar quarter of each year" for "during the
last calendar quarter of each year, beginning in 1973,", "the
following calendar year" for "the 12-month period commencing July 1
of the next year", and "for that following calendar year" for "for
such next year".
EFFECTIVE DATE OF 2000 AMENDMENT
Pub. L. 106-554, Sec. 1(a)(6) [title III, Sec. 331(b)], Dec. 21,
2000, 114 Stat. 2763, 2763A-502, provided that: "The amendments
made by subsection (a) [amending this section] shall apply to
premiums for months beginning with January 1, 2002."
EFFECTIVE DATE OF 1997 AMENDMENT
Section 4453(b) of Pub. L. 105-33 provided that: "The amendments
made by subsection (a) [amending this section] shall apply to
premiums for months beginning with January 1998, and months before
such month may be taken into account for purposes of meeting the
requirement of section 1818(d)(5)(B)(iii) of the Social Security
Act [subsec. (d)(5)(B)(iii) of this section], as added by
subsection (a)."
EFFECTIVE DATE OF 1993 AMENDMENT
Section 13508(b) of Pub. L. 103-66 provided that: "The amendments
made by this section [amending this section] shall apply to monthly
premiums under section 1818 of the Social Security Act [this
section] for months beginning with January 1, 1994."
EFFECTIVE DATE OF 1990 AMENDMENT
Section 4008(g)(2) of Pub. L. 101-508 provided that: "The
amendment made by paragraph (1) [amending this section] shall take
effect on February 1, 1991."
EFFECTIVE DATE OF 1989 AMENDMENT
Amendment by section 6012(a)(1) of Pub. L. 101-239 effective Dec.
19, 1989, but not applicable so as to provide coverage under this
part for any month before July 1990, see section 6012(b) of Pub. L.
101-239, set out as an Effective Date note under section 1395i-2a
of this title.
Section 6013(c) of Pub. L. 101-239 provided that: "The amendments
made by this section [amending this section and section 1395v of
this title] shall become effective January 1, 1990."
EFFECTIVE DATE OF 1988 AMENDMENTS
Amendment by Pub. L. 100-485 effective as if originally included
in the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100-360,
see section 608(g)(1) of Pub. L. 100-485, set out as a note under
section 704 of this title.
Amendment by section 103 of Pub. L. 100-360 effective Jan. 1,
1989, except as otherwise provided, and applicable to inpatient
hospital deductible for 1989 and succeeding years, to care and
services furnished on or after Jan. 1, 1989, to premiums for
January 1989 and succeeding months, and to blood or blood cells
furnished on or after Jan. 1, 1989, see section 104(a) of Pub. L.
100-360, set out as a note under section 1395d of this title.
Except as specifically provided in section 411 of Pub. L.
100-360, amendment by section 411(b)(8)(D) of Pub. L. 100-360, as
it relates to a provision in the Omnibus Budget Reconciliation Act
of 1987, Pub. L. 100-203, effective as if included in the enactment
of that provision in Pub. L. 100-203, see section 411(a) of Pub. L.
100-360, set out as a Reference to OBRA; Effective Date note under
section 106 of Title 1, General Provisions.
EFFECTIVE DATE OF 1986 AMENDMENT
Section 9124(b) of Pub. L. 99-272 provided that:
"(1) The amendment made by subsection (a)(3) [amending this
section] shall apply to premiums paid for months beginning with
July 1986.
"(2) In applying that amendment, months (before, during, or after
April 1986) in which an individual was required to pay a premium
increased under the section that was so amended shall be taken into
account in determining the month in which the premium will no
longer be subject to an increase under that section as so amended."
EFFECTIVE DATE OF 1984 AMENDMENT
Amendment by section 2315(e) of Pub. L. 98-369 effective as
though included in the enactment of the Social Security Amendments
of 1983, Pub. L. 98-21, see section 2315(g) of Pub. L. 98-369, set
out as an Effective and Termination Dates of 1984 Amendments note
under section 1395ww of this title.
Amendment by section 2354(b)(3), (4) of Pub. L. 98-369 effective
July 18, 1984, but not to be construed as changing or affecting any
right, liability, status, or interpretation which existed (under
the provisions of law involved) before that date, see section
2354(e)(1) of Pub. L. 98-369, set out as a note under section
1320a-1 of this title.
EFFECTIVE DATE OF 1983 AMENDMENT; TRANSITIONAL RULE
Amendment by Pub. L. 98-21 applicable to premiums for months
beginning with January 1984, but for months after June 1983 and
before January 1984, the monthly premium for June 1983 shall apply
to individuals enrolled under parts A and B of this subchapter, see
section 606(c) of Pub. L. 98-21, set out as a note under section
1395r of this title.
SPECIAL ENROLLMENT PROVISIONS FOR MERCHANT SEAMEN
Pub. L. 97-248, title I, Sec. 125, Sept. 3, 1982, 96 Stat. 365,
provided that:
"(a) Any individual who -
"(1) was entitled to medical, surgical, and dental treatment
and hospitalization under section 322(a) of the Public Health
Service Act [section 249(a) of this title] (as in effect on
September 30, 1981), including such entitlement on the basis of
continuing medical care under 42 C.F.R. Sec. 32.17, at any time
during the period beginning on March 10, 1981, and ending on
October 1, 1981, and
"(2) as of September 30, 1981, was eligible under section
1818(a) or section 1836 of the Social Security Act [this section
or section 1395o of this title] to enroll in the insurance
program established by part A or part B, respectively, of title
XVIII of that Act [this subchapter] (hereinafter in this section
referred to as the 'respective program'),
may enroll (if not otherwise enrolled) in the respective program
during the period beginning on the first day of the first month
beginning at least 20 days after the date of the enactment of this
Act [Sept. 3, 1982] and ending on December 31, 1982.
"(b)(1) The coverage period under the respective program of an
individual who enrolls under subsection (a) shall begin -
"(A) on the first day of the month following the month in which
the individual enrolls, or
"(B) on October 1, 1981, if the individual files a request for
this subparagraph to apply and pays the monthly premiums for the
months so covered.
"(2) The coverage period under the respective program of an
individual described in subsection (a) who enrolled in the
respective program before the enrollment period described in that
subsection shall be retroactively extended to October 1, 1981, if
the individual files a request before January 1, 1983, for such
retroactive extension and pays the monthly premiums for the months
so covered.
"(c)(1) For purposes of section 1839(d) of the Social Security
Act [section 1395r(d) of this title] with respect to the monthly
premium for months after September 1981, if an individual described
in subsection (a) has enrolled in the insurance program under part
B of title XVIII of the Social Security Act [part B of this
subchapter] at any time before the end of the enrollment period
described in subsection (a), any month (before the end of that
enrollment period) in which he was not enrolled in that program
shall not be treated as a month in which he could have been
enrolled in the program.
"(2) Paragraph (1) shall not apply to an individual -
"(A) if the individual has enrolled in the insurance program
before March 10, 1981, unless the enrollment was terminated
solely because the individual lost eligibility to be so enrolled,
or
"(B) unless the individual applies for the benefit of such
paragraph before January 1, 1983.
"(d)(1) The Secretary of Health and Human Services, beginning as
soon as possible but not later than 30 days after the date of the
enactment of this Act [Sept. 3, 1982], shall provide for the
dissemination of information -
"(A) to unions and other associations representing or assisting
seamen,
"(B) to offices enrolling individuals under the respective
programs, and
"(C) to such other entities and in such a manner as will
effectively inform individuals eligible for benefits under this
section,
concerning the special benefits provided under this section.
"(2) An individual may establish that the individual was entitled
at a date to medical, surgical, and dental treatment and
hospitalization under section 322(a) of the Public Health Service
Act [section 249(a) of this title] (as in effect before October 1,
1981) by providing -
"(A) documentation relating to the status under which the
individual was provided care in (or under arrangements with) a
Public Health Service facility on that date,
"(B) the individual's seamen's papers covering that date, or
"(C) such other reasonable documentation as the Secretary may
require."
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 1395i-2a, 1395p, 1395v,
1395ff, 1395gg, 1396d of this title; title 25 section 1644; title
26 section 6103.
-FOOTNOTE-
(!1) So in original. Probably should be followed by a comma.
(!2) So in original.
-End-
-CITE-
42 USC Sec. 1395i-2a 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395i-2a. Hospital insurance benefits for disabled individuals
who have exhausted other entitlement
-STATUTE-
(a) Eligibility
Every individual who -
(1) has not attained the age of 65;
(2)(A) has been entitled to benefits under this part under
section 426(b) of this title, and
(B)(i) continues to have the disabling physical or mental
impairment on the basis of which the individual was found to be
under a disability or to be a disabled qualified railroad
retirement beneficiary, or (ii) is blind (within the meaning of
section 416(i)(1) of this title), but
(C) whose entitlement under section 426(b) of this title ends
due solely to the individual having earnings that exceed the
substantial gainful activity amount (as defined in section
423(d)(4) of this title); and
(3) is not otherwise entitled to benefits under this part,
shall be eligible to enroll in the insurance program established by
this part.
(b) Enrollment
(1) An individual may enroll under this section only in such
manner and form as may be prescribed in regulations, and only
during an enrollment period prescribed in or under this section.
(2) The individual's initial enrollment period shall begin with
the month in which the individual receives notice that the
individual's entitlement to benefits under section 426(b) of this
title will end due solely to the individual having earnings that
exceed the substantial gainful activity amount (as defined in
section 423(d)(4) of this title and shall end 7 months later.
(3) There shall be a general enrollment period during the period
beginning on January 1 and ending on March 31 of each year
(beginning with 1990).
(c) Coverage period
(1) The period (in this subsection referred to as a "coverage
period") during which an individual is entitled to benefits under
the insurance program under this part shall begin on whichever of
the following is the latest:
(A) In the case of an individual who enrolls under subsection
(b)(2) of this section before the month in which the individual
first satisfies subsection (a) of this section, the first day of
such month.
(B) In the case of an individual who enrolls under subsection
(b)(2) of this section in the month in which the individual first
satisfies subsection (a) of this section, the first day of the
month following the month in which the individual so enrolls.
(C) In the case of an individual who enrolls under subsection
(b)(2) of this section in the month following the month in which
the individual first satisfies subsection (a) of this section,
the first day of the second month following the month in which
the individual so enrolls.
(D) In the case of an individual who enrolls under subsection
(b)(2) of this section more than one month following the month in
which the individual first satisfies subsection (a) of this
section, the first day of the third month following the month in
which the individual so enrolls.
(E) In the case of an individual who enrolls under subsection
(b)(3) of this section, the July 1 following the month in which
the individual so enrolls.
(2) An individual's coverage period under this section shall
continue until the individual's enrollment is terminated as
follows:
(A) As of the month following the month in which the Secretary
provides notice to the individual that the individual no longer
meets the condition described in subsection (a)(2)(B) of this
section.
(B) As of the month following the month in which the individual
files notice that the individual no longer wishes to participate
in the insurance program established by this part.
(C) As of the month before the first month in which the
individual becomes eligible for hospital insurance benefits under
section 426(a) or 426-1 of this title.
(D) As of a date, determined under regulations of the
Secretary, for nonpayment of premiums.
The regulations under subparagraph (D) may provide a grace period
of not longer than 90 days, which may be extended to not to exceed
180 days in any case where the Secretary determines that there was
good cause for failure to pay the overdue premiums within such
90-day period. Termination of coverage under this section shall
result in simultaneous termination of any coverage affected under
any other part of this subchapter.
(3) The provisions of subsections (h) and (i) of section 1395p of
this title apply to enrollment and nonenrollment under this section
in the same manner as they apply to enrollment and nonenrollment
and special enrollment periods under section 1395i-2 of this title.
(d) Payment of premiums
(1)(A) Premiums for enrollment under this section shall be paid
to the Secretary at such times, and in such manner, as the
Secretary shall by regulations prescribe, and shall be deposited in
the Treasury to the credit of the Federal Hospital Insurance Trust
Fund.
(B)(i) Subject to clause (ii), such premiums shall be payable for
the period commencing with the first month of an individual's
coverage period and ending with the month in which the individual
dies or, if earlier, in which the individual's coverage period
terminates.
(ii) Such premiums shall not be payable for any month in which
the individual is eligible for benefits under this part pursuant to
section 426(b) of this title.
(2) The provisions of subsections (d) through (f) of section
1395i-2 of this title (relating to premiums) shall apply to
individuals enrolled under this section in the same manner as they
apply to individuals enrolled under that section.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1818A, as added Pub. L.
