42 USC 1395y. Exclusions from coverage and medicare as secondary payer
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Items or services specifically excluded
Notwithstanding any other provision of this subchapter, no payment
may be made under part A or part B of this subchapter for any expenses
incurred for items or services --
(1)(A) which, except for items and services described in a succeeding
subparagraph, are not reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a
malformed body member,
(B) in the case of items and services described in section
1395x(s)(10) of this title, which are not reasonable and necessary for
the prevention of illness,
(C) in the case of hospice care, which are not reasonable and
necessary for the palliation or management of terminal illness,
(D) in the case of clinical care items and services provided with the
concurrence of the Secretary and with respect to research and
experimentation conducted by, or under contract with, the Prospective
Payment Assessment Commission or the Secretary, which are not reasonable
and necessary to carry out the purposes of section 1395ww(e)(6) of this
title,
(E) in the case of research conducted pursuant to section 1320b-12 of
this title, which is not reasonable and necessary to carry out the
purposes of that section, and
(F) in the case of screening mammography, which is performed more
frequently than is covered under section 1395m(c)(2) of this title or
which does not meet the standards established under section 1395m(c)(3)
of this title, and, in the case of screening pap smear, which is
performed more frequently than is provided under section 1395x(nn) of
this title;
(2) for which the individual furnished such items or services has no
legal obligation to pay, and which no other person (by reason of such
individual's membership in a prepayment plan or otherwise) has a legal
obligation to provide or pay for, except in the case of Federally
qualified health center services;
(3) which are paid for directly or indirectly by a governmental
entity (other than under this chapter and other than under a health
benefits or insurance plan established for employees of such an entity),
except in the case of rural health clinic services, as defined in
section 1395x(aa)(1) of this title,, /1/ in the case of Federally
qualified health center services, as defined in section 1395x(aa)(3) of
this title, and in such other cases as the Secretary may specify;
(4) which are not provided within the United States (except for
inpatient hospital services furnished outside the United States under
the conditions described in section 1395f(f) of this title and, subject
to such conditions, limitations, and requirements as are provided under
or pursuant to this subchapter, physicians' services and ambulance
services furnished an individual in conjunction with such inpatient
hospital services but only for the period during which such inpatient
hospital services were furnished);
(5) which are required as a result of war, or of an act of war,
occurring after the effective date of such individual's current coverage
under such part;
(6) which constitute personal comfort items (except, in the case of
hospice care, as is otherwise permitted under paragraph (1)(C));
(7) where such expenses are for routine physical checkups, eyeglasses
(other than eyewear described in section 1395x(s)(8) of this title) or
eye examinations for the purpose of prescribing, fitting, or changing
eyeglasses, procedures performed (during the course of any eye
examination) to determine the refractive state of the eyes, hearing aids
or examinations therefor, or immunizations (except as otherwise allowed
under section 1395x(s)(10) of this title and paragraph (1)(B) or under
paragraph (1)(F));
(8) where such expenses are for orthopedic shoes or other supportive
devices for the feet, other than shoes furnished pursuant to section
1395x(s)(12) of this title;
(9) where such expenses are for custodial care (except, in the case
of hospice care, as is otherwise permitted under paragraph (1)(C));
(10) where such expenses are for cosmetic surgery or are incurred in
connection therewith, except as required for the prompt repair of
accidental injury or for improvement of the functioning of a malformed
body member;
(11) where such expenses constitute charges imposed by immediate
relatives of such individual or members of his household;
(12) where such expenses are for services in connection with the
care, treatment, filling, removal, or replacement of teeth or structures
directly supporting teeth, except that payment may be made under part A
of this subchapter in the case of inpatient hospital services in
connection with the provision of such dental services if 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;
(13) where such expenses are for --
(A) the treatment of flat foot conditions and the prescription of
supportive devices therefor,
(B) the treatment of subluxations of the foot, or
(C) routine foot care (including the cutting or removal of corns or
calluses, the trimming of nails, and other routine hygienic care);
(14) which are other than physicians' services (as defined in
regulations promulgated specifically for purposes of this paragraph),
services described by section 1395x(s)(2)(K)(i) of this title, certified
nurse-midwife services, qualified psychologist services, and services of
a certified registered nurse anesthetist, and which are furnished to an
individual who is a patient of a hospital or rural primary care hospital
by an entity other than the hospital or rural primary care hospital,
unless the services are furnished under arrangements (as defined in
section 1395x(w)(1) of this title) with the entity made by the hospital
or rural primary care hospital;
(15)(A) which are for services of an assistant at surgery in a
cataract operation (including subsequent insertion of an intraocular
lens) unless, before the surgery is performed, the appropriate
utilization and quality control peer review organization (under part B
of subchapter XI of this chapter) or a carrier under section 1395u of
this title has approved of the use of such an assistant in the surgical
procedure based on the existence of a complicating medical condition, or
(B) which are for services of an assistant at surgery to which
section 1395w-4(i)(2)(B) of this title applies; or
(16) furnished in connection with a surgical procedure for which a
second opinion is required under section 1320c-13(c)(2) of this title
and has not been obtained.
Paragraph (7) shall not apply to Federally qualified health center
services described in section 1395x(aa)(3)(B) of this title.
(b) Medicare as secondary payer
(1) Requirements of group health plans
(A) Working aged under group health plans
(i) In general
A group health plan --
(I) may not take into account, for any item or service furnished to
an individual 65 years of age or older at the time the individual is
covered under the plan by reason of the current employment of the
individual (or the individual's spouse), that the individual is entitled
to benefits under this subchapter under section 426(a) of this title,
and
(II) shall provide that any employee age 65 or older, and any
employee's spouse age 65 or older, shall be entitled to the same
benefits under the plan under the same conditions as any employee, and
the spouse of such employee, under age 65.
(ii) Exclusion of group health plan of a small employer
Clause (i) shall not apply to a group health plan unless the plan is
sponsored by or contributed to by an employer that has 20 or more
employees for each working day in each of 20 or more calendar weeks in
the current calendar year or the preceding calendar year.
(iii) Exception for small employers in multiemployer or multiple
employer group health plans
Clause (i) also shall not apply with respect to individuals enrolled
in a multiemployer or multiple employer group health plan if the
coverage of the individuals under the plan is by virtue of employment
with an employer that does not have 20 or more employees for each
working day in each of 20 or more calendar weeks in the current calendar
year or the preceding calendar year; except that the exception provided
in this clause shall only apply if the plan elects treatment under this
clause.
(iv) Exception for individuals with end stage renal disease
Clause (i) shall not apply to an item or service furnished in a month
to an individual if for the month the individual is, or would upon
application be, entitled to benefits under section 426-1 of this title.
(v) ''Group health plan'' defined
In this subparagraph, and subparagraph (C), the term ''group health
plan'' has the meaning given such term in section 5000(b)(1) of the
Internal Revenue Code of 1986.
(B) Disabled active individuals in large group health plans
(i) In general
A large group health plan (as defined in clause (iv)(II)) may not
take into account that an active individual (as defined in clause
(iv)(I)) is entitled to benefits under this subchapter under section
426(b) of this title.
(ii) Exception for individuals with end stage renal disease
Clause (i) shall not apply to an item or service furnished in a month
to an individual if for the month the individual is, or would upon
application be, entitled to benefits under section 426-1 of this title.
(iii) Sunset
Clause (i) shall only apply to items and services furnished on or
after January 1, 1987, and before October 1, 1995.
(iv) Definitions
In this subparagraph:
The term ''active individual'' means an employee (as may be defined
in regulations), the employer, self-employed individual (such as the
employer), an individual associated with the employer in a business
relationship, or a member of the family of any of such persons.
The term ''large group health plan'' has the meaning given such term
in section 5000(b)(2) of the Internal Revenue Code of 1986.
(C) Individuals with end stage renal disease
A group health plan (as defined in subparagraph (A)(v)) --
(i) may not take into account that an individual is entitled to
benefits under this subchapter solely by reason of section 426-1 of this
title during the 12-month period which begins with the first month in
which the individual becomes entitled to benefits under part A of this
subchapter under the provisions of section 426-1 of this title, or, if
earlier, the first month in which the individual would have been
entitled to benefits under such part under the provisions of section
426-1 of this title if the individual had filed an application for such
benefits; and
(ii) may not differentiate in the benefits it provides between
individuals having end stage renal disease and other individuals covered
by such plan on the basis of the existence of end stage renal disease,
the need for renal dialysis, or in any other manner;
except that clause (ii) shall not prohibit a plan from taking into
account that an individual is entitled to benefits under this subchapter
solely by reason of section 426-1 of this title after the end of the
12-month period described in clause (i). Effective for items and
services furnished on or after February 1, 1991, and on or before
January 1, 1996, /2/ (with respect to periods beginning on or after
February 1, 1990), clauses (i) and (ii) shall be applied by substituting
''18-month'' for ''12-month'' each place it appears.
(D) Treatment of certain members of religious orders
In this subsection, an individual shall not be considered to be
employed, or an employee, with respect to the performance of services as
a member of a religious order which are considered employment only by
virtue of an election made by the religious order under section 3121(r)
of the Internal Revenue Code of 1986.
(2) Medicare secondary payer
(A) In general
Payment under this subchapter may not be made, except as provided in
subparagraph (B), with respect to any item or service to the extent that
--
(i) payment has been made, or can reasonably be expected to be made,
with respect to the item or service as required under paragraph (1), or
(ii) payment has been made, or can reasonably be expected to be made
promptly (as determined in accordance with regulations) under a
workmen's compensation law or plan of the United States or a State or
under an automobile or liability insurance policy or plan (including a
self-insured plan) or under no fault insurance.
In this subsection, the term ''primary plan'' means a group health
plan or large group health plan, to the extent that clause (i) applies,
and a workmen's compensation law or plan, an automobile or liability
insurance policy or plan (including a self-insured plan) or no fault
insurance, to the extent that clause (ii) applies.
(B) Conditional payment
(i) Primary plans
Any payment under this subchapter with respect to any item or service
to which subparagraph (A) applies shall be conditioned on reimbursement
to the appropriate Trust Fund established by this subchapter when notice
or other information is received that payment for such item or service
has been or could be made under such subparagraph.
(ii) Action by United States
In order to recover payment under this subchapter for such an item or
service, the United States may bring an action against any entity which
is required or responsible under this subsection to pay with respect to
such item or service (or any portion thereof) under a primary plan (and
may, in accordance with paragraph (3)(A) collect double damages against
that entity), or against any other entity (including any physician or
provider) that has received payment from that entity with respect to the
item or service, and may join or intervene in any action related to the
events that gave rise to the need for the item or service.
(iii) Subrogation rights
The United States shall be subrogated (to the extent of payment made
under this subchapter for such an item or service) to any right under
this subsection of an individual or any other entity to payment with
respect to such item or service under a primary plan.
(iv) Waiver of rights
The Secretary may waive (in whole or in part) the provisions of this
subparagraph in the case of an individual claim if the Secretary
determines that the waiver is in the best interests of the program
established under this subchapter.
(3) Enforcement
(A) Private cause of action
There is established a private cause of action for damages (which
shall be in an amount double the amount otherwise provided) in the case
of a primary plan which fails to provide for primary payment (or
appropriate reimbursement) in accordance with such paragraphs (1) and
(2)(A).
(B) Reference to excise tax with respect to nonconforming group
health plans
For provision imposing an excise tax with respect to nonconforming
group health plans, see section 5000 of the Internal Revenue Code of
1986.
(C) Prohibition of financial incentives not to enroll in a group
health plan
It is unlawful for an employer or other entity to offer any financial
or other incentive for an individual entitled to benefits under this
subchapter not to enroll (or to terminate enrollment) under a group
health plan which would (in the case of such enrollment) be a primary
plan (as defined in paragraph (2)(A)), unless such incentive is also
offered to all individuals who are eligible for coverage under the plan.
Any entity that violates the previous sentence is subject to a civil
money penalty of not to exceed $5,000 for each such violation. The
provisions of section 1320a-7a of this title (other than the first
sentence of subsection (a) and other than subsection (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.
(4) Coordination of benefits
Where payment for an item or service by a primary plan is less than
the amount of the charge for such item or service and is not payment in
full, payment may be made under this subchapter (without regard to
deductibles and coinsurance under this subchapter) for the remainder of
such charge, but --
(A) payment under this subchapter may not exceed an amount which
would be payable under this subchapter for such item or service if
paragraph (2)(A) did not apply; and
(B) payment under this subchapter, when combined with the amount
payable under the primary plan, may not exceed --
(i) in the case of an item or service payment for which is determined
under this subchapter on the basis of reasonable cost (or other
cost-related basis) or under section 1395ww of this title, the amount
which would be payable under this subchapter on such basis, and
(ii) in the case of an item or service for which payment is
authorized under this subchapter on another basis --
(I) the amount which would be payable under the primary plan (without
regard to deductibles and coinsurance under such plan), or
(II) the reasonable charge or other amount which would be payable
under this subchapter (without regard to deductibles and coinsurance
under this subchapter),
whichever is greater.