101-239, title VI, Sec. 6012(a)(2), Dec. 19, 1989, 103 Stat. 2161;
amended Pub. L. 101-508, title IV, Sec. 4008(m)(3)(C), Nov. 5,
1990, 104 Stat. 1388-54.)
-MISC1-
AMENDMENTS
1990 - Subsec. (d)(1)(A). Pub. L. 101-508, Sec. 4008(m)(3)(C)(i),
inserted "for enrollment under this section" after "Premiums".
Subsec. (d)(1)(C). Pub. L. 101-508, Sec. 4008(m)(3)(C)(ii),
struck out subpar. (C) which read as follows: "For purposes of
applying section 1395r(g) of this title and section 59B(f)(1)(B)(i)
of the Internal Revenue Code of 1986, any reference to section
1395i-2 of this title shall be deemed to include a reference to
this section."
EFFECTIVE DATE
Section 6012(b) of Pub. L. 101-239 provided that: "The amendments
made by this section [enacting this section and amending section
1395i-2 of this title] shall take effect on the date of the
enactment of this Act [Dec. 19, 1989], but shall not apply so as to
provide for coverage under part A of title XVIII of the Social
Security Act [this part] for any month before July 1990."
-End-
-CITE-
42 USC Sec. 1395i-3 01/06/03
-EXPCITE-
TITLE 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED
Part A - Hospital Insurance Benefits for Aged and Disabled
-HEAD-
Sec. 1395i-3. Requirements for, and assuring quality of care in,
skilled nursing facilities
-STATUTE-
(a) "Skilled nursing facility" defined
In this subchapter, the term "skilled nursing facility" means an
institution (or a distinct part of an institution) which -
(1) is primarily engaged in providing to residents -
(A) skilled nursing care and related services for residents
who require medical or nursing care, or
(B) rehabilitation services for the rehabilitation of
injured, disabled, or sick persons,
and is not primarily for the care and treatment of mental
diseases;
(2) has in effect a transfer agreement (meeting the
requirements of section 1395x(l) of this title) with one or more
hospitals having agreements in effect under section 1395cc of
this title; and
(3) meets the requirements for a skilled nursing facility
described in subsections (b), (c), and (d) of this section.
(b) Requirements relating to provision of services
(1) Quality of life
(A) In general
A skilled nursing facility must care for its residents in
such a manner and in such an environment as will promote
maintenance or enhancement of the quality of life of each
resident.
(B) Quality assessment and assurance
A skilled nursing facility must maintain a quality assessment
and assurance committee, consisting of the director of nursing
services, a physician designated by the facility, and at least
3 other members of the facility's staff, which (i) meets at
least quarterly to identify issues with respect to which
quality assessment and assurance activities are necessary and
(ii) develops and implements appropriate plans of action to
correct identified quality deficiencies. A State or the
Secretary may not require disclosure of the records of such
committee except insofar as such disclosure is related to the
compliance of such committee with the requirements of this
subparagraph.
(2) Scope of services and activities under plan of care
A skilled nursing facility must provide services to attain or
maintain the highest practicable physical, mental, and
psychosocial well-being of each resident, in accordance with a
written plan of care which -
(A) describes the medical, nursing, and psychosocial needs of
the resident and how such needs will be met;
(B) is initially prepared, with the participation to the
extent practicable of the resident or the resident's family or
legal representative, by a team which includes the resident's
attending physician and a registered professional nurse with
responsibility for the resident; and
(C) is periodically reviewed and revised by such team after
each assessment under paragraph (3).
(3) Residents' assessment
(A) Requirement
A skilled nursing facility must conduct a comprehensive,
accurate, standardized, reproducible assessment of each
resident's functional capacity, which assessment -
(i) describes the resident's capability to perform daily
life functions and significant impairments in functional
capacity;
(ii) is based on a uniform minimum data set specified by
the Secretary under subsection (f)(6)(A) of this section;
(iii) uses an instrument which is specified by the State
under subsection (e)(5) of this section; and
(iv) includes the identification of medical problems.
(B) Certification
(i) In general
Each such assessment must be conducted or coordinated (with
the appropriate participation of health professionals) by a
registered professional nurse who signs and certifies the
completion of the assessment. Each individual who completes a
portion of such an assessment shall sign and certify as to
the accuracy of that portion of the assessment.
(ii) Penalty for falsification
(I) An individual who willfully and knowingly certifies
under clause (i) a material and false statement in a resident
assessment is subject to a civil money penalty of not more
than $1,000 with respect to each assessment.
(II) An individual who willfully and knowingly causes
another individual to certify under clause (i) a material and
false statement in a resident assessment is subject to a
civil money penalty of not more than $5,000 with respect to
each assessment.
(III) The provisions of section 1320a-7a of this title
(other than subsections (a) and (b)) shall apply to a civil
money penalty under this clause in the same manner as such
provisions apply to a penalty or proceeding under section
1320a-7a(a) of this title.
(iii) Use of independent assessors
If a State determines, under a survey under subsection (g)
of this section or otherwise, that there has been a knowing
and willful certification of false assessments under this
paragraph, the State may require (for a period specified by
the State) that resident assessments under this paragraph be
conducted and certified by individuals who are independent of
the facility and who are approved by the State.
(C) Frequency
(i) In general
Subject to the timeframes prescribed by the Secretary under
section 1395yy(e)(6) of this title, such an assessment must
be conducted -
(I) promptly upon (but no later than 14 days after the
date of) admission for each individual admitted on or after
October 1, 1990, and by not later than January 1, 1991, for
each resident of the facility on that date;
(II) promptly after a significant change in the
resident's physical or mental condition; and
(III) in no case less often than once every 12 months.
(ii) Resident review
The skilled nursing facility must examine each resident no
less frequently than once every 3 months and, as appropriate,
revise the resident's assessment to assure the continuing
accuracy of the assessment.
(D) Use
The results of such an assessment shall be used in
developing, reviewing, and revising the resident's plan of care
under paragraph (2).
(E) Coordination
Such assessments shall be coordinated with any State-required
preadmission screening program to the maximum extent
practicable in order to avoid duplicative testing and effort.
(4) Provision of services and activities
(A) In general
To the extent needed to fulfill all plans of care described
in paragraph (2), a skilled nursing facility must provide,
directly or under arrangements (or, with respect to dental
services, under agreements) with others for the provision of -
(i) nursing services and specialized rehabilitative
services to attain or maintain the highest practicable
physical, mental, and psychosocial well-being of each
resident;
(ii) medically-related social services to attain or
maintain the highest practicable physical, mental, and
psychosocial well-being of each resident;
(iii) pharmaceutical services (including procedures that
assure the accurate acquiring, receiving, dispensing, and
administering of all drugs and biologicals) to meet the needs
of each resident;
(iv) dietary services that assure that the meals meet the
daily nutritional and special dietary needs of each resident;
(v) an on-going program, directed by a qualified
professional, of activities designed to meet the interests
and the physical, mental, and psychosocial well-being of each
resident;
(vi) routine and emergency dental services to meet the
needs of each resident; and
(vii) treatment and services required by mentally ill and
mentally retarded residents not otherwise provided or
arranged for (or required to be provided or arranged for) by
the State.
The services provided or arranged by the facility must meet
professional standards of quality. Nothing in clause (vi) shall
be construed as requiring a facility to provide or arrange for
dental services described in that clause without additional
charge.
(B) Qualified persons providing services
Services described in clauses (i), (ii), (iii), (iv), and
(vi) of subparagraph (A) must be provided by qualified persons
in accordance with each resident's written plan of care.
(C) Required nursing care
(i) In general
Except as provided in clause (ii), a skilled nursing
facility must provide 24-hour licensed nursing service which
is sufficient to meet nursing needs of its residents and must
use the services of a registered professional nurse at least
at least (!1) 8 consecutive hours a day, 7 days a week.
(ii) Exception
To the extent that clause (i) may be deemed to require that
a skilled nursing facility engage the services of a
registered professional nurse for more than 40 hours a week,
the Secretary is authorized to waive such requirement if the
Secretary finds that -
(I) the facility is located in a rural area and the
supply of skilled nursing facility services in such area is
not sufficient to meet the needs of individuals residing
therein,
(II) the facility has one full-time registered
professional nurse who is regularly on duty at such
facility 40 hours a week,
(III) the facility either has only patients whose
physicians have indicated (through physicians' orders or
admission notes) that each such patient does not require
the services of a registered nurse or a physician for a
48-hour period, or has made arrangements for a registered
professional nurse or a physician to spend such time at
such facility as may be indicated as necessary by the
physician to provide necessary skilled nursing services on
days when the regular full-time registered professional
nurse is not on duty,
(IV) the Secretary provides notice of the waiver to the
State long-term care ombudsman (established under section
307(a)(12) (!2) of the Older Americans Act of 1965) and the
protection and advocacy system in the State for the
mentally ill and the mentally retarded, and
(V) the facility that is granted such a waiver notifies
residents of the facility (or, where appropriate, the
guardians or legal representatives of such residents) and
members of their immediate families of the waiver.
A waiver under this subparagraph shall be subject to annual
renewal.
(5) Required training of nurse aides
(A) In general
(i) Except as provided in clause (ii), a skilled nursing
facility must not use on a full-time basis any individual as a
nurse aide in the facility on or after October 1, 1990 for more
than 4 months unless the individual -
(I) has completed a training and competency evaluation
program, or a competency evaluation program, approved by the
State under subsection (e)(1)(A) of this section, and
(II) is competent to provide nursing or nursing-related
services.
(ii) A skilled nursing facility must not use on a temporary,
per diem, leased, or on any basis other than as a permanent
employee any individual as a nurse aide in the facility on or
after January 1, 1991, unless the individual meets the
requirements described in clause (i).
(B) Offering competency evaluation programs for current
employees
A skilled nursing facility must provide, for individuals used
as a nurse aide (!3) by the facility as of January 1, 1990, for
a competency evaluation program approved by the State under
subsection (e)(1) of this section and such preparation as may
be necessary for the individual to complete such a program by
October 1, 1990.
(C) Competency
The skilled nursing facility must not permit an individual,
other than in a training and competency evaluation program
approved by the State, to serve as a nurse aide or provide
services of a type for which the individual has not
demonstrated competency and must not use such an individual as
a nurse aide unless the facility has inquired of any State
registry established under subsection (e)(2)(A) of this section
that the facility believes will include information concerning
the individual.
(D) Re-training required
For purposes of subparagraph (A), if, since an individual's
most recent completion of a training and competency evaluation
program, there has been a continuous period of 24 consecutive
months during none of which the individual performed nursing or
nursing-related services for monetary compensation, such
individual shall complete a new training and competency
evaluation program or a new competency evaluation program.
(E) Regular in-service education
The skilled nursing facility must provide such regular
performance review and regular in-service education as assures
that individuals used as nurse aides are competent to perform
services as nurse aides, including training for individuals
providing nursing and nursing-related services to residents
with cognitive impairments.
(F) "Nurse aide" defined
In this paragraph, the term "nurse aide" means any individual
providing nursing or nursing-related services to residents in a
skilled nursing facility, but does not include an individual -
(i) who is a licensed health professional (as defined in
subparagraph (G)) or a registered dietician, or
(ii) who volunteers to provide such services without
monetary compensation.
(G) "Licensed health professional" defined
In this paragraph, the term "licensed health professional"
means a physician, physician assistant, nurse practitioner,
physical, speech, or occupational therapist, physical or
occupational therapy assistant, registered professional nurse,
licensed practical nurse, licensed or certified social worker,
registered respiratory therapist, or certified respiratory
therapy technician.
(6) Physician supervision and clinical records
A skilled nursing facility must -
(A) require that the medical care of every resident be
provided under the supervision of a physician;
(B) provide for having a physician available to furnish
necessary medical care in case of emergency; and
(C) maintain clinical records on all residents, which records
include the plans of care (described in paragraph (2)) and the
residents' assessments (described in paragraph (3)).
(7) Required social services
In the case of a skilled nursing facility with more than 120
beds, the facility must have at least one social worker (with at
least a bachelor's degree in social work or similar professional
qualifications) employed full-time to provide or assure the
provision of social services.
(8) Information on nurse staffing
(A) In general
A skilled nursing facility shall post daily for each shift
the current number of licensed and unlicensed nursing staff
directly responsible for resident care in the facility. The
information shall be displayed in a uniform manner (as
specified by the Secretary) and in a clearly visible place.
(B) Publication of data
A skilled nursing facility shall, upon request, make
available to the public the nursing staff data described in
subparagraph (A).
(c) Requirements relating to residents' rights
(1) General rights
(A) Specified rights
A skilled nursing facility must protect and promote the
rights of each resident, including each of the following
rights:
(i) Free choice
The right to choose a personal attending physician, to be
fully informed in advance about care and treatment, to be
fully informed in advance of any changes in care or treatment
that may affect the resident's well-being, and (except with
respect to a resident adjudged incompetent) to participate in
planning care and treatment or changes in care and treatment.
(ii) Free from restraints
The right to be free from physical or mental abuse,
corporal punishment, involuntary seclusion, and any physical
or chemical restraints imposed for purposes of discipline or
convenience and not required to treat the resident's medical
symptoms. Restraints may only be imposed -
(I) to ensure the physical safety of the resident or
other residents, and
(II) only upon the written order of a physician that
specifies the duration and circumstances under which the
restraints are to be used (except in emergency
circumstances specified by the Secretary until such an
order could reasonably be obtained).
(iii) Privacy
The right to privacy with regard to accommodations, medical
treatment, written and telephonic communications, visits, and
meetings of family and of resident groups.
(iv) Confidentiality
The right to confidentiality of personal and clinical
records and to access to current clinical records of the
resident upon request by the resident or the resident's legal
representative, within 24 hours (excluding hours occurring
during a weekend or holiday) after making such a request.
(v) Accommodation of needs
The right -
(I) to reside and receive services with reasonable
accommodation of individual needs and preferences, except
where the health or safety of the individual or other
residents would be endangered, and
(II) to receive notice before the room or roommate of the
resident in the facility is changed.
(vi) Grievances
The right to voice grievances with respect to treatment or
care that is (or fails to be) furnished, without
discrimination or reprisal for voicing the grievances and the
right to prompt efforts by the facility to resolve grievances
the resident may have, including those with respect to the
behavior of other residents.
(vii) Participation in resident and family groups
The right of the resident to organize and participate in
resident groups in the facility and the right of the
resident's family to meet in the facility with the families
of other residents in the facility.
(viii) Participation in other activities
The right of the resident to participate in social,
religious, and community activities that do not interfere
with the rights of other residents in the facility.
(ix) Examination of survey results
The right to examine, upon reasonable request, the results
of the most recent survey of the facility conducted by the
Secretary or a State with respect to the facility and any
plan of correction in effect with respect to the facility.
(x) Refusal of certain transfers
The right to refuse a transfer to another room within the
facility, if a purpose of the transfer is to relocate the
resident from a portion of the facility that is a skilled
nursing facility (for purposes of this subchapter) to a
portion of the facility that is not such a skilled nursing
facility.
(xi) Other rights
Any other right established by the Secretary.
Clause (iii) shall not be construed as requiring the provision
of a private room. A resident's exercise of a right to refuse
transfer under clause (x) shall not affect the resident's
eligibility or entitlement to benefits under this subchapter or
to medical assistance under subchapter XIX of this chapter.
(B) Notice of rights and services
A skilled nursing facility must -
(i) inform each resident, orally and in writing at the time
of admission to the facility, of the resident's legal rights
during the stay at the facility;
(ii) make available to each resident, upon reasonable
request, a written statement of such rights (which statement
is updated upon changes in such rights) including the notice
(if any) of the State developed under section 1396r(e)(6) of
this title; and
(iii) inform each other resident, in writing before or at
the time of admission and periodically during the resident's
stay, of services available in the facility and of related
charges for such services, including any charges for services
not covered under this subchapter or by the facility's basic
per diem charge.
The written description of legal rights under this subparagraph
shall include a description of the protection of personal funds
under paragraph (6) and a statement that a resident may file a
complaint with a State survey and certification agency
respecting resident abuse and neglect and misappropriation of
resident property in the facility.
(C) Rights of incompetent residents
In the case of a resident adjudged incompetent under the laws
of a State, the rights of the resident under this subchapter
shall devolve upon, and, to the extent judged necessary by a
court of competent jurisdiction, be exercised by, the person
appointed under State law to act on the resident's behalf.
(D) Use of psychopharmacologic drugs
Psychopharmacologic drugs may be administered only on the
orders of a physician and only as part of a plan (included in
the written plan of care described in paragraph (2)) designed
to eliminate or modify the symptoms for which the drugs are
prescribed and only if, at least annually, an independent,
external consultant reviews the appropriateness of the drug
plan of each resident receiving such drugs. In determining
whether such a consultant is qualified to conduct reviews under
the preceding sentence, the Secretary shall take into account
the needs of nursing facilities under this subchapter to have
access to the services of such a consultant on a timely basis.
(E) Information respecting advance directives
A skilled nursing facility must comply with the requirement
of section 1395cc(f) of this title (relating to maintaining
written policies and procedures respecting advance directives).
(2) Transfer and discharge rights
(A) In general
A skilled nursing facility must permit each resident to
remain in the facility and must not transfer or discharge the
resident from the facility unless -
(i) the transfer or discharge is necessary to meet the
resident's welfare and the resident's welfare cannot be met
in the facility;
(ii) the transfer or discharge is appropriate because the
resident's health has improved sufficiently so the resident
no longer needs the services provided by the facility;
(iii) the safety of individuals in the facility is
endangered;
(iv) the health of individuals in the facility would
otherwise be endangered;
(v) the resident has failed, after reasonable and
appropriate notice, to pay (or to have paid under this
subchapter or subchapter XIX of this chapter on the
resident's behalf) for a stay at the facility; or
(vi) the facility ceases to operate.
In each of the cases described in clauses (i) through (v), the
basis for the transfer or discharge must be documented in the
resident's clinical record. In the cases described in clauses
(i) and (ii), the documentation must be made by the resident's
physician, and in the cases described in clauses (iii) and (iv)
the documentation must be made by a physician.
(B) Pre-transfer and pre-discharge notice
(i) In general
Before effecting a transfer or discharge of a resident, a
skilled nursing facility must -
(I) notify the resident (and, if known, a family member
of the resident or legal representative) of the transfer or
discharge and the reasons therefor,
(II) record the reasons in the resident's clinical record
(including any documentation required under subparagraph
(A)), and
(III) include in the notice the items described in clause
(iii).
(ii) Timing of notice
The notice under clause (i)(I) must be made at least 30
days in advance of the resident's transfer or discharge
except -
(I) in a case described in clause (iii) or (iv) of
subparagraph (A);
(II) in a case described in clause (ii) of subparagraph
(A), where the resident's health improves sufficiently to
allow a more immediate transfer or discharge;
(III) in a case described in clause (i) of subparagraph
(A), where a more immediate transfer or discharge is
necessitated by the resident's urgent medical needs; or
(IV) in a case where a resident has not resided in the
facility for 30 days.
In the case of such exceptions, notice must be given as many
days before the date of the transfer or discharge as is
practicable.
(iii) Items included in notice
Each notice under clause (i) must include -
(I) for transfers or discharges effected on or after
October 1, 1990, notice of the resident's right to appeal
the transfer or discharge under the State process
established under subsection (e)(3) of this section; and
(II) the name, mailing address, and telephone number of
the State long-term care ombudsman (established under title
III or VII of the Older Americans Act of 1965 [42 U.S.C.
3021 et seq., 3058 et seq.] in accordance with section 712
of the Act [42 U.S.C. 3058g]).
(C) Orientation
A skilled nursing facility must provide sufficient
preparation and orientation to residents to ensure safe and
orderly transfer or discharge from the facility.
(3) Access and visitation rights
A skilled nursing facility must -
(A) permit immediate access to any resident by any
representative of the Secretary, by any representative of the
State, by an ombudsman described in paragraph (2)(B)(iii)(II),
or by the resident's individual physician;
(B) permit immediate access to a resident, subject to the
resident's right to deny or withdraw consent at any time, by
immediate family or other relatives of the resident;
(C) permit immediate access to a resident, subject to
reasonable restrictions and the resident's right to deny or
withdraw consent at any time, by others who are visiting with
the consent of the resident;
(D) permit reasonable access to a resident by any entity or
individual that provides health, social, legal, or other
services to the resident, subject to the resident's right to
deny or withdraw consent at any time; and
(E) permit representatives of the State ombudsman (described
in paragraph (2)(B)(iii)(II)), with the permission of the
resident (or the resident's legal representative) and
consistent with State law, to examine a resident's clinical
records.
(4) Equal access to quality care
A skilled nursing facility must establish and maintain
identical policies and practices regarding transfer, discharge,
and covered services under this subchapter for all individuals
regardless of source of payment.
(5) Admissions policy
(A) Admissions
With respect to admissions practices, a skilled nursing
facility must -
(i)(I) not require individuals applying to reside or
residing in the facility to waive their rights to benefits
under this subchapter or under a State plan under subchapter
XIX of this chapter, (II) not require oral or written
assurance that such individuals are not eligible for, or will
not apply for, benefits under this subchapter or such a State
plan, and (III) prominently display in the facility and
provide to such individuals written information about how to
apply for and use such benefits and how to receive refunds
for previous payments covered by such benefits; and
(ii) not require a third party guarantee of payment to the
facility as a condition of admission (or expedited admission)
to, or continued stay in, the facility.
(B) Construction
(i) No preemption of stricter standards
Subparagraph (A) shall not be construed as preventing
States or political subdivisions therein from prohibiting,
under State or local law, the discrimination against
individuals who are entitled to medical assistance under this
subchapter with respect to admissions practices of skilled
nursing facilities.
(ii) Contracts with legal representatives
Subparagraph (A)(ii) shall not be construed as preventing a
facility from requiring an individual, who has legal access
to a resident's income or resources available to pay for care
in the facility, to sign a contract (without incurring
personal financial liability) to provide payment from the
resident's income or resources for such care.
(6) Protection of resident funds
(A) In general
The skilled nursing facility -
(i) may not require residents to deposit their personal
funds with the facility, and
(ii) upon the written authorization of the resident, must
hold, safeguard, and account for such personal funds under a
system established and maintained by the facility in
accordance with this paragraph.
(B) Management of personal funds
Upon written authorization of a resident under subparagraph
(A)(ii), the facility must manage and account for the personal
funds of the resident deposited with the facility as follows:
(i) Deposit
The facility must deposit any amount of personal funds in
excess of $100 with respect to a resident in an interest
bearing account (or accounts) that is separate from any of
the facility's operating accounts and credits (!4) all
interest earned on such separate account to such account.
With respect to any other personal funds, the facility must
maintain such funds in a non-interest bearing account or
petty cash fund.
(ii) Accounting and records
The facility must assure a full and complete separate
accounting of each such resident's personal funds, maintain a
written record of all financial transactions involving the
personal funds of a resident deposited with the facility, and
afford the resident (or a legal representative of the
resident) reasonable access to such record.
(iii) Conveyance upon death
Upon the death of a resident with such an account, the
facility must convey promptly the resident's personal funds
(and a final accounting of such funds) to the individual
administering the resident's estate.
(C) Assurance of financial security
The facility must purchase a surety bond, or otherwise
provide assurance satisfactory to the Secretary, to assure the
security of all personal funds of residents deposited with the
facility.
(D) Limitation on charges to personal funds
The facility may not impose a charge against the personal
funds of a resident for any item or service for which payment
is made under this subchapter or subchapter XIX of this
chapter.
(d) Requirements relating to administration and other matters
(1) Administration
(A) In general
A skilled nursing facility must be administered in a manner
that enables it to use its resources effectively and
efficiently to attain or maintain the highest practicable
physical (!5) mental, and psychosocial well-being of each
resident (consistent with requirements established under
subsection (f)(5) of this section).
(B) Required notices
If a change occurs in -
(i) the persons with an ownership or control interest (as
defined in section 1320a-3(a)(3) of this title) in the
facility,
(ii) the persons who are officers, directors, agents, or
managing employees (as defined in section 1320a-5(b) of this
title) of the facility,
(iii) the corporation, association, or other company
responsible for the management of the facility, or
(iv) the individual who is the administrator or director of
nursing of the facility,
the skilled nursing facility must provide notice to the State
agency responsible for the licensing of the facility, at the
time of the change, of the change and of the identity of each
new person, company, or individual described in the respective
clause.
(C) Skilled nursing facility administrator
The administrator of a skilled nursing facility must meet
standards established by the Secretary under subsection (f)(4)
of this section.
(2) Licensing and Life Safety Code
(A) Licensing
A skilled nursing facility must be licensed under applicable
State and local law.