(5) Identification of secondary payer situations
(A) Requesting matching information
(i) Commissioner of Social Security
The Commissioner of Social Security shall, not less often than
annually, transmit to the Secretary of the Treasury a list of the names
and TINs of medicare beneficiaries (as defined in section 6103(l)(12) of
the Internal Revenue Code of 1986) and request that the Secretary
disclose to the Commissioner the information described in subparagraph
(A) of such section.
(ii) Administrator
The Administrator of the Health Care Financing Administration shall
request, not less often than annually, the Commissioner of the Social
Security Administration to disclose to the Administrator the information
described in subparagraph (B) of section 6103(l)(12) of the Internal
Revenue Code of 1986.
(B) Disclosure to fiscal intermediaries and carriers
In addition to any other information provided under this subchapter
to fiscal intermediaries and carriers, the Administrator shall disclose
to such intermediaries and carriers (or to such a single intermediary or
carrier as the Secretary may designate) the information received under
subparagraph (A) for the purposes of carrying out this subsection.
(C) Contacting employers
(i) In general
With respect to each individual (in this subparagraph referred to as
an ''employee'') who was furnished a written statement under section
6051 of the Internal Revenue Code of 1986 by a qualified employer (as
defined in section 6103(l)(12)(D)(iii) of such Code), as disclosed under
subparagraph (B), the appropriate fiscal intermediary or carrier shall
contact the employer in order to determine during what period the
employee or employee's spouse may be (or have been) covered under a
group health plan of the employer and the nature of the coverage that is
or was provided under the plan (including the name, address, and
identifying number of the plan).
(ii) Employer response
Within 30 days of the date of receipt of the inquiry, the employer
shall notify the intermediary or carrier making the inquiry as to the
determinations described in clause (i). An employer (other than a
Federal or other governmental entity) who willfully or repeatedly fails
to provide timely and accurate notice in accordance with the previous
sentence shall be subject to a civil money penalty of not to exceed
$1,000 for each individual with respect to which such an inquiry is
made. 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) Sunset on requirement
Clause (ii) shall not apply to inquiries made after September 30,
1995.
(c) Drug products
No payment may be made under part B of this subchapter for any
expenses incurred for --
(1) a drug product --
(A) which is described in section 107(c)(3) of the Drug Amendments of
1962,
(B) which may be dispensed only upon prescription,
(C) for which the Secretary has issued a notice of an opportunity for
a hearing under subsection (e) of section 355 of title 21 on a proposed
order of the Secretary to withdraw approval of an application for such
drug product under such section because the Secretary has determined
that the drug is less than effective for all conditions of use
prescribed, recommended, or suggested in its labeling, and
(D) for which the Secretary has not determined there is a compelling
justification for its medical need; and
(2) any other drug product --
(A) which is identical, related, or similar (as determined in
accordance with section 310.6 of title 21 of the Code of Federal
Regulations) to a drug product described in paragraph (1), and
(B) for which the Secretary has not determined there is a compelling
justification for its medical need,
until such time as the Secretary withdraws such proposed order.
(d) Repealed. Pub. L. 100-93, 8(c)(1)(A), Aug. 18, 1987, 101 Stat.
692
(e) Item or service by excluded individual or entity or at direction
of excluded physician; limitation of liability of beneficiaries with
respect to services furnished by excluded individuals and entities
(1) No payment may be made under this subchapter with respect to any
item or service (other than an emergency item or service, not including
items or services furnished in an emergency room of a hospital)
furnished --
(A) by an individual or entity during the period when such individual
or entity is excluded pursuant to section 1320a-7, 1320a-7a, 1320c-5 or
1395u(j)(2) of this title from participation in the program under this
subchapter; or
(B) at the medical direction or on the prescription of a physician
during the period when he is excluded pursuant to section 1320a-7,
1320a-7a, 1320c-5 or 1395u(j)(2) of this title from participation in the
program under this subchapter and when the person furnishing such item
or service knew or had reason to know of the exclusion (after a
reasonable time period after reasonable notice has been furnished to the
person).
(2) Where an individual eligible for benefits under this subchapter
submits a claim for payment for items or services furnished by an
individual or entity excluded from participation in the programs under
this subchapter, pursuant to section 1320a-7, 1320a-7a, 1320c-5, 1320c-9
(as in effect on September 2, 1982), 1395u(j)(2), 1395y(d) (as in effect
on August 18, 1987), or 1395cc of this title, and such beneficiary did
not know or have reason to know that such individual or entity was so
excluded, then, to the extent permitted by this subchapter, and
notwithstanding such exclusion, payment shall be made for such items or
services. In each such case the Secretary shall notify the beneficiary
of the exclusion of the individual or entity furnishing the items or
services. Payment shall not be made for items or services furnished by
an excluded individual or entity to a beneficiary after a reasonable
time (as determined by the Secretary in regulations) after the Secretary
has notified the beneficiary of the exclusion of that individual or
entity.
(f) Utilization guidelines for provision of home health services
The Secretary shall establish utilization guidelines for the
determination of whether or not payment may be made, consistent with
paragraph (1)(A) of subsection (a) of this section, under part A or part
B of this subchapter for expenses incurred with respect to the provision
of home health services, and shall provide for the implementation of
such guidelines through a process of selective postpayment coverage
review by intermediaries or otherwise.
(g) Contracts with utilization and quality control peer review
organizations
The Secretary shall, in making the determinations under paragraphs
(1) and (9) of subsection (a) of this section, and for the purposes of
promoting the effective, efficient, and economical delivery of health
care services, and of promoting the quality of services of the type for
which payment may be made under this subchapter, enter into contracts
with utilization and quality control peer review organizations pursuant
to part B of subchapter XI of this chapter.
(h) Registry of cardiac pacemaker devices and leads; testing of
devices and leads; withholding of payment
(1)(A) The Secretary shall, through the Commissioner of the Food and
Drug Administration, provide for a registry of all cardiac pacemaker
devices and pacemaker leads for which payment was made under this
subchapter.
(B) Such registry shall include the manufacturer, model, and serial
number of each such device or lead, the name of the recipient of such
device or lead, the date and location of the implantation or removal of
the device or lead, the name of the physician implanting or removing
such device or lead, the name of the hospital or other provider billing
for such procedure, any express or implied warranties associated with
such device or lead under contract or State law (and any amount paid to
a provider under any such warranty), and such other information as the
Secretary deems to be appropriate.
(C) Each physician and provider of services performing the
implantation or replacement of pacemaker devices and leads for which
payment is made or requested to be made under this subchapter shall, in
accordance with regulations of the Secretary, submit information
respecting such implantation or replacement for the registry.
(D) Such registry shall be for the purposes of assisting the
Secretary in determining when payments may properly be made under this
subchapter, in tracing the performance of cardiac pacemaker devices and
leads, in determining when inspection by the manufacturer of such a
device or lead may be necessary under paragraph (3), in determining the
amount subject to repayment under paragraph (2)(C), and in carrying out
studies with respect to the use of such devices and leads. In carrying
out any such study, the Secretary may not reveal any specific
information which identifies any pacemaker device or lead recipient by
name (or which would otherwise identify a specific recipient).
(E) Any person or organization may provide information to the
registry with respect to cardiac pacemaker devices and leads other than
those for which payment is made under this subchapter.
(2) The Secretary may, by regulation, require each provider of
services --
(A) to return, to the manufacturer of the device or lead for testing
under paragraph (3), any cardiac pacemaker device or lead which is
removed from a patient and payment for the implantation or replacement
of which was made or requested by such provider under this subchapter,
(B) not to charge any beneficiary for replacement of such a device or
lead if the device or lead has not been returned in accordance with
subparagraph (A), and
(C) to make repayment to the Secretary of amounts paid under this
subchapter to the provider with respect to any cardiac pacemaker device
or lead which has been replaced by the manufacturer, or for which the
manufacturer has made payment to the provider, under an express or
implied warranty.
(3) The Secretary may, by regulation, require the manufacturer of a
cardiac pacemaker device or lead (A) to test or analyze each pacemaker
device or lead for which payment is made or requested under this
subchapter and which is returned to the manufacturer by a provider of
services under paragraph (2), and (B) to provide the results of such
test or analysis to that provider, together with information and
documentation with respect to any warranties covering such device or
lead. In any case where the Secretary has reason to believe, based upon
information in the pacemaker registry or otherwise available to him,
that replacement of a cardiac pacemaker device or lead for which payment
is or may be requested under this subchapter is related to the
malfunction of a device or lead, the Secretary may require that
personnel of the Food and Drug Administration be present at the testing
of such device by the manufacturer, to determine whether such device was
functioning properly.
(4) The Secretary may deny payment under this subchapter, in whole or
in part and for such period of time as the Secretary determines to be
appropriate, with respect to the implantation or replacement of a
pacemaker device or lead of a manufacturer performed by a physician and
provider of services after the Secretary determines (in accordance with
the procedures established under subsections (c), (f), and (g) of
section 1320a-7 of this title) that --
(A) the physician or provider of services has failed to submit
information to the registry as required under paragraph (1)(C),
(B) the provider of services has failed to return devices and leads
as required under paragraph (2)(A), has improperly charged beneficiaries
as prohibited under paragraph (2)(B), or has failed to make repayment to
the Secretary as required under paragraph (2)(C), or
(C) the manufacturer of the device or lead has failed to perform and
to report on the testing of devices and leads returned to it as required
under paragraph (3).
(i) Awards and contracts for original research and experimentation of
new and existing medical procedures; conditions
In order to supplement the activities of the Prospective Payment
Assessment Commission under section 1395ww(e) of this title in assessing
the safety, efficacy, and cost-effectiveness of new and existing medical
procedures, the Secretary may carry out, or award grants or contracts
for, original research and experimentation of the type described in
clause (ii) of section 1395ww(e)(6)(E) of this title with respect to
such a procedure if the Secretary finds that --
(1) such procedure is not of sufficient commercial value to justify
research and experimentation by a commercial organization;
(2) research and experimentation with respect to such procedure is
not of a type that may appropriately be carried out by an institute,
division, or bureau of the National Institutes of Health; and
(3) such procedure has the potential to be more cost-effective in the
treatment of a condition than procedures currently in use with respect
to such condition.
(Aug. 14, 1935, ch. 531, title XVIII, 1862, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 325, and amended Jan. 2,
1968, Pub. L. 90-248, title I, 127(b), 128, 81 Stat. 846, 847; Oct.
30, 1972, Pub. L. 92-603, title II, 210, 211(c)(1), 229(a), 256(c), 86
Stat. 1382, 1384, 1408, 1447; Dec. 31, 1973, Pub. L. 93-233,
18(k)(3), 87 Stat. 970; Oct. 26, 1974, Pub. L. 93-480, 4(a), 88 Stat.
1454; Dec. 31, 1975, Pub. L. 94-182, title I, 103, 89 Stat. 1051;
Oct. 25, 1977, Pub. L. 95-142, 7(a), 13(a), (b)(1), (2), 91 Stat.
1192, 1197, 1198; Dec. 13, 1977, Pub. L. 95-210, 1(f), 91 Stat. 1487;
June 17, 1980, Pub. L. 96-272, title III, 308(a), 94 Stat. 531; Dec.
5, 1980, Pub. L. 96-499, title IX, 913(b), 936(c), 939(a), 953, 94
Stat. 2620, 2640, 2647; Dec. 28, 1980, Pub. L. 96-611, 1(a)(3), 94
Stat. 3566; Aug. 13, 1981, Pub. L. 97-35, title XXI, 2103(a)(1),
2146(a), 2152(a), 95 Stat. 787, 800, 802; Sept. 3, 1982, Pub. L.