(B) Life Safety Code
A skilled nursing facility must meet such provisions of such
edition (as specified by the Secretary in regulation) of the
Life Safety Code of the National Fire Protection Association as
are applicable to nursing homes; except that -
(i) the Secretary may waive, for such periods as he deems
appropriate, specific provisions of such Code which if
rigidly applied would result in unreasonable hardship upon a
facility, but only if such waiver would not adversely affect
the health and safety of residents or personnel, and
(ii) the provisions of such Code shall not apply in any
State if the Secretary finds that in such State there is in
effect a fire and safety code, imposed by State law, which
adequately protects residents of and personnel in skilled
nursing facilities.
(3) Sanitary and infection control and physical environment
A skilled nursing facility must -
(A) establish and maintain an infection control program
designed to provide a safe, sanitary, and comfortable
environment in which residents reside and to help prevent the
development and transmission of disease and infection, and
(B) be designed, constructed, equipped, and maintained in a
manner to protect the health and safety of residents,
personnel, and the general public.
(4) Miscellaneous
(A) Compliance with Federal, State, and local laws and
professional standards
A skilled nursing facility must operate and provide services
in compliance with all applicable Federal, State, and local
laws and regulations (including the requirements of section
1320a-3 of this title) and with accepted professional standards
and principles which apply to professionals providing services
in such a facility.
(B) Other
A skilled nursing facility must meet such other requirements
relating to the health, safety, and well-being of residents or
relating to the physical facilities thereof as the Secretary
may find necessary.
(e) State requirements relating to skilled nursing facility
requirements
The requirements, referred to in section 1395aa(d) of this title,
with respect to a State are as follows:
(1) Specification and review of nurse aide training and
competency evaluation programs and of nurse aide competency
evaluation programs
The State must -
(A) by not later than January 1, 1989, specify those training
and competency evaluation programs, and those competency
evaluation programs, that the State approves for purposes of
subsection (b)(5) of this section and that meet the
requirements established under subsection (f)(2) of this
section, and
(B) by not later than January 1, 1990, provide for the review
and reapproval of such programs, at a frequency and using a
methodology consistent with the requirements established under
subsection (f)(2)(A)(iii) of this section.
The failure of the Secretary to establish requirements under
subsection (f)(2) of this section shall not relieve any State of
its responsibility under this paragraph.
(2) Nurse aide registry
(A) In general
By not later than January 1, 1989, the State shall establish
and maintain a registry of all individuals who have
satisfactorily completed a nurse aide training and competency
evaluation program, or a nurse aide competency evaluation
program, approved under paragraph (1) in the State, or any
individual described in subsection (f)(2)(B)(ii) of this
section or in subparagraph (B), (C), or (D) of section
6901(b)(4) of the Omnibus Budget Reconciliation Act of 1989.
(B) Information in registry
The registry under subparagraph (A) shall provide (in
accordance with regulations of the Secretary) for the inclusion
of specific documented findings by a State under subsection
(g)(1)(C) of this section of resident neglect or abuse or
misappropriation of resident property involving an individual
listed in the registry, as well as any brief statement of the
individual disputing the findings, but shall not include any
allegations of resident abuse or neglect or misappropriation of
resident property that are not specifically documented by the
State under such subsection. The State shall make available to
the public information in the registry. In the case of
inquiries to the registry concerning an individual listed in
the registry, any information disclosed concerning such a
finding shall also include disclosure of any such statement in
the registry relating to the finding or a clear and accurate
summary of such a statement.
(C) Prohibition against charges
A State may not impose any charges on a nurse aide relating
to the registry established and maintained under subparagraph
(A).
(3) State appeals process for transfers and discharges
The State, for transfers and discharges from skilled nursing
facilities effected on or after October 1, 1989, must provide for
a fair mechanism for hearing appeals on transfers and discharges
of residents of such facilities. Such mechanism must meet the
guidelines established by the Secretary under subsection (f)(3)
of this section; but the failure of the Secretary to establish
such guidelines shall not relieve any State of its responsibility
to provide for such a fair mechanism.
(4) Skilled nursing facility administrator standards
By not later than January 1, 1990, the State must have
implemented and enforced the skilled nursing facility
administrator standards developed under subsection (f)(4) of this
section respecting the qualification of administrators of skilled
nursing facilities.
(5) Specification of resident assessment instrument
Effective July 1, 1990, the State shall specify the instrument
to be used by nursing facilities in the State in complying with
the requirement of subsection (b)(3)(A)(iii) of this section.
Such instrument shall be -
(A) one of the instruments designated under subsection
(f)(6)(B) of this section, or
(B) an instrument which the Secretary has approved as being
consistent with the minimum data set of core elements, common
definitions, and utilization guidelines specified by the
Secretary under subsection (f)(6)(A) of this section.
(f) Responsibilities of Secretary relating to skilled nursing
facility requirements
(1) General responsibility
It is the duty and responsibility of the Secretary to assure
that requirements which govern the provision of care in skilled
nursing facilities under this subchapter, and the enforcement of
such requirements, are adequate to protect the health, safety,
welfare, and rights of residents and to promote the effective and
efficient use of public moneys.
(2) Requirements for nurse aide training and competency
evaluation programs and for nurse aide competency evaluation
programs
(A) In general
For purposes of subsections (b)(5) and (e)(1)(A) of this
section, the Secretary shall establish, by not later than
September 1, 1988 -
(i) requirements for the approval of nurse aide training
and competency evaluation programs, including requirements
relating to (I) the areas to be covered in such a program
(including at least basic nursing skills, personal care
skills, recognition of mental health and social service
needs, care of cognitively impaired residents, basic
restorative services, and residents' rights) and content of
the curriculum, (II) minimum hours of initial and ongoing
training and retraining (including not less than 75 hours in
the case of initial training), (III) qualifications of
instructors, and (IV) procedures for determination of
competency;
(ii) requirements for the approval of nurse aide competency
evaluation programs, including requirement relating to the
areas to be covered in such a program, including at least
basic nursing skills, personal care skills, recognition of
mental health and social service needs, care of cognitively
impaired residents, basic restorative services, residents'
rights, and procedures for determination of competency;
(iii) requirements respecting the minimum frequency and
methodology to be used by a State in reviewing such programs'
compliance with the requirements for such programs; and
(iv) requirements, under both such programs, that -
(I) provide procedures for determining competency that
permit a nurse aide, at the nurse aide's option, to
establish competency through procedures or methods other
than the passing of a written examination and to have the
competency evaluation conducted at the nursing facility at
which the aide is (or will be) employed (unless the
facility is described in subparagraph (B)(iii)(I)),
(II) prohibit the imposition on a nurse aide who is
employed by (or who has received an offer of employment
from) a facility on the date on which the aide begins
either such program of any charges (including any charges
for textbooks and other required course materials and any
charges for the competency evaluation) for either such
program, and
(III) in the case of a nurse aide not described in
subclause (II) who is employed by (or who has received an
offer of employment from) a facility not later than 12
months after completing either such program, the State
shall provide for the reimbursement of costs incurred in
completing such program on a prorata (!6) basis during the
period in which the nurse aide is so employed.
(B) Approval of certain programs
Such requirements -
(i) may permit approval of programs offered by or in
facilities (subject to clause (iii)), as well as outside
facilities (including employee organizations), and of
programs in effect on December 22, 1987;
(ii) shall permit a State to find that an individual who
has completed (before July 1, 1989) a nurse aide training and
competency evaluation program shall be deemed to have
completed such a program approved under subsection (b)(5) of
this section if the State determines that, at the time the
program was offered, the program met the requirements for
approval under such paragraph; and
(iii) subject to subparagraph (C), shall prohibit approval
of such a program -
(I) offered by or in a skilled nursing facility which,
within the previous 2 years -
(a) has operated under a waiver under subsection
(b)(4)(C)(ii)(II) of this section;
(b) has been subject to an extended (or partial
extended) survey under subsection (g)(2)(B)(i) of this
section or section 1396r(g)(2)(B)(i) of this title,
unless the survey shows that the facility is in
compliance with the requirements of subsections (b), (c),
and (d) of this section; or
(c) has been assessed a civil money penalty described
in subsection (h)(2)(B)(ii) of this section or section
1396r(h)(2)(A)(ii) of this title of not less than $5,000,
or has been subject to a remedy described in clause (i)
or (iii) of subsection (h)(2)(B) of this section,
subsection (h)(4) of this section, section
1396r(h)(1)(B)(i) of this title, or in clause (i), (iii),
or (iv) of section 1396r(h)(2)(A) of this title, or
(II) offered by or in a skilled nursing facility unless
the State makes the determination, upon an individual's
completion of the program, that the individual is competent
to provide nursing and nursing-related services in skilled
nursing facilities.
A State may not delegate (through subcontract or otherwise)
its responsibility under clause (iii)(II) to the skilled
nursing facility.
(C) Waiver authorized
Clause (iii)(I) of subparagraph (B) shall not apply to a
program offered in (but not by) a nursing facility (or skilled
nursing facility for purposes of this subchapter) in a State if
the State -
(i) determines that there is no other such program offered
within a reasonable distance of the facility,
(ii) assures, through an oversight effort, that an adequate
environment exists for operating the program in the facility,
and
(iii) provides notice of such determination and assurances
to the State long-term care ombudsman.
(3) Federal guidelines for State appeals process for transfers
and discharges
For purposes of subsections (c)(2)(B)(iii)(I) and (e)(3) of
this section, by not later than October 1, 1988, the Secretary
shall establish guidelines for minimum standards which State
appeals processes under subsection (e)(3) of this section must
meet to provide a fair mechanism for hearing appeals on transfers
and discharges of residents from skilled nursing facilities.
(4) Secretarial standards for qualification of administrators
For purposes of subsections (d)(1)(C) and (e)(4) of this
section, the Secretary shall develop, by not later than March 1,
1989, standards to be applied in assuring the qualifications of
administrators of skilled nursing facilities.
(5) Criteria for administration
The Secretary shall establish criteria for assessing a skilled
nursing facility's compliance with the requirement of subsection
(d)(1) of this section with respect to -
(A) its governing body and management,
(B) agreements with hospitals regarding transfers of
residents to and from the hospitals and to and from other
skilled nursing facilities,
(C) disaster preparedness,
(D) direction of medical care by a physician,
(E) laboratory and radiological services,
(F) clinical records, and
(G) resident and advocate participation.
(6) Specification of resident assessment data set and instruments
The Secretary shall -
(A) not later than January 1, 1989, specify a minimum data
set of core elements and common definitions for use by nursing
facilities in conducting the assessments required under
subsection (b)(3) of this section, and establish guidelines for
utilization of the data set; and
(B) by not later than April 1, 1990, designate one or more
instruments which are consistent with the specification made
under subparagraph (A) and which a State may specify under
subsection (e)(5)(A) of this section for use by nursing
facilities in complying with the requirements of subsection
(b)(3)(A)(iii) of this section.
(7) List of items and services furnished in skilled nursing
facilities not chargeable to the personal funds of a resident
(A) Regulations required
Pursuant to the requirement of section 21(b) of the
Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, the
Secretary shall issue regulations, on or before the first day
of the seventh month to begin after December 22, 1987, that
define those costs which may be charged to the personal funds
of residents in skilled nursing facilities who are individuals
receiving benefits under this part and those costs which are to
be included in the reasonable cost (or other payment amount)
under this subchapter for extended care services.
(B) Rule if failure to publish regulations
If the Secretary does not issue the regulations under
subparagraph (A) on or before the date required in such
subparagraph, in the case of a resident of a skilled nursing
facility who is eligible to receive benefits under this part,
the costs which may not be charged to the personal funds of
such resident (and for which payment is considered to be made
under this subchapter) shall include, at a minimum, the costs
for routine personal hygiene items and services furnished by
the facility.
(g) Survey and certification process
(1) State and Federal responsibility
(A) In general
Pursuant to an agreement under section 1395aa of this title,
each State shall be responsible for certifying, in accordance
with surveys conducted under paragraph (2), the compliance of
skilled nursing facilities (other than facilities of the State)
with the requirements of subsections (b), (c), and (d) of this
section. The Secretary shall be responsible for certifying, in
accordance with surveys conducted under paragraph (2), the
compliance of State skilled nursing facilities with the
requirements of such subsections.
(B) Educational program
Each State shall conduct periodic educational programs for
the staff and residents (and their representatives) of skilled
nursing facilities in order to present current regulations,
procedures, and policies under this section.