97-248, title I, 116(b), 122(f), (g)(1), 128(a)(2)-(4), 142, 148(a),
96 Stat. 353, 362, 366, 381, 394; Jan. 12, 1983, Pub. L. 97-448, title
III, 309(b)(10), 96 Stat. 2409; Apr. 20, 1983, Pub. L. 98-21, title
VI, 601(f), 602(e), 97 Stat. 162, 163; July 18, 1984, Pub. L. 98-369,
div. B, title III, 2301(a), 2304(c), 2313(c), 2344(a)-(c),
2354(b)(30), (31), 98 Stat. 1063, 1068, 1078, 1095, 1101, 1102; Apr. 7,
1986, Pub. L. 99-272, title IX, 9201(a), 9307(a), 9401(c)(1), 100
Stat. 170, 193, 199; Oct. 21, 1986, Pub. L. 99-509, title IX,
9316(b), 9319(a), (b), 9320(h)(1), 9343(c)(1), 100 Stat. 2007, 2010,
2011, 2016, 2040; Oct. 22, 1986, Pub. L. 99-514, 2, 100 Stat. 2095;
Aug. 18, 1987, Pub. L. 100-93, 8(c)(1), (3), 10, 101 Stat. 692, 693,
696; Dec. 22, 1987, Pub. L. 100-203, title IV, 4009(j)(6)(C),
4034(a), 4036(a)(1), 4039(c)(1), 4072(c), 4085(i)(15), (16), 101 Stat.
1330-59, 1330-77, 1330-79, 1330-82, 1330-117, 1330-133; July 1, 1988,
Pub. L. 100-360, title II, 202(d), 204(d)(2), 205(e)(1), title IV,
411(f)(4)(D)(i), (i)(4)(D), 102 Stat. 715, 729, 731, 778, 790; Oct. 13,
1988, Pub. L. 100-485, title VI, 608(d)(7), (24)(C), 102 Stat. 2415,
2421; Dec. 13, 1989, Pub. L. 101-234, title II, 201(a), 103 Stat.
1981; Dec. 19, 1989, Pub. L. 101-239, title VI, 6003(g)(3)(D)(xi),
6103(b)(3)(B), 6115(b), 6202(a)(2)(A), (b)(1), (e)(1), 6411(d)(2), 103
Stat. 2154, 2199, 2219, 2228, 2229, 2234, 2271; Nov. 5, 1990, Pub. L.
101-508, title IV, 4107(b), 4153(b)(2)(B), 4157(c)(1), 4161(a)(3)(C),
4163(d)(2), 4203(a)(1), (b), (c)(1), 4204(g)(1), 104 Stat. 1388-62,
1388-84, 1388-89, 1388-94, 1388-100, 1388-107, 1388-112.)
For contingent effective date of amendment by section 4072(c) of Pub.
L. 100-203, enacting subsection (a)(8) of this section, see section
4072(e) of Pub. L. 100-203, set out as an Effective Date of 1987
Amendment note under section 1395x of this title.
Parts A and B of this subchapter, referred to in text, are classified
to sections 1395c et seq. and 1395j et seq., respectively, of this
title.
Part B of subchapter XI of this chapter, referred to in subsecs.
(a)(15) and (g), is classified to section 1320c et seq. of this title.
The Internal Revenue Code of 1986, referred to in subsec. (b), is
classified generally to Title 26, Internal Revenue Code.
Section 107(c)(3) of the Drug Amendments of 1962, referred to in
subsec. (c)(1)(A), is section 107(c)(3) of Pub. L. 87-781, title I,
Oct. 10, 1962, 76 Stat. 788, which is set out as an Effective Date of
1962 Amendment note under section 321 of Title 21, Food and Drugs.
1990 -- Subsec. (a). Pub. L. 101-508, 4161(a)(3)(C)(iii), inserted
at end ''Paragraph (7) shall not apply to Federally qualified health
center services described in section 1395x(aa)(3)(B) of this title.''
Subsec. (a)(1)(A). Pub. L. 101-508, 4163(d)(2)(A)(i), substituted
''a succeeding subparagraph'' for ''subparagraph (B), (C), (D), or
(E)''.
Subsec. (a)(1)(F). Pub. L. 101-508, 4163(d)(2)(A)(ii)-(iv), added
subpar. (F).
Subsec. (a)(2). Pub. L. 101-508, 4161(a)(3)(C)(i), inserted before
semicolon at end '', except in the case of Federally qualified health
center services''.
Subsec. (a)(3). Pub. L. 101-508, 4161(a)(3)(C)(ii), inserted '', in
the case of Federally qualified health center services, as defined in
section 1395x(aa)(3) of this title,'' after ''section 1395x(aa)(1) of
this title,''.
Subsec. (a)(7). Pub. L. 101-508, 4163(d)(2)(B), inserted ''or under
paragraph (1)(F)'' after ''paragraph (1)(B)''.
Pub. L. 101-508, 4153(b)(2)(B), inserted ''(other than eyewear
described in section 1395x(s)(8) of this title)'' after first reference
to ''eyeglasses''.
Subsec. (a)(14). Pub. L. 101-508, 4157(c)(1), inserted '', services
described by section 1395x(s)(2)(K)(i) of this title, certified
nurse-midwife services, qualified psychologist services, and services of
a certified registered nurse anesthetist,'' after ''this paragraph)''
and struck out before semicolon at end ''or are services of a certified
registered nurse anesthetist''.
Subsec. (a)(15). Pub. L. 101-508, 4107(b), designated existing
provisions as par. (A), substituted '', or'' for ''; or'' at end, and
added par. (B).
Subsec. (b)(1)(B)(iii). Pub. L. 101-508, 4203(b), substituted
''October 1, 1995'' for ''January 1, 1992''.
Subsec. (b)(1)(C). Pub. L. 101-508, 4203(c)(1)(B), inserted at end
''Effective for items and services furnished on or after February 1,
1991, and on or before January 1, 1996, (with respect to periods
beginning on or after February 1, 1990), clauses (i) and (ii) shall be
applied by substituting '18-month' for '12-month' each place it
appears.''
Subsec. (b)(1)(C)(i). Pub. L. 101-508, 4203(c)(1)(A), substituted
''during the 12-month period which begins with the first month in which
the individual becomes entitled to benefits under part A of this
subchapter under the provisions of section 426-1 of this title, or, if
earlier, the first month in which the individual would have been
entitled to benefits under such part under the provisions of section
426-1 of this title if the individual had filed an application for such
benefits; and'' for ''during the 12-month period which begins with the
earlier of --
''(I) the month in which a regular course of renal dialysis is
initiated, or
''(II) in the case of an individual who receives a kidney transplant,
the first month in which he would be eligible for benefits under part A
of this subchapter (if he had filed an application for such benefits)
under the provisions of section 426-1(b)(1)(B) of this title; and''.
Subsec. (b)(3)(C). Pub. L. 101-508, 4204(g)(1), added subpar. (C).
Subsec. (b)(5)(C)(iii). Pub. L. 101-508, 4203(a)(1), substituted
''September 30, 1995'' for ''September 30, 1991''.
1989 -- Pub. L. 101-239, 6202(b)(1)(A), inserted ''and medicare as
secondary payer'' in section catchline.
Subsec. (a)(1)(A). Pub. L. 101-234 repealed Pub. L. 100-360,
204(d)(2)(A)(i), 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)(E). Pub. L. 101-239, 6103(b)(3)(B), substituted
''section 1320b-12'' for ''section 1395ll(c)''.
Subsec. (a)(1)(F). Pub. L. 101-239, 6115(b), inserted before
semicolon at end '', and, in the case of screening pap smear, which is
performed more frequently than is provided under 1395x(nn) of this
title''.
Pub. L. 101-234 repealed Pub. L. 100-360, 204(d)(2)(A)(ii)-(iv),
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)(G), (6), (7). Pub. L. 101-234 repealed Pub. L.
100-360, 204(d)(2)(B), 205(e)(1), and provided that the provisions of
law amended or repealed by such sections are restored or revived as if
such sections had not been enacted, see 1988 Amendment notes below.
Subsec. (a)(14). Pub. L. 101-239, 6003(g)(3)(D)(xi), substituted
''hospital or rural primary care hospital'' for ''hospital'' in three
places.
Subsec. (b). Pub. L. 101-239, 6202(b)(1)(B), amended heading and
text generally, substituting pars. (1) to (4) relating to medicare as
secondary payer for former pars. (1) to (5) relating to items or
services paid under workmen's compensation laws and end stage renal
disease program.
Subsec. (b)(1)(D). Pub. L. 101-239, 6202(e)(1), added subpar. (D).
Subsec. (b)(5). Pub. L. 101-239, 6202(a)(2)(A), added par. (5).
Subsec. (c). Pub. L. 101-234 repealed Pub. L. 100-360, 202(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. (e)(1). Pub. L. 101-239, 6411(d)(2), inserted '', not
including items or services furnished in an emergency room of a
hospital'' after ''(other than an emergency item or service''.
1988 -- Subsec. (a)(1)(A). Pub. L. 100-360, 204(d)(2)(A)(i),
substituted ''a succeeding subparagraph'' for ''subparagraph (B), (C),
(D), or (E)''.
Subsec. (a)(1)(F). Pub. L. 100-360, 204(d)(2)(A)(ii)-(iv), added
subpar. (F) relating to screening mammography.
Subsec. (a)(1)(G). Pub. L. 100-360, 205(e)(1)(A), as amended by Pub.
L. 100-485, 608(d)(7), added subpar. (G) relating to in-home care for
chronically dependent individuals.
Subsec. (a)(6). Pub. L. 100-360, 205(e)(1)(B), inserted ''and
except, in the case of in-home care, as is otherwise permitted under
paragraph (1)(G)'' after ''paragraph (1)(C)''.
Subsec. (a)(7). Pub. L. 100-360, 204(d)(2)(B), inserted ''or under
paragraph (1)(F)'' after ''(1)(B)''.
Subsec. (a)(15). Pub. L. 100-360, 411(f)(4)(D)(i), inserted
''(including subsequent insertion of an intraocular lens)'' after
''operation''.
Subsec. (c). Pub. L. 100-360, 202(d), designated existing provisions
as par. (1), redesignated former par. (1) as subpar. (A),
redesignated former subpars. (A) to (D) as cls. (i) to (iv),
redesignated former par. (2) as subpar. (B), redesignated former
subpar. (A) as cl. (i) and substituted ''subparagraph (A)'' for
''paragraph (1)'', redesignated former subpar. (B) as cl. (ii), and
added par. (2) prohibiting payment for expenses incurred for a covered
outpatient drug if the drug is dispensed in a quantity exceeding a
supply of 30 days with an exception.
Subsec. (e)(1). Pub. L. 100-360, 411(i)(4)(D)(i), as amended by Pub.
L. 100-485, 608(d)(24)(C)(i), designated existing provisions of
subsec. (e) as par. (1), redesignated former par. (1) as subpar.
(A), substituted '', 1320a-7a, 1320c-5 or 1395u(j)(2)'' for ''or section
1320a-7a'', redesignated former par. (2) as subpar. (B), and
substituted '', 1320a-7a, 1320c-5 or 1395u(j)(2)'' for ''or section
1320a-7a''.
Subsec. (e)(2). Pub. L. 100-360, 411(i)(4)(D)(ii), as amended by
Pub. L. 100-485, 608(d)(24)(C)(ii), amended former section 1395aaa of
this title by striking out the catchline ''Limitation of liability of
beneficiaries with respect to services furnished by excluded individuals
and entities'', substituting ''(2)'' for the section designation,
inserting ''1395u(j)(2),'' in text, and transferring the text to par.
(2) of subsec. (e) of this section.
1987 -- Subsec. (a)(1)(A). Pub. L. 100-203, 4085(i)(15),
substituted ''(D), or (E)'' for ''or (D)''.
Subsec. (a)(8). Pub. L. 100-203, 4072(c), inserted '', other than
shoes furnished pursuant to section 1395x(s)(12) of this title'' before
semicolon.
Subsec. (a)(14). Pub. L. 100-203, 4085(i)(16), substituted ''a
patient'' for ''an patient''.
Pub. L. 100-203, 4009(j)(6)(C), made technical amendment to Pub. L.
99-509, 9320(h)(1). See 1986 Amendment note below.
Subsec. (b)(2)(A)(ii). Pub. L. 100-203, 4036(a)(1), substituted
''can reasonably be expected to be made under such a plan'' for ''the
Secretary determines will be made under such a plan as promptly as would
otherwise be the case if payment were made by the Secretary under this
subchapter''.
Subsec. (b)(4)(B)(i). Pub. L. 100-203, 4034(a), substituted
''subsection (b) of section 5000 of the Internal Revenue Code of 1986
without regard to subsection (d) of such section'' for ''section 5000(b)
of the Internal Revenue Code of 1986''.
Subsec. (d). Pub. L. 100-93, 8(c)(1)(A), struck out subsec. (d),
which provided that no payment be made under this subchapter for any
item or services to an individual by a person where Secretary determines
such person knowingly and willfully made any false statement or
representation of a material fact, submitted excessive bills or
requests, or furnished excessive services or supplies, and provided a
dissatisfied person with a hearing on determination of the Secretary.
Subsec. (e) (formerly 1395aaa). Pub. L. 100-93, 10, added par.
(2). See 1988 Amendment note above.
Pub. L. 100-93, 8(c)(1)(B), amended subsec. (e) generally. Prior
to amendment, subsec. (e) read as follows: ''No payment may be made
under this subchapter with respect to any item or service furnished by a
physician or other individual during the period when he is barred
pursuant to section 1320a-7 of this title from participation in the
program under this subchapter.''
Subsec. (h)(1)(B). Pub. L. 100-203, 4039(c)(1)(A), substituted ''law
(and any amount paid to a provider under any such warranty),'' for
''law,''.
Subsec. (h)(1)(D). Pub. L. 100-203, 4039(c)(1)(B), inserted ''in
determining the amount subject to repayment under paragraph (2)(C),''
after ''(3),''.
Subsec. (h)(2)(C). Pub. L. 100-203, 4039(c)(1)(C), added subpar.
(C).
Subsec. (h)(4). Pub. L. 100-93, 8(c)(3), substituted ''subsections
(c), (f), and (g) of section 1320a-7 of this title'' for ''paragraphs
(2) and (3) of subsection (d) of this section''.
Subsec. (h)(4)(B). Pub. L. 100-203, 4039(c)(1)(D), substituted '',
has improperly'' for ''or has improperly'' and inserted ''or has failed
to make repayment to the Secretary as required under paragraph (2)(C),''
after ''(2)(B),''.
1986 -- Subsec. (a)(1)(E). Pub. L. 99-509, 9316(b), added subpar.
(E).
Subsec. (a)(14). Pub. L. 99-509, 9343(c)(1), substituted ''patient''
for ''inpatient''.
Pub. L. 99-509, 9320(h)(1), as amended by Pub. L. 100-203,
4009(j)(6)(C), inserted ''or are services of a certified registered
nurse anesthetist'' after ''hospital'' at end.
Subsec. (a)(15). Pub. L. 99-272, 9307(a), added par. (15).
Subsec. (a)(16). Pub. L. 99-272, 9401(c)(1), added par. (16).
Subsec. (b)(2)(A). Pub. L. 99-514 substituted ''Internal Revenue Code
of 1986'' for ''Internal Revenue Code of 1954''.
Subsec. (b)(3)(A)(i). Pub. L. 99-272, 9201(a)(1), substituted ''(or
to the spouse of such individual)'' for ''who is under 70 years of age
during any part of such month (or to the spouse of such individual, if
the spouse is under 70 years of age during any part of such month)''.
Subsec. (b)(3)(A)(iii). Pub. L. 99-272, 9201(a)(2), struck out ''and
ending with the month before the month in which such individual attains
the age of 70'' after ''section 426(a) of this title''.
Subsec. (b)(3)(A)(iv). Pub. L. 99-514 substituted ''Internal Revenue
Code of 1986'' for ''Internal Revenue Code of 1954''.
Subsec. (b)(4). Pub. L. 99-509, 9319(a), added par. (4).
Subsec. (b)(5). Pub. L. 99-509, 9319(b), added par. (5).
1984 -- Subsec. (a)(12). Pub. L. 98-369, 2354(b)(30), struck out
second comma after ''dental procedure''.
Subsec. (b)(1). Pub. L. 98-369, 2344(a), substituted ''to be made
promptly'' for ''to be made'' and ''has been or could be made under such
a law'' for ''has been made under such a law'', and inserted ''In order
to recover payment made under this subchapter for an item or service,
the United States may bring an action against any entity which would be
responsible for payment with respect to such item or service (or any
portion thereof) under such a law, policy, plan, or insurance, or
against any entity (including any physician or provider) which has been
paid with respect to such item or service under such law, policy, plan,
or insurance, and may join or intervene in any action related to the
events that gave rise to the need for such item or service. The United
States shall be subrogated (to the extent of payment made under this
subchapter for an item or service) to any right of an individual or any
other entity to payment with respect to such item or service under such
a law, policy, plan, or insurance.''
Subsec. (b)(2)(B). Pub. L. 98-369, 2344(b), substituted ''has been
or could be made under a plan'' for ''has been made under a plan'', and
inserted ''In order to recover payment made under this subchapter for an
item or service, the United States may bring an action against any
entity which would be responsible for payment with respect to such item
or service (or any portion thereof) under such a plan, or against any
entity (including any physician or provider) which has been paid with
respect to such item or service under such plan, and may join or
intervene in any action related to the events that gave rise to the need
for such item or service. The United States shall be subrogated (to the
extent of payment made under this subchapter for an item or service) to
any right of an individual or any other entity to payment with respect
to such item or service under such a plan.''
Subsec. (b)(3)(A)(i). Pub. L. 98-369, 2301(a), struck out ''over 64
but'' before ''under 70 years'' in two places.
Subsec. (b)(3)(A)(ii). Pub. L. 98-369, 2344(c), substituted ''has
been or could be made under a group health plan'' for ''has been made
under a group health plan'', and inserted ''In order to recover payment
made under this title for an item or service, the United States may
bring an action against any entity which would be responsible for
payment with respect to such item or service (or any portion thereof)
under such a plan, or against any entity (including any physician or
provider) which has been paid with respect to such item or service under
such plan, and may join or intervene in any action related to the events
that gave rise to the need for such item or service. The United States
shall be subrogated (to the extent of payment made under this title for
an item or service) to any right of an individual or any other entity to
payment with respect to such item or service under such a plan.''
Subsec. (b)(3)(A)(iii). Pub. L. 98-369, 2354(b)(31), inserted
''before the month'' after ''ending with the month''.
Subsec. (h). Pub. L. 98-369, 2304(c), added subsec. (h).
Subsec. (i). Pub. L. 98-369, 2313(c), added subsec. (i).
1983 -- Subsec. (a)(1)(A). Pub. L. 98-21, 601(f)(1), inserted
reference to subpar. (D).
Subsec. (a)(1)(D). Pub. L. 98-21, 601(f)(2)-(4), added subpar. (D).
Subsec. (a)(14). Pub. L. 98-21, 602(e), added par. (14).
Subsec. (b)(3)(A)(i). Pub. L. 97-448 inserted ''in any month'' after
''service furnished'', and ''during any part of such month'' after ''70
years of age'' wherever appearing.
1982 -- Subsec. (a)(1). Pub. L. 97-248, 122(f)(1), designated
existing provisions as subpars. (A) and (B), in subpar. (A) as so
designated inserted exception to provisions for items and services
described in subpar. (B) or (C), substituted ''and'' for ''or'' as the
connector between provisions, and added subpar. (C).
Subsec. (a)(6). Pub. L. 97-248, 122(f)(2), inserted ''(except, in
the case of hospice care, as is otherwise permitted under paragraph
(1)(C))''.
Subsec. (a)(7). Pub. L. 97-248, 122(f)(3), substituted ''paragraph
(1)(B)'' for ''paragraph (1)''.
Subsec. (a)(9). Pub. L. 97-248, 122(f)(4), inserted ''(except, in
the case of hospice care, as is otherwise permitted under paragraph
(1)(C))''.
Subsec. (b)(1). Pub. L. 97-248, 128(a)(2), struck out ''or plan''
after ''service has been made under such a law''.
Subsec. (b)(2)(A). Pub. L. 97-248, 128(a)(3), substituted ''section
162(i)(2)'' for ''section 162(h)(2)''.
Subsec. (b)(2)(B). Pub. L. 97-248, 128(a)(4), inserted ''furnished''
before ''to an individual''.
Subsec. (b)(3). Pub. L. 97-248, 116(b), added par. (3).
Subsec. (d)(1)(C). Pub. L. 97-248, 148(a), substituted ''on the
basis of information acquired by the Secretary in the administration of
this subchapter'' for '', on the basis of reports transmitted to him in
accordance with section 1320c-6 of this title (or, in the absence of any
such report, on the basis of such data as he acquires in the
administration of the program under this subchapter),''.
Subsec. (f). Pub. L. 97-248, 122(g)(1), substituted ''paragraph
(1)(A)'' for ''paragraph (1)''.
Subsec. (g). Pub. L. 97-248, 142, added subsec. (g).
1981 -- Subsec. (b). Pub. L. 97-35, 2146(a), designated existing
provisions as par. (1) and added par. (2).
Subsec. (c). Pub. L. 97-35, 2103(a)(1), added subsec. (c).
Subsec. (f). Pub. L. 97-35, 2152(a), added subsec. (f).
1980 -- Subsec. (a)(1). Pub. L. 96-611, 1(a)(3)(A), inserted '',
or, in the case of items and services described in section 1395x(s)(10)
of this title, which are not reasonable and necessary for the prevention
of illness'' after ''of a malformed body member''.
Subsec. (a)(7). Pub. L. 96-611, 1(a)(3)(B), inserted ''(except as
otherwise allowed under section 1395x(s)(10) of this title and paragraph
(1))'' after ''immunizations''.
Subsec. (a)(12). Pub. L. 96-499, 936(c), inserted ''or because of
the severity of the dental procedure,'' after ''and clinical status''.
Subsec. (a)(13)(C). Pub. L. 96-499, 939(a), struck out '', warts,''
after ''corns''.
Subsec. (b). Pub. L. 96-499, 953, inserted ''or under an automobile
or liability insurance policy or plan (including a self-insured plan) or
under no fault insurance'' and '', policy, plan, or insurance'' after
''or a State'' and '', policy, plan, or insurance'' after ''law or
plan'' and inserted provision authorizing the Secretary to waive the
provisions of this subsection in the case of an individual claim if he
determined that the probability of recovery or amount involved did not
warrant the pursuit of the claim.
Subsec. (d)(4). Pub. L. 96-272 added par. (4).
Subsec. (e). Pub. L. 96-499, 913(b), substituted provisions barring
payment under this subchapter with respect to items or services
furnished by a physician or other individual during a period when such
physician or other individual was barred pursuant to section 1320a-7 of
this title from participation under this subchapter for provisions
authorizing the Secretary to suspend a physician or individual
practitioner from participation under this subchapter upon determining
that such physician or practitioner had been convicted of a criminal
offense related to such physician's or practitioner's involvement in the
programs under this subchapter or the program under subchapter XIX of
this chapter.
1977 -- Subsec. (a)(3). Pub. L. 95-210 substituted ''except in the
case of rural health clinic services, as defined in section 1395x(aa)(1)
of this title, and in such other cases as the Secretary may specify''
for ''except in such cases as the Secretary may specify''.
Subsec. (d)(1)(B). Pub. L. 95-142, 13(b)(1), struck out requirement
for concurrence of appropriate program review team for finding of
Secretary under this paragraph.
Subsec. (d)(1)(C). Pub. L. 95-142, 13(b)(2), substituted provisions
relating to determinations by the Secretary on the basis of reports
transmitted to him in accordance with section 1320c-6 of this title or
other data acquired in the administration of this subchapter, for
provisions relating to determinations by the Secretary with the
concurrence of appropriate review team members.
Subsec. (d)(4). Pub. L. 95-142, 13(a), struck out par. (4) which
set forth provisions relating to appointment and functions of program
review teams.
Subsec. (e). Pub. L. 95-142, 7(a), added subsec. (e).
1975 -- Subsec. (c). Pub. L. 94-182 struck out subsec. (c)
prohibiting payments to Federal employees under this subchapter unless a
determination and certification by the Secretary of a modification of
any health benefits plan under chapter 89 of Title 5 was made which
would allow a Federal employee benefits under part A or B of this
subchapter.
1974 -- Subsec. (c). Pub. L. 93-480 substituted ''January 1, 1976''
for ''January 1, 1975''.
1973 -- Subsec. (a)(12). Pub. L. 93-233 substituted ''the provision
of such dental services if the individual, because of his underlying
medical condition and clinical status, requires hospitalization in
connection with the provision of such services'' for ''a dental
procedure where the individual suffers from impairments of such severity
as to require hospitalization''.
1972 -- Subsec. (a)(4). Pub. L. 92-603, 211(c)(1), inserted
reference to physicians' services and ambulance services furnished an
individual in conjunction with emergency inpatient hospital services.
Subsec. (a)(12). Pub. L. 92-603, 256(c), authorized payment under
part A in the case of inpatient hospital services in connection with a
dental procedure where the individual suffers from impairments of such
severity as to require hospitalization.