(C) Investigation of allegations of resident neglect and abuse
and misappropriation of resident property
The State shall provide, through the agency responsible for
surveys and certification of nursing facilities under this
subsection, for a process for the receipt and timely review and
investigation of allegations of neglect and abuse and
misappropriation of resident property by a nurse aide of a
resident in a nursing facility or by another individual used by
the facility in providing services to such a resident. The
State shall, after providing the individual involved with a
written notice of the allegations (including a statement of the
availability of a hearing for the individual to rebut the
allegations) and the opportunity for a hearing on the record,
make a written finding as to the accuracy of the allegations.
If the State finds that a nurse aide has neglected or abused a
resident or misappropriated resident property in a facility,
the State shall notify the nurse aide and the registry of such
finding. If the State finds that any other individual used by
the facility has neglected or abused a resident or
misappropriated resident property in a facility, the State
shall notify the appropriate licensure authority. A State shall
not make a finding that an individual has neglected a resident
if the individual demonstrates that such neglect was caused by
factors beyond the control of the individual.
(D) Removal of name from nurse aide registry
(i) In general
In the case of a finding of neglect under subparagraph (C),
the State shall establish a procedure to permit a nurse aide
to petition the State to have his or her name removed from
the registry upon a determination by the State that -
(I) the employment and personal history of the nurse aide
does not reflect a pattern of abusive behavior or neglect;
and
(II) the neglect involved in the original finding was a
singular occurrence.
(ii) Timing of determination
In no case shall a determination on a petition submitted
under clause (i) be made prior to the expiration of the
1-year period beginning on the date on which the name of the
petitioner was added to the registry under subparagraph (C).
(E) Construction
The failure of the Secretary to issue regulations to carry
out this subsection shall not relieve a State of its
responsibility under this subsection.
(2) Surveys
(A) Standard survey
(i) In general
Each skilled nursing facility shall be subject to a
standard survey, to be conducted without any prior notice to
the facility. Any individual who notifies (or causes to be
notified) a skilled nursing facility of the time or date on
which such a survey is scheduled to be conducted is subject
to a civil money penalty of not to exceed $2,000. The
provisions of section 1320a-7a of this title (other than
subsections (a) and (b)) shall apply to a civil money penalty
under the previous sentence in the same manner as such
provisions apply to a penalty or proceeding under section
1320a-7a(a) of this title. The Secretary shall review each
State's procedures for the scheduling and conduct of standard
surveys to assure that the State has taken all reasonable
steps to avoid giving notice of such a survey through the
scheduling procedures and the conduct of the surveys
themselves.
(ii) Contents
Each standard survey shall include, for a case-mix
stratified sample of residents -
(I) a survey of the quality of care furnished, as
measured by indicators of medical, nursing, and
rehabilitative care, dietary and nutrition services,
activities and social participation, and sanitation,
infection control, and the physical environment,
(II) written plans of care provided under subsection
(b)(2) of this section and an audit of the residents'
assessments under subsection (b)(3) of this section to
determine the accuracy of such assessments and the adequacy
of such plans of care, and
(III) a review of compliance with residents' rights under
subsection (c) of this section.
(iii) Frequency
(I) In general
Each skilled nursing facility shall be subject to a
standard survey not later than 15 months after the date of
the previous standard survey conducted under this
subparagraph. The Statewide average interval between
standard surveys of skilled nursing facilities under this
subsection shall not exceed 12 months.
(II) Special surveys
If not otherwise conducted under subclause (I), a
standard survey (or an abbreviated standard survey) may be
conducted within 2 months of any change of ownership,
administration, management of a skilled nursing facility,
or the director of nursing in order to determine whether
the change has resulted in any decline in the quality of
care furnished in the facility.
(B) Extended surveys
(i) In general
Each skilled nursing facility which is found, under a
standard survey, to have provided substandard quality of care
shall be subject to an extended survey. Any other facility
may, at the Secretary's or State's discretion, be subject to
such an extended survey (or a partial extended survey).
(ii) Timing
The extended survey shall be conducted immediately after
the standard survey (or, if not practicable, not later than 2
weeks after the date of completion of the standard survey).
(iii) Contents
In such an extended survey, the survey team shall review
and identify the policies and procedures which produced such
substandard quality of care and shall determine whether the
facility has complied with all the requirements described in
subsections (b), (c), and (d) of this section. Such review
shall include an expansion of the size of the sample of
residents' assessments reviewed and a review of the staffing,
of in-service training, and, if appropriate, of contracts
with consultants.
(iv) Construction
Nothing in this paragraph shall be construed as requiring
an extended or partial extended survey as a prerequisite to
imposing a sanction against a facility under subsection (h)
of this section on the basis of findings in a standard
survey.
(C) Survey protocol
Standard and extended surveys shall be conducted -
(i) based upon a protocol which the Secretary has
developed, tested, and validated by not later than January 1,
1990, and
(ii) by individuals, of a survey team, who meet such
minimum qualifications as the Secretary establishes by not
later than such date.
The failure of the Secretary to develop, test, or validate such
protocols or to establish such minimum qualifications shall not
relieve any State of its responsibility (or the Secretary of
the Secretary's responsibility) to conduct surveys under this
subsection.
(D) Consistency of surveys
Each State and the Secretary shall implement programs to
measure and reduce inconsistency in the application of survey
results among surveyors.
(E) Survey teams
(i) In general
Surveys under this subsection shall be conducted by a
multidisciplinary team of professionals (including a
registered professional nurse).
(ii) Prohibition of conflicts of interest
A State may not use as a member of a survey team under this
subsection an individual who is serving (or has served within
the previous 2 years) as a member of the staff of, or as a
consultant to, the facility surveyed respecting compliance
with the requirements of subsections (b), (c), and (d) of
this section, or who has a personal or familial financial
interest in the facility being surveyed.
(iii) Training
The Secretary shall provide for the comprehensive training
of State and Federal surveyors in the conduct of standard and
extended surveys under this subsection, including the
auditing of resident assessments and plans of care. No
individual shall serve as a member of a survey team unless
the individual has successfully completed a training and
testing program in survey and certification techniques that
has been approved by the Secretary.
(3) Validation surveys
(A) In general
The Secretary shall conduct onsite surveys of a
representative sample of skilled nursing facilities in each
State, within 2 months of the date of surveys conducted under
paragraph (2) by the State, in a sufficient number to allow
inferences about the adequacies of each State's surveys
conducted under paragraph (2). In conducting such surveys, the
Secretary shall use the same survey protocols as the State is
required to use under paragraph (2). If the State has
determined that an individual skilled nursing facility meets
the requirements of subsections (b), (c), and (d) of this
section, but the Secretary determines that the facility does
not meet such requirements, the Secretary's determination as to
the facility's noncompliance with such requirements is binding
and supersedes that of the State survey.
(B) Scope
With respect to each State, the Secretary shall conduct
surveys under subparagraph (A) each year with respect to at
least 5 percent of the number of skilled nursing facilities
surveyed by the State in the year, but in no case less than 5
skilled nursing facilities in the State.
(C) Remedies for substandard performance
If the Secretary finds, on the basis of such surveys, that a
State has failed to perform surveys as required under paragraph
(2) or that a State's survey and certification performance
otherwise is not adequate, the Secretary shall provide for an
appropriate remedy, which may include the training of survey
teams in the State.
(D) Special surveys of compliance
Where the Secretary has reason to question the compliance of
a skilled nursing facility with any of the requirements of
subsections (b), (c), and (d) of this section, the Secretary
may conduct a survey of the facility and, on the basis of that
survey, make independent and binding determinations concerning
the extent to which the skilled nursing facility meets such
requirements.
(4) Investigation of complaints and monitoring compliance
Each State shall maintain procedures and adequate staff to -
(A) investigate complaints of violations of requirements by
skilled nursing facilities, and
(B) monitor, on-site, on a regular, as needed basis, a
skilled nursing facility's compliance with the requirements of
subsections (b), (c), and (d) of this section, if -
(i) the facility has been found not to be in compliance
with such requirements and is in the process of correcting
deficiencies to achieve such compliance;
(ii) the facility was previously found not to be in
compliance with such requirements, has corrected deficiencies
to achieve such compliance, and verification of continued
compliance is indicated; or
(iii) the State has reason to question the compliance of
the facility with such requirements.
A State may maintain and utilize a specialized team (including an
attorney, an auditor, and appropriate health care professionals)
for the purpose of identifying, surveying, gathering and
preserving evidence, and carrying out appropriate enforcement
actions against substandard skilled nursing facilities.
(5) Disclosure of results of inspections and activities
(A) Public information
Each State, and the Secretary, shall make available to the
public -
(i) information respecting all surveys and certifications
made respecting skilled nursing facilities, including
statements of deficiencies, within 14 calendar days after
such information is made available to those facilities, and
approved plans of correction,
(ii) copies of cost reports of such facilities filed under
this subchapter or subchapter XIX of this chapter,
(iii) copies of statements of ownership under section
1320a-3 of this title, and
(iv) information disclosed under section 1320a-5 of this
title.
(B) Notice to ombudsman
Each State shall notify the State long-term care ombudsman
(established under title III or VII of the Older Americans Act
of 1965 [42 U.S.C. 3021 et seq., 3058 et seq.] in accordance
with section 712 of the Act [42 U.S.C. 3058g]) of the State's
findings of noncompliance with any of the requirements of
subsections (b), (c), and (d) of this section, or of any
adverse action taken against a skilled nursing facility under
paragraph (1), (2), or (4) of subsection (h) of this section,
with respect to a skilled nursing facility in the State.
(C) Notice to physicians and skilled nursing facility
administrator licensing board
If a State finds that a skilled nursing facility has provided
substandard quality of care, the State shall notify -
(i) the attending physician of each resident with respect
to which such finding is made, and
(ii) the State board responsible for the licensing of the
skilled nursing facility administrator at the facility.
(D) Access to fraud control units
Each State shall provide its State medicaid fraud and abuse
control unit (established under section 1396b(q) of this title)
with access to all information of the State agency responsible
for surveys and certifications under this subsection.
(h) Enforcement process
(1) In general
If a State finds, on the basis of a standard, extended, or
partial extended survey under subsection (g)(2) of this section
or otherwise, that a skilled nursing facility no longer meets a
requirement of subsection (b), (c), or (d) of this section, and
further finds that the facility's deficiencies -
(A) immediately jeopardize the health or safety of its
residents, the State shall recommend to the Secretary that the
Secretary take such action as described in paragraph (2)(A)(i);
or
(B) do not immediately jeopardize the health or safety of its
residents, the State may recommend to the Secretary that the
Secretary take such action as described in paragraph
(2)(A)(ii).
If a State finds that a skilled nursing facility meets the
requirements of subsections (b), (c), and (d) of this section,
but, as of a previous period, did not meet such requirements, the
State may recommend a civil money penalty under paragraph
(2)(B)(ii) for the days in which it finds that the facility was
not in compliance with such requirements.
(2) Secretarial authority
(A) In general
With respect to any skilled nursing facility in a State, if
the Secretary finds, or pursuant to a recommendation of the
State under paragraph (1) finds, that a skilled nursing
facility no longer meets a requirement of subsection (b), (c),
(d), or (e) of this section, and further finds that the
facility's deficiencies -
(i) immediately jeopardize the health or safety of its
residents, the Secretary shall take immediate action to
remove the jeopardy and correct the deficiencies through the
remedy specified in subparagraph (B)(iii), or terminate the
facility's participation under this subchapter and may
provide, in addition, for one or more of the other remedies
described in subparagraph (B); or
(ii) do not immediately jeopardize the health or safety of
its residents, the Secretary may impose any of the remedies
described in subparagraph (B).
Nothing in this subparagraph shall be construed as restricting
the remedies available to the Secretary to remedy a skilled
nursing facility's deficiencies. If the Secretary finds, or
pursuant to the recommendation of the State under paragraph (1)
finds, that a skilled nursing facility meets such requirements
but, as of a previous period, did not meet such requirements,
the Secretary may provide for a civil money penalty under
subparagraph (B)(ii) for the days on which he finds that the
facility was not in compliance with such requirements.
(B) Specified remedies
The Secretary may take the following actions with respect to
a finding that a facility has not met an applicable
requirement:
(i) Denial of payment
The Secretary may deny any further payments under this
subchapter with respect to all individuals entitled to
benefits under this subchapter in the facility or with
respect to such individuals admitted to the facility after
the effective date of the finding.
(ii) Authority with respect to civil money penalties
The Secretary may impose a civil money penalty in an amount
not to exceed $10,000 for each day of noncompliance. The
provisions of section 1320a-7a of this title (other than
subsections (a) and (b)) shall apply to a civil money penalty
under the previous sentence in the same manner as such
provisions apply to a penalty or proceeding under section
1320a-7a(a) of this title.
(iii) Appointment of temporary management
In consultation with the State, the Secretary may appoint
temporary management to oversee the operation of the facility
and to assure the health and safety of the facility's
residents, where there is a need for temporary management
while -
(I) there is an orderly closure of the facility, or
(II) improvements are made in order to bring the facility
into compliance with all the requirements of subsections
(b), (c), and (d) of this section.
The temporary management under this clause shall not be
terminated under subclause (II) until the Secretary has
determined that the facility has the management capability to
ensure continued compliance with all the requirements of
subsections (b), (c), and (d) of this section.
The Secretary shall specify criteria, as to when and how each
of such remedies is to be applied, the amounts of any fines,
and the severity of each of these remedies, to be used in the
imposition of such remedies. Such criteria shall be designed so
as to minimize the time between the identification of
violations and final imposition of the remedies and shall
provide for the imposition of incrementally more severe fines
for repeated or uncorrected deficiencies. In addition, the
Secretary may provide for other specified remedies, such as
directed plans of correction.
(C) Continuation of payments pending remediation
The Secretary may continue payments, over a period of not
longer than 6 months after the effective date of the findings,
under this subchapter with respect to a skilled nursing
facility not in compliance with a requirement of subsection
(b), (c), or (d) of this section, if -
(i) the State survey agency finds that it is more
appropriate to take alternative action to assure compliance
of the facility with the requirements than to terminate the
certification of the facility,
(ii) the State has submitted a plan and timetable for
corrective action to the Secretary for approval and the
Secretary approves the plan of corrective action, and
(iii) the facility agrees to repay to the Federal
Government payments received under this subparagraph if the
corrective action is not taken in accordance with the
approved plan and timetable.
The Secretary shall establish guidelines for approval of
corrective actions requested by States under this subparagraph.
(D) Assuring prompt compliance
If a skilled nursing facility has not complied with any of
the requirements of subsections (b), (c), and (d) of this
section, within 3 months after the date the facility is found
to be out of compliance with such requirements, the Secretary
shall impose the remedy described in subparagraph (B)(i) for
all individuals who are admitted to the facility after such
date.
(E) Repeated noncompliance
In the case of a skilled nursing facility which, on 3
consecutive standard surveys conducted under subsection (g)(2)
of this section, has been found to have provided substandard
quality of care, the Secretary shall (regardless of what other
remedies are provided) -
(i) impose the remedy described in subparagraph (B)(i), and
(ii) monitor the facility under subsection (g)(4)(B) of
this section,
until the facility has demonstrated, to the satisfaction of the
Secretary, that it is in compliance with the requirements of
subsections (b), (c), and (d) of this section, and that it will
remain in compliance with such requirements.
(3) Effective period of denial of payment
A finding to deny payment under this subsection shall terminate
when the Secretary finds that the facility is in substantial
compliance with all the requirements of subsections (b), (c), and
(d) of this section.
(4) Immediate termination of participation for facility where
Secretary finds noncompliance and immediate jeopardy
If the Secretary finds that a skilled nursing facility has not
met a requirement of subsection (b), (c), or (d) of this section,
and finds that the failure immediately jeopardizes the health or
safety of its residents, the Secretary shall take immediate
action to remove the jeopardy and correct the deficiencies
through the remedy specified in paragraph (2)(B)(iii), or the
Secretary shall terminate the facility's participation under this
subchapter. If the facility's participation under this subchapter
is terminated, the State shall provide for the safe and orderly
transfer of the residents eligible under this subchapter
consistent with the requirements of subsection (c)(2) of this
section.
(5) Construction
The remedies provided under this subsection are in addition to
those otherwise available under State or Federal law and shall
not be construed as limiting such other remedies, including any
remedy available to an individual at common law. The remedies
described in clauses (i),(!7) and (iii) of paragraph (2)(B) may
be imposed during the pendency of any hearing.
(6) Sharing of information
Notwithstanding any other provision of law, all information
concerning skilled nursing facilities required by this section to
be filed with the Secretary or a State agency shall be made
available by such facilities to Federal or State employees for
purposes consistent with the effective administration of programs
established under this subchapter and subchapter XIX of this
chapter, including investigations by State medicaid fraud control
units.
(i) Construction
Where requirements or obligations under this section are
identical to those provided under section 1396r of this title, the
fulfillment of those requirements or obligations under section
1396r of this title shall be considered to be the fulfillment of
the corresponding requirements or obligations under this section.
-SOURCE-
(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1819, as added and
amended Pub. L. 100-203, title IV, Secs. 4201(a)(3), 4202(a)(2),
4203(a)(2), 4206, Dec. 22, 1987, 101 Stat. 1330-160, 1330-175,
1330-179, 1330-182; Pub. L. 100-360, title IV, Sec. 411(l)(1)(A),
(2)(A)-(D), (F)-(L)(i), (4), (5), (7), (11), July 1, 1988, 102
Stat. 800-805, as amended Pub. L. 100-485, title VI, Sec.
608(d)(27)(A), (C), (D), (I), (L), Oct. 13, 1988, 102 Stat. 2422,
2423; Pub. L. 101-239, title VI, Sec. 6901(b)(1), (3), (d)(4), Dec.
19, 1989, 103 Stat. 2298, 2301; Pub. L. 101-508, title IV, Secs.
4008(h)(1)(B)-(F)(i), (G), (2)(B)-(N), (m)(3)(F)[(E)], 4206(d)(1),
Nov. 5, 1990, 104 Stat. 1388-46 to 1388-50, 1388-54, 1388-116; Pub.
L. 102-375, title VII, Sec. 708(a)(1)(A), Sept. 30, 1992, 106 Stat.
1291; Pub. L. 103-432, title I, Secs. 106(c)(1)(A), (2)(A), (3)(A),
(4)(A), (B), (d)(1)-(5), 110(b), Oct. 31, 1994, 108 Stat.
4406-4408; Pub. L. 105-15, Sec. 1, May 15, 1997, 111 Stat. 34; Pub.
L. 105-33, title IV, Secs. 4432(b)(5)(A), 4755(a), Aug. 5, 1997,
111 Stat. 421, 526; Pub. L. 106-554, Sec. 1(a)(6) [title IX, Sec.
941(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A-585.)
-REFTEXT-
REFERENCES IN TEXT
The Older Americans Act of 1965, referred to in subsecs.
(b)(4)(C)(ii)(IV), (c)(2)(B)(iii)(II), and (g)(5)(B), is Pub. L.
89-73, July 14, 1965, 79 Stat. 218, as amended. Section 307(a)(12)
of the Act was repealed by Pub. L. 106-501, title III, Sec. 306(5),
Nov. 13, 2000, 114 Stat. 2244. Similar provisions are now contained
in section 307(a)(9) of the Act, which is classified to section
3027(a)(9) of this title. Titles III and VII of the Act are
classified generally to subchapters III (Sec. 3021 et seq.) and XI
(Sec. 3058 et seq.) of chapter 35 of this title. For complete
classification of this Act to the Code, see Short Title note set
out under section 3001 of this title and Tables.
Subparagraphs (B), (C), and (D) of section 6901(b)(4) of the
Omnibus Budget Reconciliation Act of 1989 [Pub. L. 101-239],
referred to in subsec. (e)(2)(A), are set out below.
Section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse
Amendments of 1977, referred to in subsec. (f)(7)(A), probably
means section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse
Amendments, Pub. L. 95-142, which is set out as a note under
section 1395x of this title.
-MISC1-
AMENDMENTS
2000-Subsec. (b)(8). Pub. L. 106-554 added par. (8).
1997 - Subsec. (b)(3)(C)(i). Pub. L. 105-33, Sec. 4432(b)(5)(A),
substituted "Subject to the timeframes prescribed by the Secretary
under section 1395yy(e)(6) of this title, such" for "Such" in
introductory provisions.
Subsec. (f)(2)(B)(iii). Pub. L. 105-15, Sec. 1(1), inserted
"subject to subparagraph (C)," after "(iii)".
Subsec. (f)(2)(C). Pub. L. 105-15, Sec. 1(2), added subpar. (C).
Subsec. (g)(1)(D), (E). Pub. L. 105-33, Sec. 4755(a), added
subpar. (D) and redesignated former subpar. (D) as (E).
1994 - Subsec. (b)(3)(C)(i)(I). Pub. L. 103-432, Sec. 110(b),
substituted "but no later than 14 days" for "but no later than not
later than 14 days".
Subsec. (b)(5)(D). Pub. L. 103-432, Sec. 106(d)(1), struck out
comma before "or a new competency evaluation program".
Subsec. (b)(5)(G). Pub. L. 103-432, Sec. 106(d)(2), substituted
"licensed or certified social worker, registered respiratory
therapist, or certified respiratory therapy technician" for "or
licensed or certified social worker".
Subsec. (c)(1)(D). Pub. L. 103-432, Sec. 106(c)(2)(A), inserted
at end "In determining whether such a consultant is qualified to
conduct reviews under the preceding sentence, the Secretary shall
take into account the needs of nursing facilities under this
subchapter to have access to the services of such a consultant on a
timely basis."
Subsec. (c)(6)(B)(i). Pub. L. 103-432, Sec. 106(c)(3)(A),
substituted "$100" for "$50".
Subsec. (e)(2)(B). Pub. L. 103-432, Sec. 106(c)(4)(A), inserted
", but shall not include any allegations of resident abuse or
neglect or misappropriation of resident property that are not
specifically documented by the State under such subsection" after
"individual disputing the findings" in first sentence.
Subsec. (f)(2)(B)(i). Pub. L. 103-432, Sec. 106(d)(3),
substituted "facilities (subject to clause (iii))," for
"facilities,".
Subsec. (f)(2)(B)(iii)(I)(b). Pub. L. 103-432, Sec. 106(c)(1)(A),
inserted before semicolon at end ", unless the survey shows that
the facility is in compliance with the requirements of subsections
(b), (c), and (d) of this section".
Subsec. (f)(2)(B)(iii)(I)(c). Pub. L. 103-432, Sec. 106(d)(4),
substituted "clause" for "clauses" in two places.
Subsec. (g)(1)(C). Pub. L. 103-432, Sec. 106(c)(4)(B),
substituted second sentence for former second sentence which read
as follows: "The State shall, after notice to the individual
involved and a reasonable opportunity for a hearing for the
individual to rebut allegations, make a finding as to the accuracy
of the allegations."
Subsec. (g)(5)(B). Pub. L. 103-432, Sec. 106(d)(5), substituted
"paragraph" for "paragraphs" before "(1), (2), or (4) of subsection
(h)".
1992 - Subsecs. (c)(2)(B)(iii)(II), (g)(5)(B). Pub. L. 102-375
substituted "title III or VII of the Older Americans Act of 1965 in
accordance with section 712 of the Act" for "section 307(a)(12) of
the Older Americans Act of 1965".
1990 - Subsec. (b)(1)(B). Pub. L. 101-508, Sec. 4008(h)(2)(B),
inserted at end "A State or the Secretary may not require
disclosure of the records of such committee except insofar as such
disclosure is related to the compliance of such committee with the
requirements of this subparagraph."
Subsec. (b)(3)(C)(i)(I). Pub. L. 101-508, Sec. 4008(h)(2)(C),
substituted "not later than 14 days" for "4 days".
Subsec. (b)(4)(A)(vii). Pub. L. 101-508, Sec. 4008(h)(2)(D),
added cl. (vii).
Subsec. (b)(4)(C)(ii)(IV), (V). Pub. L. 101-508, Sec.
4008(h)(2)(E), added subcls. (IV) and (V).
Subsec. (b)(5)(A). Pub. L. 101-508, Sec. 4008(h)(1)(B),
designated existing provisions as cl. (i), in introductory
provisions substituted "Except as provided in clause (ii), a
skilled nursing facility" for "A skilled nursing facility" and "on
a full-time basis" for "(on a full-time, temporary, per diem, or
other basis)", redesignated former cls. (i) and (ii) as subcls. (I)
and (II), respectively, and added cl. (ii).
Subsec. (b)(5)(C). Pub. L. 101-508, Sec. 4008(h)(1)(C),
substituted "any State registry established under subsection
(e)(2)(A) of this section that the facility believes will include
information" for "the State registry established under subsection
(e)(2)(A) of this section as to information in the registry".
Subsec. (b)(5)(D). Pub. L. 101-508, Sec. 4008(h)(1)(D), inserted
before period at end ", or a new competency evaluation program"
after "and competency evaluation program".
Subsec. (b)(5)(F)(i). Pub. L. 101-508, Sec. 4008(h)(2)(F),
substituted "(G)) or a registered dietician," for "(G)),".