Subsec. (c). Pub. L. 92-603, 210, added subsec. (c).
Subsec. (d). Pub. L. 92-603, 229(a), added subsec. (d).
1968 -- Subsec. (a)(7). Pub. L. 90-248, 128, prohibited payment for
procedures performed (during the course of any eye examination) to
determine the refractive state of the eyes.
Subsec. (a)(13). Pub. L. 90-248, 127(b), added par. (13).
Amendment by section 4153(b)(2)(B) of Pub. L. 101-508 applicable to
items furnished on or after Jan. 1, 1991, see section 4153(b)(2)(C) of
Pub. L. 101-508, set out as a note under section 1395x of this title.
Amendment by section 4157(c)(1) of Pub. L. 101-508 applicable to
services furnished on or after Jan. 1, 1991, see section 4157(d) of
Pub. L. 101-508, set out as a note under section 1395k of this title.
Amendment by section 4161(a)(3)(C) of Pub. L. 101-508 applicable to
services furnished on or after Oct. 1, 1991, see section 4161(a)(8) of
Pub. L. 101-508, set out as a note under section 1395k of this title.
Amendment by section 4163(d)(2) of Pub. L. 101-508 applicable to
screening mammography performed on or after Jan. 1, 1991, see section
4163(e) of Pub. L. 101-508, set out as a note under section 1395l of
this title.
Section 4204(g)(2) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply to
incentives offered on or after the date of the enactment of this Act
(Nov. 5, 1990).''
Amendment by section 6115(b) of Pub. L. 101-239 applicable to
screening pap smears performed on or after July 1, 1990, see section
6115(d) of Pub. L. 101-239, set out as a note under section 1395x of
this title.
Amendment by section 6202(b)(1) of Pub. L. 101-239 applicable to
items and services furnished after Dec. 19, 1989, see section
6202(b)(5) of Pub. L. 101-239, set out as a note under section 162 of
Title 26, Internal Revenue Code.
Section 6202(e)(2) of Pub. L. 101-239 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply to
items and services furnished on or after October 1, 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.
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 202(d) of Pub. L. 100-360 applicable to items
dispensed on or after Jan. 1, 1990, see section 202(m)(1) of Pub. L.
100-360, set out as a note under section 1395u of this title.
Amendment by section 204(d)(2) of Pub. L. 100-360 applicable to
screening mammography performed on or after Jan. 1, 1990, see section
204(e) of Pub. L. 100-360, set out as a note under section 1395m of
this title.
Amendment by section 205(e)(1) of Pub. L. 100-360 applicable to
items and services furnished on or after Jan. 1, 1990, see section
205(f) of Pub. L. 100-360, set out as a note under section 1395k of
this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(i)(4)(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.
Section 411(f)(4)(D)(ii) of Pub. L. 100-360 provided that: ''The
amendment made by clause (i) (amending this section) shall apply to
operations performed on or after 60 days after the date of the enactment
of this Act (July 1, 1988).''
Section 4009(j)(6) of Pub. L. 100-203, provided that the amendment
made by that section is effective as if included in the enactment of
Pub. L. 99-509.
Section 4034(b) of Pub. L. 100-203 provided that: ''The amendment
made by subsection (a) (amending this section) shall be effective as if
included in the enactment of section 9319(a) of the Omnibus Budget
Reconciliation Act of 1986 (Pub. L. 99-509).''
Section 4036(a)(2) of Pub. L. 100-203 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply with
respect to items and services furnished on or after 30 days after the
date of the enactment of this Act (Dec. 22, 1987).''
Section 4039(c)(2) of Pub. L. 100-203 provided that: ''The
amendments made by paragraph (1) (amending this section) shall become
effective on January 1, 1988.''
For contingent effective date of amendment by section 4072(c) of Pub.
L. 100-203, see section 4072(e) of Pub. L. 100-203, set out as a note
under section 1395x of this title.
Amendment by Pub. L. 100-93 effective at end of fourteen-day period
beginning Aug. 18, 1987, and inapplicable to administrative proceedings
commenced before end of such period, see section 15(a) of Pub. L.
100-93, set out as a note under section 1320a-7 of this title.
Section 9319(f) of Pub. L. 99-509 provided that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (enacting section 5000 of Title 26, Internal Revenue Code,
and amending this section and sections 1395p and 1395r of this title)
shall apply to items and services furnished on or after January 1, 1987.
''(2) The amendments made by subsection (c) (amending sections 1395p
and 1395r of this title) shall apply to enrollments occurring on or
after January 1, 1987.''
Amendment by section 9320(h)(1) of Pub. L. 99-509 applicable to
services furnished on or after Jan. 1, 1989, with exceptions for
hospitals located in rural areas which meet certain requirements related
to certified registered nurse anesthetists, see section 9320(i), (k) of
Pub. L. 99-509, as amended, set out as notes under section 1395k of
this title.
Amendment by section 9343(c)(1) of Pub. L. 99-509 applicable to
services furnished after June 30, 1987, see section 9343(h)(2) of Pub.
L. 99-509, as amended, set out as a note under section 1395l of this
title.
Section 9201(d)(1) of Pub. L. 99-272 provided that: ''The
amendments made by subsection (a) (amending this section) shall apply
with respect to items and services furnished on or after May 1, 1986.''
Amendment by section 9307(a) of Pub. L. 99-272 applicable to
services performed on or after Apr. 1, 1986, see section 9307(e) of
Pub. L. 99-272, set out as a note under section 1320c-3 of this title.
Section 2301(c)(1) of Pub. L. 98-369 provided that: ''The amendment
made by subsection (a) (amending this section) shall be effective with
respect to items and services furnished on or after January 1, 1985.''
Amendment by section 2304(c) of Pub. L. 98-369 applicable to
pacemaker devices and leads implanted or removed on or after the
effective date of final regulations promulgated to carry out such
amendment, see section 2304(d) of Pub. L. 98-369, set out as a note
below.
Section 2313(e) of Pub. L. 98-369 provided that: ''The amendments
made by this section (amending this section and section 1395ww of this
title) shall become effective on the date of the enactment of this Act
(July 18, 1984).''
Section 2344(d) of Pub. L. 98-369 provided that: ''The amendments
made by this section (amending this section) shall apply to items and
services furnished on or after the date of the enactment of this Act
(July 18, 1984).''
Amendment by section 2354(b)(30), (31) 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 601(f) of 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, and amendment by section 602(e)(3) of Pub.
L. 98-21 effective Oct. 1, 1983, see section 604(a)(1), (2) 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.
Amendment by section 116(b) of Pub. L. 97-248 applicable with
respect to items and services furnished on or after Jan. 1, 1983, see
section 116(c) of Pub. L. 97-248, set out as a note under section 623
of Title 29, Labor.
Amendment by section 122(f), (g)(1) 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.
Amendment by section 128(a)(2)-(4) of Pub. L. 97-248 effective as if
originally included as part of this section as this section was amended
by the Omnibus Budget Reconciliation Act of 1981, Pub. L. 97-35, see
section 128(e)(2) of Pub. L. 97-248, set out as a note under section
1395x of this title.
Amendment by sections 142 and 148(a) 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.
Section 2103(a)(2) of Pub. L. 97-35 provided that: ''The amendment
made by paragraph (1) (amending this section) shall apply with respect
to expenses incurred on or after October 1, 1981.''
Section 2146(c)(1) of Pub. L. 97-35 provided that: ''The amendments
made by subsection (a) (amending this section) shall become effective on
October 1, 1981.''
Amendment by Pub. L. 96-611 effective July 1, 1981, and applicable
to services furnished on or after that date, see section 2 of Pub. L.
96-611, set out as a note under section 1395l of this title.
Amendment by section 936(c) of Pub. L. 96-499 applicable with
respect to services provided on or after July 1, 1981, see section
936(d) of Pub. L. 96-499, set out as a note under section 1395f of this
title.
Section 939(b) of Pub. L. 96-499 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply with respect
to services furnished on or after July 1, 1981.''
Amendment by Pub. L. 95-210 applicable to services rendered on or
after first day of third calendar month which begins after Dec. 31,
1977, see section 1(j) of Pub. L. 95-210, set out as a note under
section 1395k of this title.
Section 13(c) of Pub. L. 95-142 provided that: ''The amendments
made by this section (amending this section and sections 1320c-6 and
1395cc of this title) shall take effect on the date of the enactment of
this Act (Oct. 25, 1977).''
Amendment by Pub. L. 93-233 effective with respect to admissions
subject to the provisions of section 1395(a)(2) of this title which
occur after Dec. 31, 1973, see section 18(z-3)(2) of Pub. L. 93-233,
set out as a note under section 1395f of this title.
Amendment by section 211(c)(1) of Pub. L. 92-603 applicable to
services furnished with respect to admissions occurring after Dec. 31,
1972, see section 211(d) of Pub. L. 92-603, set out as a note under
section 1395f of this title.
Amendment by section 256(c) of Pub. L. 92-603 applicable with
respect to admissions occurring after the second month following the
month of enactment of Pub. L. 92-603 which was approved on Oct. 30,
1972, see section 256(d) of Pub. L. 92-603, set out as a note under
section 1395f of this title.
Amendment by section 127(b) of Pub. L. 90-248 applicable with
respect to services furnished after Dec. 31, 1967, see section 127(c)
of Pub. L. 90-248, set out as a note under section 1395x of this title.
Section 4203(c)(2) of Pub. L. 101-508 provided that:
''(A) The Comptroller General shall conduct a study of the impact of
the application of clause (iii) of section 1862(b)(1)(C) of the Social
Security Act (subsec. (b)(1)(C) of this section does not contain a cl.
(iii)) on individuals entitled to benefits under title XVIII of such Act
(this subchapter) by reason of section 226A of such Act (section 426-1
of this title), and shall include in such report information relating to
--
''(i) the number (and geographic distribution) of such individuals
for whom medicare is secondary;
''(ii) the amount of savings to the medicare program achieved
annually by reason of the application of such clause;
''(iii) the effect on access to employment, and employment-based
health insurance, for such individuals and their family members
(including coverage by employment-based health insurance of cost-sharing
requirements under medicare after such employment-based insurance
becomes secondary);
''(iv) the effect on the amount paid for each dialysis treatment
under employment-based health insurance;
''(v) the effect on cost-sharing requirements under employment-based
health insurance (and on out-of-pocket expenses of such individuals)
during the period for which medicare is secondary;
''(vi) the appropriateness of applying the provisions of section
1862(b)(1)(C) (subsec. (b)(1)(C) of this section) to all group health
plans.
''(B) The Comptroller General shall submit a preliminary report on
the study conducted under subparagraph (A) to the Committees on Ways and
Means and Energy and Commerce of the House of Representatives and the
Committee on Finance of the Senate not later than January 1, 1993, and a
final report on such study not later than January 1, 1995.''
Section 6202(a)(2)(B) of Pub. L. 101-239 provided that: ''The
Commissioner of Social Security shall first --
''(i) transmit to the Secretary of the Treasury information under
paragraph (5)(A)(i) of section 1862(b) of the Social Security Act
(subsec. (b)(5)(A)(i) of this section) (as inserted by subparagraph
(A)), and
''(ii) request from the Secretary disclosure of information described
in section 6013(l)(12)(A) of the Internal Revenue Code of 1986 (26
U.S.C. 6013(l)(12)(A)),
by not later than 14 days after the date of the enactment of this Act
(Dec. 19, 1989).''
Section 4009(b) of Pub. L. 100-203 provided that: ''For purposes of
determining whether a pediatric hospital that performs pediatric heart
transplants meets the criteria established by the Secretary of Health
and Human Services for facilities in which the heart transplants
performed will be considered to meet the requirement of section
1862(a)(1)(A) of the Social Security Act (subsec. (a)(1)(A) of this
section), the Secretary shall treat such a hospital as meeting such
criteria if --
''(1) the hospital's pediatric heart transplant program is operated
jointly by the hospital and another facility that meets such criteria,
''(2) the unified program shares the same transplant surgeons and
quality assurance program (including oversight committee, patient
protocol, and patient selection criteria), and
''(3) the hospital demonstrates to the satisfaction of the Secretary
that it is able to provide the specialized facilities, services, and
personnel that are required by pediatric heart transplant patients.''
Section 1895(b)(16)(C) of Pub. L. 99-514 provided that: ''For
purposes of section 1862(a)(15) of the Social Security Act (42 U.S.C.