Subsec. (c)(1)(A). Pub. L. 101-508, Sec. 4008(h)(2)(G)(B)[(ii)],
inserted at end "A resident's exercise of a right to refuse
transfer under clause (x) shall not affect the resident's
eligibility or entitlement to benefits under this subchapter or to
medical assistance under subchapter XIX of this chapter."
Subsec. (c)(1)(A)(iv). Pub. L. 101-508, Sec. 4008(h)(2)(H),
inserted before period at end "and to access to current clinical
records of the resident upon request by the resident or the
resident's legal representative, within 24 hours (excluding hours
occurring during a weekend or holiday) after making such a
request".
Subsec. (c)(1)(A)(x), (xi). Pub. L. 101-508, Sec.
4008(h)(2)(G)(i), added cl. (x) and redesignated former cl. (x) as
(xi).
Subsec. (c)(1)(B)(ii). Pub. L. 101-508, Sec. 4008(h)(2)(I),
inserted "including the notice (if any) of the State developed
under section 1396r(e)(6) of this title" after "in such rights)".
Subsec. (c)(1)(E). Pub. L. 101-508, Sec. 4206(d)(1), added
subpar. (E).
Subsec. (e)(1)(A). Pub. L. 101-508, Sec. 4008(h)(2)(J),
substituted "subsection (f)(2) of this section" for "clause (i) or
(ii) of subsection (f)(2)(A) of this section".
Subsec. (e)(2)(A). Pub. L. 101-508, Sec. 4008(h)(2)(K)(i),
inserted before period at end ", or any individual described in
subsection (f)(2)(B)(ii) of this section or in subparagraph (B),
(C), or (D) of section 6901(b)(4) of the Omnibus Budget
Reconciliation Act of 1989".
Subsec. (e)(2)(C). Pub. L. 101-508, Sec. 4008(h)(2)(K)(ii), added
subpar. (C).
Subsec. (f)(2)(A)(ii). Pub. L. 101-508, Sec. 4008(m)(3)(F)[(E)],
struck out "and" after semicolon at end.
Subsec. (f)(2)(A)(iv). Pub. L. 101-508, Sec. 4008(h)(1)(E),
struck out "and" at end of subcl. (I), inserted "who is employed by
(or who has received an offer of employment from) a facility on the
date on which the aide begins either such program" after "nurse
aide" and substituted ", and" for period at end of subcl. (II), and
added subcl. (III).
Subsec. (f)(2)(B). Pub. L. 101-508, Sec. 4008(h)(1)(G), inserted
"(through subcontract or otherwise)" after "may not delegate" in
second sentence.
Subsec. (f)(2)(B)(iii)(I). Pub. L. 101-508, Sec.
4008(h)(1)(F)(i), amended subcl. (I) generally. Prior to amendment,
subcl. (I) read as follows: "offered by or in a skilled nursing
facility which has been determined to be out of compliance with the
requirements of subsection (b), (c), or (d) of this section, within
the previous 2 years, or".
Subsec. (g)(1)(C). Pub. L. 101-508, Sec. 4008(h)(2)(L), inserted
at end "A State shall not make a finding that an individual has
neglected a resident if the individual demonstrates that such
neglect was caused by factors beyond the control of the
individual."
Subsec. (g)(5)(A)(i). Pub. L. 101-508, Sec. 4008(h)(2)(M),
substituted "deficiencies, within 14 calendar days after such
information is made available to those facilities, and approved
plans" for "deficiencies and plans".
Subsec. (g)(5)(B). Pub. L. 101-508, Sec. 4008(h)(2)(N),
substituted "or of any adverse action taken against a skilled
nursing facility under paragraphs (1), (2), or (4) of subsection
(h) of this section, with respect" for "with respect".
1989 - Subsec. (b)(5)(A). Pub. L. 101-239, Sec. 6901(b)(1)(A),
substituted "October 1, 1990" for "January 1, 1990" in introductory
provisions.
Subsec. (b)(5)(B). Pub. L. 101-239, Sec. 6901(b)(1)(B),
substituted "January 1, 1990" and "October 1, 1990" for "July 1,
1989" and "January 1, 1990", respectively.
Subsec. (c)(1)(A)(ii)(II). Pub. L. 101-239, Sec. 6901(d)(4)(A),
substituted "Secretary until such an order could reasonably be
obtained)" for "Secretary) until such an order could reasonably be
obtained".
Subsec. (c)(1)(A)(v)(I). Pub. L. 101-239, Sec. 6901(d)(4)(B),
substituted "accommodation" for "accommodations".
Subsec. (f)(2)(A)(i)(I). Pub. L. 101-239, Sec. 6901(d)(4)(C),
substituted "and content of the curriculum" for ", content of the
curriculum".
Pub. L. 101-239, Sec. 6901(b)(3)(A), inserted "care of
cognitively impaired residents," after "social service needs,".
Subsec. (f)(2)(A)(ii). Pub. L. 101-239, Sec. 6901(b)(3)(B),
substituted "recognition of mental health and social service needs,
care of cognitively impaired residents" for "cognitive, behavioral
and social care".
Subsec. (f)(2)(A)(iv). Pub. L. 101-239, Sec. 6901(b)(3)(C), (D),
added cl. (iv).
Subsec. (h)(2)(C). Pub. L. 101-239, Sec. 6901(d)(4)(D), inserted
"after the effective date of the findings" after "6 months" in
introductory provisions.
1988 - Subsec. (b)(3)(A)(iii). Pub. L. 100-360, Sec.
411(l)(2)(B), struck out "in the case of a resident eligible for
benefits under subchapter XIX of this chapter," before "uses an
instrument".
Subsec. (b)(3)(A)(iv). Pub. L. 100-360, Sec. 411(l)(2)(A), as
amended by Pub. L. 100-485, Sec. 608(d)(27)(C), struck out "in the
case of a resident eligible for benefits under this part," before
"includes the identification".
Subsec. (b)(3)(B)(ii)(III). Pub. L. 100-360, Sec. 411(l)(2)(C),
amended subcl. (III) generally. Prior to amendment, subcl. (III)
read as follows: "The Secretary shall provide for imposition of
civil money penalties under this clause in a manner similar to that
for the imposition of civil money penalties under section 1320a-7a
of this title."
Subsec. (b)(3)(C)(i)(I). Pub. L. 100-360, Sec. 411(l)(1)(A)(i),
substituted "than January 1, 1991" for "than October 1, 1990".
Subsec. (b)(4)(C)(i). Pub. L. 100-360, Sec. 411(l)(1)(A)(ii),
substituted "24-hour licensed nursing" for "24-hour nursing", "must
use" for "must employ", and "at least 8 consecutive hours a day,"
for "during the day tour of duty (of at least 8 hours a day)".
Subsec. (b)(5)(A). Pub. L. 100-360, Sec. 411(l)(2)(D)(i), as
amended by Pub. L. 100-485, Sec. 608(d)(27)(D), struck out ", who
is not a licensed health professional (as defined in subparagraph
(E))," after "any individual".
Pub. L. 100-360, Sec. 411(l)(1)(A)(iii), substituted "January 1,
1990" for "October 1, 1989, (or January 1, 1990, in the case of an
individual used by the facility as a nurse aide before July 1,
1989)".
Subsec. (b)(5)(A)(ii). Pub. L. 100-360, Sec. 411(l)(2)(D)(ii),
substituted "nursing or nursing-related services" for "such
services".
Subsec. (b)(5)(G). Pub. L. 100-360, Sec. 411(l)(2)(D)(iii),
inserted "physical or occupational therapy assistant," after
"occupational therapist,".
Subsec. (c)(1)(D). Pub. L. 100-360, Sec. 411(l)(1)(A)(iv), as
added by Pub. L. 100-485, Sec. 608(d)(27)(A), added subpar. (D).
Subsec. (c)(2)(A)(v). Pub. L. 100-360, Sec. 411(l)(2)(F),
substituted "for a stay at the facility" for "an allowable charge
imposed by the facility for an item or service requested by the
resident and for which a charge may be imposed consistent with this
subchapter and subchapter XIX of this chapter".
Subsec. (c)(6). Pub. L. 100-360, Sec. 411(l)(2)(G), substituted
"upon the written" for "once the facility accepts the written" in
subpar. (A)(ii), and "Upon written" for "Upon a facility's
acceptance of written" in subpar. (B).
Subsec. (e)(1)(A). Pub. L. 100-360, Sec. 411(l)(1)(A)(v),
formerly Sec. 411(l)(1)(A)(iv), as redesignated by Pub. L. 100-485,
Sec. 608(d)(27)(A), substituted "January" for "March".
Subsec. (e)(1)(B). Pub. L. 100-360, Sec. 411(l)(1)(A)(vi),
formerly Sec. 411(l)(1)(A)(v), as redesignated by Pub. L. 100-485,
Sec. 608(d)(27)(A), substituted "January" for "March".
Subsec. (e)(2)(A). Pub. L. 100-360, Sec. 411(l)(1)(A)(vii),
formerly Sec. 411(l)(1)(A)(vi), as redesignated by Pub. L. 100-485,
Sec. 608(d)(27)(A), substituted "January" for "March".
Subsec. (e)(2)(B). Pub. L. 100-360, Sec. 411(l)(2)(H), inserted
after first sentence "The State shall make available to the public
information in the registry."
Subsec. (e)(3). Pub. L. 100-360, Sec. 411(l)(2)(I), inserted "and
discharges" after "transfers" in heading and in two places in text.
Pub. L. 100-360, Sec. 411(l)(1)(A)(viii), formerly Sec.
411(l)(1)(A)(vii), as redesignated by Pub. L. 100-485, Sec.
608(d)(27)(A), substituted "1989" for "1990".
Subsec. (e)(5). Pub. L. 100-360, Sec. 411(l)(1)(A)(ix), formerly
Sec. 411(l)(1)(A)(viii), as redesignated by Pub. L. 100-485, Sec.
608(d)(27)(A), substituted "1990" for "1989" in introductory
provisions.
Subsec. (f)(2)(A)(i)(I). Pub. L. 100-360, Sec. 411(l)(2)(J),
substituted "recognition of mental health and social service needs"
for "cognitive, behavioral and social care".
Subsec. (f)(3). Pub. L. 100-360, Sec. 411(l)(2)(I), inserted "and
discharges" after "transfers" in heading and in text.
Pub. L. 100-360, Sec. 411(l)(1)(A)(x), formerly Sec.
411(l)(1)(A)(ix), as redesignated by Pub. L. 100-485, Sec.
608(d)(27)(A), substituted "1988" for "1989".
Subsec. (f)(6)(A). Pub. L. 100-360, Sec. 411(l)(1)(A)(xi),
formerly Sec. 411(l)(1)(A)(x), as redesignated by Pub. L. 100-485,
Sec. 608(d)(27)(A), substituted "January" for "July".
Subsec. (f)(6)(B). Pub. L. 100-360, Sec. 411(l)(1)(A)(xii),
formerly Sec. 411(l)(1)(A)(xi), as redesignated by Pub. L. 100-485,
Sec. 608(d)(27)(A), substituted "April" for "October".
Subsec. (f)(7)(A). Pub. L. 100-360, Sec. 411(l)(2)(K),
substituted "residents" for "patients".
Subsec. (f)(7)(B). Pub. L. 100-360, Sec. 411(l)(2)(L)(i),
substituted "shall include" for "shall not include".
Subsec. (g)(1)(C). Pub. L. 100-360, Sec. 411(l)(5)(A)-(C),
substituted "and timely review" for ", review,", inserted "or by
another individual used by the facility in providing services to
such a resident" after "a nursing facility", and substituted "The
State shall, after notice to the individual involved and a
reasonable opportunity for a hearing for the individual to rebut
allegations, make a finding as to the accuracy of the allegations.
If the State finds that a nurse aide has neglected or abused a
resident or misappropriated resident property in a facility, the
State shall notify the nurse aide and the registry of such finding.
If the State finds that any other individual used by the facility
has neglected or abused a resident or misappropriated resident
property in a facility, the State shall notify the appropriate
licensure authority." for "If the State finds, after notice to the
nurse aide involved and a reasonable opportunity for a hearing for
the nurse aide to rebut allegations, that a nurse aide whose name
is contained in a nurse aide registry has neglected or abused a
resident or misappropriated resident property in a facility, the
State shall notify the nurse aide and the registry of such
finding."
Subsec. (g)(1)(D). Pub. L. 100-360, Sec. 411(l)(5)(D),
substituted "to issue regulations to carry out this subsection" for
"to establish standards under subsection (f) of this section".