1395y(a)(15)), added by section 9307(a)(3) of COBRA, and for surgical
procedures performed during the period beginning on April 1, 1986, and
ending on December 15, 1986, a carrier is deemed to have approved the
use of an assistant in a surgical procedure, before the surgery is
performed, based on the existence of a complicating medical condition if
the carrier determines after the surgery is performed that the use of
the assistant in the procedure was appropriate based on the existence of
a complicating medical condition before or during the surgery.''
Section 9305(f) of Pub. L. 99-509, as amended by Pub. L. 100-360,
title IV, 426(a), July 1, 1988, 102 Stat. 814; Pub. L. 101-508,
title IV, 4008(a)(2), Nov. 5, 1990, 104 Stat. 1388-44, provided that:
''(1) In general. -- The Secretary of Health and Human Services
shall, for purposes of determining whether payments to a hospice program
should be denied pursuant to section 1862(a)(1)(C) of the Social
Security Act (subsec. (a)(1)(C) of this section), apply (under section
1879(a) of such Act (section 1395pp(a) of this title)) a presumption of
compliance of 2.5 percent (based on the number of days of hospice care
billed) in a manner substantially similar to that provided to home
health agencies under policies in effect as of July 1, 1985.
''(2) Effective date. -- Paragraph (1) shall apply to hospice care
furnished on or after the first day of the first month that begins at
least 6 months after the date of the enactment of this Act (Oct. 21,
1986) and before December 31, 1995.''
(Section 4008(a)(3) of Pub. L. 101-508 provided that: ''The
amendments made by paragraphs (1) and (2) (amending section 9305(f) of
Pub. L. 99-509, set out above, and section 9126(c) of Pub. L. 99-272,
set out below) shall take effect on the date of the enactment of this
Act (Nov. 5, 1990).)
Section 9319(e) of Pub. L. 99-509 provided that: ''The Comptroller
General shall study and report to Congress, by not later than March 1,
1990, the impact of the amendments made by this section (enacting
section 5000 of Title 26, Internal Revenue Code, and amending this
section and sections 1395p and 1395r of this title) on access of
disabled individuals and members of their family to employment and
health insurance. The report shall include information relating to --
''(1) the number of disabled medicare beneficiaries for whom medicare
has become secondary, either through their employment or the employment
of a family member;
''(2) the amount of savings to the medicare program achieved annually
through this provision; and
''(3) the effect on employment, and employment-based health coverage,
of disabled individuals and family members.''
Section 9126(c) of Pub. L. 99-272, as amended by Pub. L. 100-360,
title IV, 426(b), July 1, 1988, 102 Stat. 814; Pub. L. 101-508,
title IV, 4008(a)(1), Nov. 5, 1990, 104 Stat. 1388-44, provided that:
''The Secretary of Health and Human Services shall, for purposes of
determining whether payments to a skilled nursing facility should be
denied pursuant to section 1862(a)(1)(A) of the Social Security Act
(subsec. (a)(1)(A) of this section), apply the same presumption of
compliance (5 percent) as in effect under regulations as of July 1,
1985. Such presumption shall apply for the period beginning with the
first month beginning after the date of the enactment of this Act (Apr.
7, 1986) and ending on December 31, 1995.''
Section 9205 of Pub. L. 99-272, as amended by Pub. L. 100-360,
title IV, 426(d), July 1, 1988, 102 Stat. 814, provided that: ''The
Secretary of Health and Human Services shall, for purposes of
determining whether payments to a home health agency should be denied
pursuant to section 1862(a)(1)(A) of the Social Security Act (subsec.
(a)(1)(A) of this section), apply a presumption of compliance (2.5
percent) in the same manner as under the regulations in effect as of
July 1, 1985. Such presumption shall apply until November 1, 1990.''
Section 9307(d) of Pub. L. 99-272 provided that the Secretary of
Health and Human Services, after consultation with the Physician Payment
Review Commission, develop recommendations and guidelines respecting
other surgical procedures for which an assistant at surgery was
generally not medically necessary and circumstances under which use of
an assistant at surgery was generally appropriate but should be subject
to prior approval of an appropriate entity and that the Secretary report
to Congress, not later than January 1, 1987, on these recommendations
and guidelines.
of Regulations; Effective Date of Pacemaker
Registration
Section 2304(d) of Pub. L. 98-369 provided that: ''The Secretary of
Health and Human Services shall promulgate final regulations to carry
out this section and the amendment made by this section (amending this
section and enacting provisions set out as a note under section 1395l of
this title) prior to January 1, 1985, and the amendment made by
subsection (c) (amending this section) shall apply to pacemaker devices
and leads implanted or removed on or after the effective date of such
regulations.''
Section 2325 of Pub. L. 98-369 provided that: ''The Secretary shall
provide, pursuant to section 1862(a) of the Social Security Act (subsec.
(a) of this section), that payment will not be made under part B of
title XVIII of such Act (part B of this subchapter) for a physician's
debridement of mycotic toenails to the extent such debridement is
performed for a patient more frequently than once every 60 days, unless
the medical necessity for more frequent treatment is documented by the
billing physician.''
Section 602(k) of Pub. L. 98-21, as amended by Pub. L. 99-272,
title IX, 9112(a), Apr. 7, 1986, 100 Stat. 163, provided that:
''(1) The Secretary of Health and Human Services may, for any cost
reporting period beginning prior to October 1, 1986, waive the
requirements of sections 1862(a)(14) and 1866(a)(1)(H) of the Social
Security Act (subsec. (a)(14) of this section and section
1395cc(a)(1)(H) of this title) in the case of a hospital which has
followed a practice, since prior to October 1, 1982, of allowing direct
billing under part B of title XVIII of such Act (part B of this
subchapter) for services (other than physicians' services) so
extensively, that immediate compliance with those requirements would
threaten the stability of patient care. Any such waiver shall provide
that such billing may continue to be made under part B of such title but
that the payments to such hospital under part A of such title (part A of
this subchapter) shall be reduced by the amount of the billings for such
services under part B of such title. If such a waiver is granted, at
the end of the waiver period the Secretary may provide for such methods
of payments under part A as is appropriate, given the organizational
structure of the institution.
''(2) In the case of a hospital which is receiving payments pursuant
to a waiver under paragraph (1), payment of the adjustment for indirect
costs of approved educational activities shall be made as if the
hospital were receiving under part A of title XVIII of the Social
Security Act all the payments which are made under part B of such title
solely by reason of such waiver.
''(3) Any waiver granted under paragraph (1) shall provide that, with
respect to those items and services billed under part B of title XVIII
of the Social Security Act solely by reason of such waiver --
''(A) payment under such part shall be equal to 100 percent of the
reasonable charge or other applicable payment base for the items and
services; and
''(B) the entity furnishing the items and services must agree to
accept the amount paid pursuant to subparagraph (A) as the full charge
for the items and services.''
(Section 9112(b) of Pub. L. 99-272 provided that:
(''(1) Section 602(k)(2) of the Social Security Amendments of 1983
(as added by subsection (a)) (set out above) shall apply to cost
reporting periods beginning on or after January 1, 1986.
(''(2) Section 602(k)(3) of the Social Security Amendments of 1983
(as added by subsection (a)) (set out above) shall apply to items and
services furnished after the end of the 10-day period beginning on the
date of the enactment of this Act (Apr. 7, 1986).'')
Section 115(b) of Pub. L. 97-248 provided that: ''No provision of
law limiting the use of funds for purposes of enforcing or implementing
section 1862(c) (subsec. (c) of this section) or section 1903(i)(5)
(section 1396b(i)(5) of this title) of the Social Security Act, section
2103 of the Omnibus Budget Reconciliation Act of 1981 (section 2103 of
Pub. L. 97-35, amending sections 1395y and 1396b of this title and
enacting provisions set out as notes under sections 1395y and 1396b of
this title), or any rule or regulation issued pursuant to any such
section (including any provision contained in, or incorporated by
reference into, any appropriation Act or resolution making continuing
appropriations) shall apply to any period after September 30, 1982,
unless such provision of law is enacted after the date of the enactment
of this Act (Sept. 3, 1982) and specifically states that such provision
is to supersede this section.''
Section 2152(b) of Pub. L. 97-35 directed the Secretary of Health
and Human Services to establish, and provide for the implementation of,
the guidelines described in subsec. (f) of this section not later than
Oct. 1, 1981.
Report
Section 4(b) of Pub. L. 93-480 provided that the Civil Service
Commission and the Secretary of Health, Education, and Welfare submit a
report on or before Mar. 1, 1975, on the steps which have been taken,
and the steps which are planned, to enable the Secretary to make the
determination and certification referred to in former subsec. (c) of
this section and that if such report is not submitted by Mar. 1, 1975,
the date specified in former subsec. (c) shall be deemed to be July 1,
1975, rather than Jan. 1, 1976.
sections 5000, 6103; title 45 section 231f.
/1/ So in original.
/2/ So in original. The comma probably should not appear.
42 USC 1395z. Consultation with State agencies and other organizations
to develop conditions of participation for providers of services
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
In carrying out his functions, relating to determination of
conditions of participation by providers of services, under subsections
(e)(9), (f)(4), (j)(15), /1/ (o)(6), (cc)(2)(I), and /2/ (dd)(2), and
(mm)(1) of section 1395x of this title, or by ambulatory surgical
centers under section 1395k(a)(2)(F)(i) of this title, or whether
screening mammography meets the standards established under section
1395m(c)(3) of this title, the Secretary shall consult with appropriate
State agencies and recognized national listing or accrediting bodies,
and may consult with appropriate local agencies. Such conditions
prescribed under any of such subsections may be varied for different
areas or different classes of institutions or agencies and may, at the
request of a State, provide higher requirements for such State than for
other States; except that, in the case of any State or political
subdivision of a State which imposes higher requirements on institutions
as a condition to the purchase of services (or of certain specified
services) in such institutions under a State plan approved under
subchapter I, XVI, or XIX of this chapter, the Secretary shall impose
like requirements as a condition to the payment for services (or for the
services specified by the State or subdivision) in such institutions in
such State or subdivision.
(Aug. 14, 1935, ch. 531, title XVIII, 1863, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 325, and amended Oct. 30,
1972, Pub. L. 92-603, title II, 234(g)(2), 86 Stat. 1413; Dec. 5,
1980, Pub. L. 96-499, title IX, 933(f), 934(c)(1), 94 Stat. 2636,
2639; Sept. 3, 1982, Pub. L. 97-248, title I, 122(g)(2), 96 Stat.
362; July 18, 1984, Pub. L. 98-369, div. B, title III, 2335(c),
2349(b)(1), 2354(b)(32), 98 Stat. 1090, 1097, 1102; July 1, 1988, Pub.
L. 100-360, title II, 203(e)(2), 204(c)(1), 102 Stat. 725, 728; Dec.
13, 1989, Pub. L. 101-234, title II, 201(a), 103 Stat. 1981; Dec. 19,
1989, Pub. L. 101-239, title VI, 6003(g)(3)(C)(ii), 103 Stat. 2152;
Nov. 5, 1990, Pub. L. 101-508, title IV, 4163(c)(1), 104 Stat.
1388-99.)
Subsection (j) of section 1395x of this title, referred to in text,
was amended generally by Pub. L. 100-203, title IV, 4201(a)(1), Dec.
22, 1987, 101 Stat. 1330-160, and, as so amended, does not contain a
par. (15).
1990 -- Pub. L. 101-508 inserted ''or whether screening mammography
meets the standards established under section 1395m(c)(3) of this
title,'' after ''section 1395k(a)(2)(F)(i) of this title,''.
1989 -- Pub. L. 101-239 substituted ''(jj)(3), and (mm)(1)'' for
''and (jj)(3)''.
Pub. L. 101-234 repealed Pub. L. 100-360, 203(e)(2), 204(c)(1),
and provided that the provisions of law amended or repealed by such
sections are restored or revived as if such sections had not been
enacted, see 1988 Amendment notes below.
1988 -- Pub. L. 100-360, 204(c)(1), inserted ''or whether screening
mammography meets the standards established under section 1395m(e)(3) of
this title,'' after ''1395k(a)(2)(F)(i) of this title,''.
Pub. L. 100-360, 203(e)(2), substituted ''(dd)(2), and (jj)(3)'' for
''and (dd)(2)''.
1984 -- Pub. L. 98-369, 2335(c), struck out ''(g)(4),'' after
''(e)(9), (f)(4),''.
Pub. L. 98-369, 2354(b)(32), substituted ''(j)(15)'' for
''(j)(11)''.
Pub. L. 98-369, 2349(b)(1), substituted ''appropriate State
agencies'' for ''the Health Insurance Benefits Advisory Council
established by section 1395dd of this title, appropriate State
agencies,''.
1982 -- Pub. L. 97-248 substituted ''(cc)(2)(I), and (dd)(2)'' for
''and (cc)(2)(I)''.
1980 -- Pub. L. 96-499, 933(f), substituted ''(o)(6), and
(cc)(2)(I) of section 1395x'' for ''and (o)(6) of section 1395x''.
Pub. L. 96-499, 934(c)(1), inserted ''or by ambulatory surgical
centers under section 1395k(a)(2)(F)(i) of this title,''.
1972 -- Pub. L. 92-603 substituted ''subsections (e)(9), (f)(4),
(g)(4), (j)(11), and (o)(6) of section 1395x of this title'' for
''subsections (e)(8), (f)(4), (g)(4), (j)(10), and (o)(5) of section
1395x of this title''.
Amendment by Pub. L. 101-508 applicable to screening mammography
performed on or after Jan. 1, 1991, see section 4163(e) of Pub. L.
101-508, set out as a note under section 1395l of this title.
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.
Amendment by section 203(e)(2) of Pub. L. 100-360 applicable to
items and services furnished on or after Jan. 1, 1990, see section
203(g) of Pub. L. 100-360, set out as a note under section 1320c-3 of
this title.
Amendment by section 204(c)(1) of Pub. L. 100-360 applicable to
screening mammography performed on or after Jan. 1, 1990, see section
204(e) of Pub. L. 100-360, set out as a note under section 1395m of
this title.
Amendment by section 2335(c) of Pub. L. 98-369 effective July 18,
1984, see section 2335(g) of Pub. L. 98-369, set out as a note under
section 1395f of this title.
Amendment by section 2349(b)(1) of Pub. L. 98-369 effective July 18,
1984, see section 2349(c) of Pub. L. 98-369, set out as a note under
section 907a of this title.
Amendment by section 2354(b)(32) 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 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.
Amendment by section 933(f) of Pub. L. 96-499 effective with respect
to a comprehensive outpatient rehabilitation facility's first accounting
period beginning on or after July 1, 1981, see section 933(h) of Pub.
L. 96-499, set out as a note under section 1395k of this title.
Amendment by Pub. L. 92-603 applicable with respect to providers of
services for fiscal years beginning after the 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.
Advisory councils in existence on Jan. 5, 1973, to terminate not
later than the expiration of the 2-year period following Jan. 5, 1973,
unless, in the case of a council established by the President or an
officer of the Federal Government, such council is renewed by
appropriate action prior to the expiration of such 2-year period, or in
the case of a council established by the Congress, its duration is
otherwise provided by law. See sections 3(2) and 14 of Pub. L.
92-463, Oct. 6, 1972, 86 Stat. 770, 776, set out in the Appendix to
Title 5, Government Organization and Employees.
/1/ See References in Text note below.
/2/ So in original. The word ''and'' probably should not appear.
42 USC 1395aa. Agreements with States
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Use of State agencies to determine compliance by providers of
services with conditions of participation
The Secretary shall make an agreement with any State which is able
and willing to do so under which the services of the State health agency
or other appropriate State agency (or the appropriate local agencies)
will be utilized by him for the purpose of determining whether an
institution therein is a hospital or skilled nursing facility, or
whether an agency therein is a home health agency, or whether an agency
is a hospice program or whether a facility therein is a rural health
clinic as defined in section 1395x(aa)(2) of this title, a rural primary
care hospital, as defined in section 1395x(mm)(1) of this title, or a
comprehensive outpatient rehabilitation facility as defined in section
1395x(cc)(2) of this title, or whether a laboratory meets the
requirements of paragraphs (15) and (16) of section 1395x(s) of this
title or (in the case of a laboratory that does not participate or seek
to participate in the medicare program) the requirements of section 263a
of this title, or whether a clinic, rehabilitation agency or public
health agency meets the requirements of subparagraph (A) or (B), as the
case may be, of section 1395x(p)(4) of this title, or whether an
ambulatory surgical center meets the standards specified under section
1395k(a)(2)(F)(i) of this title, or whether screening mammography meets
the standards established under section 1395m(c)(3) of this title. To
the extent that the Secretary finds it appropriate, an institution or
agency which such a State (or local) agency certifies is a hospital,
skilled nursing facility, rural health clinic, comprehensive outpatient
rehabilitation facility, home health agency, or hospice program (as
those terms are defined in section 1395x of this title) may be treated
as such by the Secretary. Any State agency which has such an agreement
may (subject to approval of the Secretary) furnish to a skilled nursing
facility, after proper request by such facility, such specialized
consultative services (which such agency is able and willing to furnish
in a manner satisfactory to the Secretary) as such facility may need to
meet one or more of the conditions specified in section 1395i-3(a) of
this title. Any such services furnished by a State agency shall be
deemed to have been furnished pursuant to such agreement. Within 90
days following the completion of each survey of any health care
facility, ambulatory surgical center, rural health clinic, comprehensive
outpatient rehabilitation facility, laboratory, clinic, agency, or
organization by the appropriate State or local agency described in the
first sentence of this subsection, the Secretary shall make public in
readily available form and place, and require (in the case of skilled
nursing facilities) the posting in a place readily accessible to
patients (and patients' representatives), the pertinent findings of each
such survey relating to the compliance of each such health care
facility, ambulatory surgical center, rural health clinic, comprehensive
outpatient rehabilitation facility, laboratory, clinic, agency, or
organization with (1) the statutory conditions of participation imposed
under this subchapter and (2) the major additional conditions which the
Secretary finds necessary in the interest of health and safety of
individuals who are furnished care or services by any such health care
facility, ambulatory surgical center, rural health clinic, comprehensive
outpatient rehabilitation facility, laboratory, clinic, agency, or
organization. Any agreement under this subsection shall provide for the
appropriate State or local agency to maintain a toll-free hotline (1) to
collect, maintain, and continually update information on home health
agencies located in the State or locality that are certified to
participate in the program established under this subchapter (which
information shall include any significant deficiencies found with
respect to patient care in the most recent certification survey
conducted by a State agency or accreditation survey conducted by a
private accreditation agency under section 1395bb of this title with
respect to the home health agency, when that survey was completed,
whether corrective actions have been taken or are planned, and the
sanctions, if any, imposed under this subchapter with respect to the
agency) and (2) to receive complaints (and answer questions) with
respect to home health agencies in the State or locality. Any such
agreement shall provide for such State or local agency to maintain a
unit for investigating such complaints that possesses enforcement
authority and has access to survey and certification reports,
information gathered by any private accreditation agency utilized by the
Secretary under section 1395bb of this title, and consumer medical
records (but only with the consent of the consumer or his or her legal
representative).
(b) Payment in advance or by way of reimbursement to State for
performance of functions of subsection (a)
The Secretary shall pay any such State, in advance or by way of
reimbursement, as may be provided in the agreement with it (and may make
adjustments in such payments on account of overpayments or underpayments
previously made), for the reasonable cost of performing the functions
specified in subsection (a) of this section, and for the Federal
Hospital Insurance Trust Fund's fair share of the costs attributable to
the planning and other efforts directed toward coordination of
activities in carrying out its agreement and other activities related to
the provision of services similar to those for which payment may be made
under part A of this subchapter, or related to the facilities and
personnel required for the provision of such services, or related to
improving the quality of such services.
(c) Use of State or local agencies to survey hospitals
The Secretary is authorized to enter into an agreement with any State
under which the appropriate State or local agency which performs the
certification function described in subsection (a) of this section will
survey, on a selective sample basis (or where the Secretary finds that a
survey is appropriate because of substantial allegations of the
existence of a significant deficiency or deficiencies which would, if
found to be present, adversely affect health and safety of patients),
hospitals which have an agreement with the Secretary under section
1395cc of this title and which are accredited by the Joint Commission on
Accreditation of Hospitals. The Secretary shall pay for such services
in the manner prescribed in subsection (b) of this section.
(d) Fulfillment of requirements by States
The Secretary may not enter an agreement under this section with a
State with respect to determining whether an institution therein is a
skilled nursing facility unless the State meets the requirements
specified in section 1395i-3(e) of this title and section 1395i-3(g) of
this title and the establishment of remedies under sections
1395i-3(h)(2)(B) and 1395i-3(h)(2)(C) of this title (relating to
establishment and application of remedies).
(e) Prohibition of user fees for survey and certification
Notwithstanding any other provision of law, the Secretary may not
impose, or require a State to impose, any fee on any facility or entity
subject to a determination under subsection (a) of this section, or any
renal dialysis facility subject to the requirements of section
1395rr(b)(1) of this title, for any such determination or any survey
relating to determining the compliance of such facility or entity with
any requirement of this subchapter.
(Aug. 14, 1935, ch. 531, title XVIII, 1864, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 326, and amended Jan. 2,
1968, Pub. L. 90-248, title I, 133(f), title II, 228(b), 81 Stat.
852, 904; Oct. 30, 1972, Pub. L. 92-603, title II, 244(a), 277,
278(a)(16), (b)(15), 299D(a), 86 Stat. 1422, 1452-1454, 1461; Dec. 13,
1977, Pub. L. 95-210, 1(i), 91 Stat. 1488; Dec. 5, 1980, Pub. L.
96-499, title IX, 933(g), 934(c)(2), 94 Stat. 2639; Dec. 28, 1980,
Pub. L. 96-611, 1(a)(2), 94 Stat. 3566; Sept. 3, 1982, Pub. L.
97-248, title I, 122(g)(3), 96 Stat. 362; July 18, 1984, Pub. L.
98-369, div. B, title III, 2354(b)(17), 98 Stat. 1101; Oct. 21, 1986,
Pub. L. 99-509, title IX, 9320(h)(3), 100 Stat. 2016; Dec. 22, 1987,
Pub. L. 100-203, title IV, 4025(a), 4072(d), 4201(a)(2), (d)(4),
4202(a)(1), (c), 4203(a)(1), 4212(b), 101 Stat. 1330-74, 1330-117,
1330-160, 1330-174, 1330-179, 1330-212, as amended July 1, 1988, Pub. L.
100-360, title IV, 411(l)(1)(C), (6)(B), 102 Stat. 804, as amended Oct.
13, 1988, Pub. L. 100-485, title VI, 608(d)(20)(B), (C), (27)(B), 102
Stat. 2419, 2420, 2422; July 1, 1988, Pub. L. 100-360, title II,
203(e)(3), 204(c)(2), (d)(3), title IV, 411(d)(4)(A), 102 Stat. 725,
728, 729, 774; Dec. 13, 1989, Pub. L. 101-234, title II, 201(a), 103
Stat. 1981; Dec. 19, 1989, Pub. L. 101-239, title VI,
6003(g)(3)(C)(iii), 6115(c), 103 Stat. 2152, 2219; Nov. 5, 1990, Pub.
L. 101-508, title IV, 4154(d)(1), 4163(c)(2), 4027(4207)(g), 104 Stat.
1388-85, 1388-100, 1388-123.)
For contingent effective date of amendment by section 4072(d) of Pub.
L. 100-203, see section 4072(e) of Pub. L. 100-203, set out as an
Effective Date of 1987 Amendment note under section 1395x of this title.
Part A of this subchapter, referred to in subsec. (b), is classified
to section 1395c et seq. of this title.
1990 -- Subsec. (a). Pub. L. 101-508, 4163(c)(2), inserted before
period at end of first sentence '', or whether screening mammography
meets the standards established under section 1395m(c)(3) of this
title''.
Pub. L. 101-508, 4154(d)(1), substituted ''section 1395x(s) of this
title or (in the case of a laboratory that does not participate or seek
to participate in the medicare program) the requirements of section 263a
of this title,'' for ''section 1395x(s) of this title,'' in first
sentence.
Subsec. (e). Pub. L. 101-508, 4027(4207)(g), added subsec. (e).
1989 -- Subsec. (a). Pub. L. 101-239, 6115(c), substituted
''paragraphs (15) and (16)'' for ''paragraphs (14) and (15)''.
Pub. L. 101-239, 6003(g)(3)(C)(iii), inserted '', a rural primary
care hospital, as defined in section 1395x(mm)(1) of this title,'' after
''1395x(aa)(2) of this title''.
Pub. L. 101-234 repealed Pub. L. 100-360, 203(e)(3), 204(c)(2),
(d)(3), and provided that the provisions of law amended or repealed by
such sections are restored or revived as if such sections had not been
enacted, see 1988 and 1989 Amendment notes.
1988 -- Subsec. (a). Pub. L. 100-360, 411(l)(6)(B), amended Pub.