Subsec. (g)(2)(A)(i). Pub. L. 100-360, Sec. 411(l)(5)(E), amended
third sentence generally. Prior to amendment, third sentence read
as follows: "The Secretary shall provide for imposition of civil
money penalties under this clause in a manner similar to that for
the imposition of civil money penalties under section 1320a-7a of
this title."
Subsec. (g)(2)(B)(ii). Pub. L. 100-360, Sec. 411(l)(5)(F), as
added by Pub. L. 100-485, Sec. 608(d)(27)(I), substituted
"practicable" for "practical".
Subsec. (g)(2)(C)(i). Pub. L. 100-360, Sec. 411(l)(4),
substituted "January" for "October".
Subsec. (g)(3)(D). Pub. L. 100-360, Sec. 411(l)(5)(G), formerly
Sec. 411(l)(5)(F), as redesignated by Pub. L. 100-485, Sec.
608(d)(27)(I), substituted "on the basis of that survey" for "on
that basis".
Subsec. (g)(4). Pub. L. 100-360, Sec. 411(l)(5)(H), formerly Sec.
411(l)(5)(G), as redesignated by Pub. L. 100-485, Sec.
608(d)(27)(I), struck out "chronically" after "enforcement actions
against" in last sentence.
Subsec. (h)(2)(B)(ii). Pub. L. 100-360, Sec. 411(l)(7)(A),
substituted ". The provisions of section 1320a-7a of this title
(other than subsections (a) and (b)) shall apply to a civil money
penalty under the previous sentence in the same manner as such
provisions apply to a penalty or proceeding under section
1320a-7a(a) of this title." for "and the Secretary shall impose and
collect such a penalty in the same manner as civil money penalties
are imposed and collected under section 1320a-7a of this title."
Subsec. (h)(5). Pub. L. 100-360, Sec. 411(l)(11), as added by
Pub. L. 100-485, Sec. 608(d)(27)(L), substituted "clauses (i), and
(iii) of paragraph (2)(B)" for "clauses (i), (iii), and (iv) of
paragraph (2)(A)".
Subsec. (h)(6). Pub. L. 100-360, Sec. 411(l)(7)(B), inserted "by
such facilities" after "be made available".
1987 - Subsecs. (g) to (i). Pub. L. 100-203, Secs. 4202(a)(2),
4203(a)(2), 4206, added subsecs. (g), (h), and (i), respectively.
EFFECTIVE DATE OF 2000 AMENDMENT
Pub. L. 106-554, Sec. 1(a)(6) [title IX, Sec. 941(c)], Dec. 21,
2000, 114 Stat. 2763, 2763A-586, provided that: "The amendments
made by this section [amending this section and section 1396r of
this title] shall take effect on January 1, 2003."
EFFECTIVE DATE OF 1997 AMENDMENT
Section 4432(d) of Pub. L. 105-33 provided that: "The amendments
made by this section [amending this section and sections 1395k,
1395l, 1395u, 1395x, 1395y, 1395cc, 1395tt, and 1395yy of this
title] are effective for cost reporting periods beginning on or
after July 1, 1998; except that the amendments made by subsection
(b) [amending this section and sections 1395k, 1395l, 1395u, 1395x,
1395y, 1395cc, 1395tt, and 1395yy of this title] shall apply to
items and services furnished on or after July 1, 1998."
EFFECTIVE DATE OF 1994 AMENDMENT
Section 106(c)(1)(B) of Pub. L. 103-432 provided that: "The
amendment made by subparagraph (A) [amending this section] shall
take effect as if included in the enactment of OBRA-1990 [Pub. L.
101-508]."
Section 106(c)(2)(B) of Pub. L. 103-432 provided that: "The
amendment made by subparagraph (A) [amending this section] shall
take effect as if included in the enactment of OBRA-1987 [Pub. L.
100-203]."
Section 106(c)(3)(B) of Pub. L. 103-432 provided that: "The
amendment made by subparagraph (A) [amending this section] shall
take effect January 1, 1995."
Section 106(c)(4)(C) of Pub. L. 103-432 provided that: "The
amendments made by this paragraph [amending this section] shall
take effect January 1, 1995."
Section 106(d)(7) of Pub. L. 103-432 provided that: "The
amendments made by this subsection [amending this section and
provisions set out as a note below] shall take effect as if
included in the enactment of OBRA-1990 [Pub. L. 101-508]."
EFFECTIVE DATE OF 1992 AMENDMENT
Amendment by Pub. L. 102-375 inapplicable with respect to fiscal
year 1993, see section 4(b) of Pub. L. 103-171, set out as a note
under section 3001 of this title.
Amendment by Pub. L. 102-375 inapplicable with respect to fiscal
year 1992, see section 905(b)(6) of Pub. L. 102-375, set out as a
note under section 3001 of this title.
EFFECTIVE DATE OF 1990 AMENDMENT
Section 4008(h)(1)(F)(ii) of Pub. L. 101-508, as amended by Pub.
L. 103-432, title I, Sec. 106(d)(6), Oct. 31, 1994, 108 Stat. 4407,
provided that:
"(I) The amendments made by clause (i) [amending this section]
shall take effect as if included in the enactment of the Omnibus
Budget Reconciliation Act of 1987 [Pub. L. 100-203], except that a
State may not approve a training and competency evaluation program
or a competency evaluation program offered by or in a skilled
nursing facility which, pursuant to any Federal or State law within
the 2-year period beginning on October 1, 1988 -
"(aa) had its participation terminated under title XVIII of the
Social Security Act [this subchapter] or under the State plan
under title XIX of such Act [subchapter XIX of this chapter];
"(bb) was subject to a denial of payment under either such
title;
"(cc) was assessed a civil money penalty not less than $5,000
for deficiencies in skilled nursing facility standards;
"(dd) operated under a temporary management appointed to
oversee the operation of the facility and to ensure the health
and safety of the facility's residents; or
"(ee) pursuant to State action, was closed or had its residents
transferred.
"(II) Notwithstanding subclause (I) and subject to section
1819(f)(2)(B)(iii)(I) of the Social Security Act [subsec.
(f)(2)(B)(iii)(I) of this section] (as amended by clause (i)), a
State may approve a training and competency evaluation program or a
competency evaluation program offered by or in a skilled nursing
facility described in subclause (I) if, during the previous 2
years, item (aa), (bb), (cc), (dd), or (ee) of subclause (I) did
not apply to the facility."
Section 4008(h)(1)(H) of Pub. L. 101-508 provided that: "Except
as provided in subparagraph (F) [amending this section and enacting
provisions set out as a note above], the amendments made by this
subsection [probably means this paragraph, amending this section]
shall take effect as if they were included in the enactment of the
Omnibus Budget Reconciliation Act of 1987 [Pub. L. 100-203]."
Section 4008(h)(2)(P) of Pub. L. 101-508 provided that: "The
amendments made by this paragraph [amending this section and
sections 1395x and 1395yy of this title] shall take effect as if
they were included in the enactment of the Omnibus Budget
Reconciliation Act of 1987 [Pub. L. 100-203]."
Section 4206(e)(1) of Pub. L. 101-508 provided that: "The
amendments made by subsections (a) and (d) [amending this section
and sections 1395cc and 1395bbb of this title] shall apply with
respect to services furnished on or after the first day of the
first month beginning more than 1 year after the date of the
enactment of this Act [Nov. 5, 1990]."
EFFECTIVE DATE OF 1989 AMENDMENT
Section 6901(b)(6) of Pub. L. 101-239 provided that:
"(A) In general. - Except as provided in subparagraph (B), the
amendments made by this subsection [amending this section and
sections 1396b and 1396r of this title] shall take effect as if
they were included in the enactment of the Omnibus Budget
Reconciliation Act of 1987 [Pub. L. 100-203].
"(B) Exception. - The amendments made by paragraph (3) [amending
this section and section 1396r of this title] shall apply to nurse
aide training and competency evaluation programs, and nurse aide
competency evaluation programs, offered on or after the end of the
90-day period beginning on the date of the enactment of this Act
[Dec. 19, 1989], but shall not affect competency evaluations
conducted under programs offered before the end of such period."
Section 6901(d)(6) of Pub. L. 101-239 provided that:
"(A) In general. - Except as provided in subparagraph (B), the
amendments made by this subsection [amending this section and
sections 1396i and 1396r of this title] shall take effect as if
they were included in the enactment of the Omnibus Budget
Reconciliation Act of 1987 [Pub. L. 100-203].
"(B) Exception. - The amendment made by paragraph (1) [amending
section 1396r of this title] shall take effect on the date of the
enactment of this Act [Dec. 19, 1989]."
EFFECTIVE DATE OF 1988 AMENDMENTS
Amendment by Pub. L. 100-485 effective as if originally included
in the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100-360,
see section 608(g)(1) of Pub. L. 100-485, set out as a note under
section 704 of this title.
Except as specifically provided in section 411 of Pub. L.
100-360, amendment by Pub. L. 100-360, as it relates to a provision
in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203,
effective as if included in the enactment of that provision in Pub.
L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a
Reference to OBRA; Effective Date note under section 106 of Title
1, General Provisions.
EFFECTIVE DATE
Section 4204 of title IV of Pub. L. 100-203, as amended by Pub.
L. 100-360, title IV, Sec. 411(l)(9), July 1, 1988, 102 Stat. 805;
Pub. L. 100-485, title VI, Sec. 608(d)(27)(K), Oct. 13, 1988, 102
Stat. 2423, provided that:
"(a) New Requirements and Survey and Certification Process. -
Except as otherwise specifically provided in section 1819 of the
Social Security Act [this section], the amendments made by sections
4201 and 4202 [enacting and amending this section and amending
sections 1395x, 1395aa, 1395tt, and 1395yy of this title] (relating
to skilled nursing facility requirements and survey and
certification requirements) shall apply to services furnished on or
after October 1, 1990, without regard to whether regulations to
implement such amendments are promulgated by such date.
"(b) Enforcement. - (1) Except as otherwise specifically provided
in section 1819 of the Social Security Act [this section], the
amendments made by section 4203 of this Act [amending this section
and section 1395aa of this title] apply January 1, 1988, without
regard to whether regulations to implement such amendments are
promulgated by such date.
"(2) In applying the amendments made by section 4203 of this Act
for services furnished by a skilled nursing facility before October
1, 1990, any reference to a requirement of subsection (b), (c), or
(d), of section 1819 of the Social Security Act is deemed a
reference to the provisions of section 1861(j) of such Act [section
1395x(j) of this title].
"(c) Waiver of Paperwork Reduction. - Chapter 35 of title 44,
United States Code, shall not apply to information required for
purposes of carrying out this part [part 1 of subtitle C (Secs.
4201-4206), enacting this section, amending this section and
sections 1395x, 1395aa, 1395tt, and 1395yy of this title, and
enacting provisions set out as notes under this section] and
implementing the amendments made by this part."
STUDY AND REPORT REGARDING STATE LICENSURE AND CERTIFICATION
STANDARDS AND RESPIRATORY THERAPY COMPETENCY EXAMINATIONS
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title I, Sec. 107],
Nov. 29, 1999, 113 Stat. 1536, 1501A-328, provided that:
"(a) Study. - The Secretary of Health and Human Services shall
conduct a study that -
"(1) identifies variations in State licensure and certification
standards for health care providers (including nursing and allied
health professionals) and other individuals providing respiratory
therapy in skilled nursing facilities;
"(2) examines State requirements relating to respiratory
therapy competency examinations for such providers and
individuals; and
"(3) determines whether regular respiratory therapy competency
examinations or certifications should be required under the
medicare program under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) for such providers and individuals.
"(b) Report. - Not later than 18 months after the date of
enactment of this Act [Nov. 29, 1999], the Secretary of Health and
Human Services shall submit to Congress a report on the results of
the study conducted under this section, together with any
recommendations for legislation that the Secretary determines to be
appropriate as a result of such study."
RETROACTIVE REVIEW
Section 4755(c) of Pub. L. 105-33 provided that: "The procedures
developed by a State under the amendments made by subsection[s] (a)
and (b) [amending this section and section 1396r of this title]
shall permit an individual to petition for a review of any finding
made by a State under section 1819(g)(1)(C) or 1919(g)(1)(C) of the
Social Security Act (42 U.S.C. 1395i-3(g)(1)(C) or 1396r(g)(1)(C))
after January 1, 1995."
Descargar
| Enviado por: | El remitente no desea revelar su nombre |
| Idioma: | inglés |
| País: | Estados Unidos |
Todos los derechos reservados.