L. 100-203, 4212(b), see 1987 Amendment note below.
Pub. L. 100-360, 411(l)(1)(C), as added by Pub. L. 100-485,
608(d)(27)(B), added Pub. L. 100-203, 4201(d)(4), see 1987 Amendment
note below.
Pub. L. 100-360, 411(d)(4)(A)(i), as amended by Pub. L. 100-485,
608(d)(20)(B)(i), substituted ''most recent certification survey
conducted by a State agency or accreditation survey conducted by a
private accreditation agency under section 1395bb of this title with
respect to the home health agency,'' for ''most recent certification
survey conducted with respect to the agency,''.
Pub. L. 100-360, 411(d)(4)(A)(ii)(I), as amended by Pub. L.
100-485, 608(d)(20)(C), substituted ''such State or local agency to
maintain a unit'' for ''such agency to maintain a unit''.
Pub. L. 100-360, 411(d)(4)(A)(ii)(II), as amended by Pub. L.
100-485, 608(d)(20)(B)(ii), substituted ''utilized by the Secretary
under section 1395bb of this title'' for ''pursuant to an agreement with
the Secretary under this section''.
Pub. L. 100-360, 204(d)(3), substituted ''paragraphs (14) and (15)''
for ''paragraphs (13) and (14)''.
Pub. L. 100-360, 204(c)(2), inserted '', or whether screening
mammography meets the standards established under section 1395m(e)(3) of
this title'' after ''section 1395k(a)(2)(F)(i) of this title''.
Pub. L. 100-360, 203(e)(3), inserted ''or a home intravenous drug
therapy provider,'' after ''hospice program'' and substituted ''hospice
program, or home intravenous drug therapy provider'' for ''or hospice
program''.
1987 -- Subsec. (a). Pub. L. 100-203, 4212(b), which directed an
amendment of subsec. (a) identical to Pub. L. 100-203, 4202(c), was
amended generally by Pub. L. 100-360, 411(l)(6)(B), so that it does
not amend this section but rather section 1396r of this title.
Pub. L. 100-203, 4202(c), inserted '', and require (in the case of
skilled nursing facilities) the posting in a place readily accessible to
patients (and patients' representatives),'' after ''place'' in fifth
sentence.
Pub. L. 100-203, 4201(d)(4), as added by Pub. L. 100-360,
411(l)(1)(C), as added by Pub. L. 100-485, 608(d)(27)(B), substituted
''conditions specified in section 1395i-3(a) of this title'' for
''conditions specified in section 1395x(j) of this title''.
Pub. L. 100-203, 4072(d), substituted ''paragraphs (13) and (14)''
for ''paragraphs (12) and (13)'' in first sentence.
Pub. L. 100-203, 4025(a), inserted at end ''Any agreement under this
subsection shall provide for the appropriate State or local agency to
maintain a toll-free hotline (1) to collect, maintain, and continually
update information on home health agencies located in the State or
locality that are certified to participate in the program established
under this subchapter (which information shall include any significant
deficiencies found with respect to patient care in the most recent
certification survey conducted with respect to the agency, when that
survey was completed, whether corrective actions have been taken or are
planned, and the sanctions, if any, imposed under this subchapter with
respect to the agency) and (2) to receive complaints (and answer
questions) with respect to home health agencies in the State or
locality. Any such agreement shall provide for such agency to maintain
a unit for investigating such complaints that possesses enforcement
authority and has access to survey and certification reports,
information gathered by any private accreditation agency pursuant to an
agreement with the Secretary under this section, and consumer medical
records (but only with the consent of the consumer or his or her legal
representative).''
Subsec. (d). Pub. L. 100-203, 4203(a)(1), inserted before period at
end ''and the establishment of remedies under sections 1395i-3(h)(2)(B)
and 1395i-3(h)(2)(C) of this title (relating to establishment and
application of remedies)''.
Pub. L. 100-203, 4202(a)(1), inserted ''and section 1395i-3(g) of
this title'' before period at end.
Pub. L. 100-203, 4201(a)(2), added subsec. (d).
1986 -- Subsec. (a). Pub. L. 99-509 substituted ''paragraphs (12)
and (13)'' for ''paragraphs (11) and (12)''.
1984 -- Subsec. (c). Pub. L. 98-369 struck out ''the'' after ''Joint
Commission on''.
1982 -- Subsec. (a). Pub. L. 97-248 inserted ''or whether an agency
is a hospice program'' and substituted ''home health agency, or hospice
program'' for ''or home health agency''.
1980 -- Subsec. (a). Pub. L. 96-611 substituted ''requirements of
paragraphs (11) and (12) of section 1395x(s) of this title'' for
''requirements of paragraphs (10) and (11) of section 1395x(s) of this
title''.
Pub. L. 96-499, 933(g), inserted ''or a comprehensive outpatient
rehabilitation facility as defined in section 1395x(cc)(2) of this
title'' after ''section 1395x(aa)(2) of this title'' and ''comprehensive
outpatient rehabilitation facility,'' after ''rural health clinic'' in
four places.
Pub. L. 96-499, 934(c)(2), inserted '', or whether an ambulatory
surgical center meets the standards specified under section
1395k(a)(2)(F) of this title'' after ''section 1395x(p)(4) of this
title'' and ''ambulatory surgical center,'' after ''health care
facility,'' in three places.
1977 -- Subsec. (a). Pub. L. 95-210 expanded enumeration of
institutions and agencies included under coverage of this subsection by
inserting references to rural health clinics in five places.
1972 -- Subsec. (a). Pub. L. 92-603, 277, 278(a)(16), (b)(15),
299D(a), provided for the furnishing of specialized consultative
services to skilled nursing facilities, authorized the Secretary to make
public the pertinent findings of each survey within 90 days following
the completion of each survey of any health care facility, etc., and
substituted ''skilled nursing facility'' for ''extended care facility''.
Subsec. (c). Pub. L. 92-603, 244(a), added subsec. (c).
1968 -- Subsec. (a). Pub. L. 90-248, 133(f), inserted clause at end
of first sentence for determining whether a clinic, rehabilitation
agency, or public health agency meets the requirements of section
1395x(p)(4)(A) or (B) of this title.
Pub. L. 90-248, 228(b), struck out last sentence providing for
utilization of State facilities to provide consultative services to
institutions furnishing medical care, covered in section 1396a(a)(24) of
this title.
Section 4154(d)(2) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall take
effect as if included in the enactment of the Clinical Laboratory
Improvement Amendments of 1988 (Pub. L. 100-578).''
Amendment by section 4163(c)(2) of Pub. L. 101-508 applicable to
screening mammography performed on or after Jan. 1, 1991, see section
4163(e) of Pub. L. 101-508, set out as a note under section 1395l of
this title.
Amendment by section 6115(c) of Pub. L. 101-239 applicable to
screening pap smears performed on or after July 1, 1990, see section
6115(d) of Pub. L. 101-239, set out as a note under section 1395x of
this title.
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.
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 203(e)(3) of Pub. L. 100-360 applicable to
items and services furnished on or after Jan. 1, 1990, see section
203(g) of Pub. L. 100-360, set out as a note under section 1320c-3 of
this title.
Amendment by section 204(c)(2), (d)(3) of Pub. L. 100-360 applicable
to screening mammography performed on or after Jan. 1, 1990, see
section 204(e) of Pub. L. 100-360, set out as a note under section
1395m of this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(d)(4)(A), (l)(1)(C), (6)(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.
Section 4025(c), formerly 4025(b), of Pub. L. 100-203, as
redesignated and amended by Pub. L. 100-360, title IV,
411(d)(4)(B)(i), July 1, 1988, 102 Stat. 774, provided that: ''The
amendment made by this section (amending this section and section 1395bb
of this title) shall apply with respect to agreements entered into or
renewed on or after the date of enactment of this Act (Dec. 22,
1987).''
For contingent effective date of amendment by section 4072(d) of Pub.
L. 100-203, see section 4072(e) of Pub. L. 100-203, set out as a note
under section 1395x of this title.
Amendments by sections 4201(a)(2), (d)(4) and 4202(a)(1), (c) of Pub.
L. 100-203 applicable to services furnished on or after Oct. 1, 1990,
without regard to whether regulations to implement such amendments are
promulgated by such date, except as otherwise specifically provided in
section 1395i-3 of this title, see section 4204(a) of Pub. L. 100-203,
as amended, set out as an Effective Date note under section 1395i-3 of
this title.
Amendment by section 4203(a)(1) of Pub. L. 100-203 applicable Jan.
1, 1988, except as otherwise specifically provided in section 1395i-3 of
this title, without regard to whether regulations to implement such
amendment are promulgated by such date, and in applying amendment by
section 4203(a)(1) of Pub. L. 100-203 for services furnished by a
skilled nursing facility before Oct. 1, 1990, any reference to a
requirement of section 1395i-3(b), (c), or (d) of this title is deemed a
reference to section 1395x(j) of this title, see section 4204(b) of Pub.
L. 100-203, as added by Pub. L. 100-485, set out as an Effective Date
note under section 1395i-3 of this title.
Amendment by Pub. L. 99-509 applicable to services furnished on or
after Jan. 1, 1989, with exceptions for hospitals located in rural
areas which meet certain requirements related to certified registered
nurse anesthetists, see section 9320(i), (k) of Pub. L. 99-509, as
amended, set out as notes under section 1395k of this title.
Amendment by 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 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.
Amendment by Pub. L. 96-611 effective July 1, 1981, and applicable
to services furnished on or after that date, see section 2 of Pub. L.
96-611, set out as a note under section 1395l of this title.
For effective date of amendment by section 933(g) of Pub. L.
96-499, see section 933(h) of Pub. L. 96-499, set out as a note under
section 1395k of this title.
Amendment by Pub. L. 95-210 applicable to services rendered on or
after first day of third calendar month which begins after Dec. 31,
1977, see section 1(j) of Pub. L. 95-210, set out as a note under
section 1395k of this title.
Section 299D(c) of Pub. L. 92-603 provided that: ''The provisions
of this section (amending this section and section 1396a of this title)
shall be effective beginning January 1, 1973, or within 6 months
following the enactment of this Act (Oct. 30, 1972), whichever is
later.''
Amendment by section 133(f) of Pub. L. 90-248 applicable with
respect to services furnished after June 30, 1968, see section 133(g) of
Pub. L. 90-248, set out as a note under section 1395k of this title.
Section 228(b) of Pub. L. 90-248 provided that the amendment made by
such section 228(b) is effective July 1, 1969.
Section 4008(h)(1)(A) of Pub. L. 101-508 provided that: ''The
Secretary of Health and Human Services may not refuse to enter into an
agreement or cancel an existing agreement with a State under section
1864 of the Social Security Act (this section) on the basis that the
State failed to meet the requirement of section 1819(e)(1)(A) of such
Act (section 1395i-3(e)(1)(A) of this title) before the effective date
of guidelines, issued by the Secretary, establishing requirements under
section 1819(f)(2)(A) of such Act, if the State demonstrates to the
satisfaction of the Secretary that it has made a good faith effort to
meet such requirement before such effective date.''
42 USC 1395bb. Effect of accreditation
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Except as provided in subsection (b) of this section and the
second sentence of section 1395z of this title, if --
(1) an institution is accredited as a hospital by the Joint
Commission on Accreditation of Hospitals, and
(2)(A) such institution authorizes the Commission to release to the
Secretary upon his request (or such State agency as the Secretary may
designate) a copy of the most current accreditation survey of such
institution made by such Commission, together with any other information
directly related to the survey as the Secretary may require (including
corrective action plans), /1/
(B) such Commission releases such a copy and any such information to
the Secretary,
then, such institution shall be deemed to meet the requirements of
the numbered paragraphs of section 1395x(e) of this title; except --
(3) paragraph (6) thereof, and
(4) any standard, promulgated by the Secretary pursuant to paragraph
(9) thereof, which is higher than the requirements prescribed for
accreditation by such Commission.
If such Commission, as a condition for accreditation of a hospital,
requires a utilization review plan (or imposes another requirement which
serves substantially the same purpose), requires a discharge planning
process (or imposes another requirement which serves substantially the
same purpose), or imposes a standard which the Secretary determines is
at least equivalent to the standard promulgated by the Secretary as
described in paragraph (4) of this subsection, the Secretary is
authorized to find that all institutions so accredited by such
Commission comply also with clause (A) or (B) of section 1395x(e)(6) of
this title or the standard described in such paragraph (4), as the case
may be. In addition, if the Secretary finds that accreditation of an
entity by the American Osteopathic Association or any other national
accreditation body provides reasonable assurance that any or all of the
conditions of section 1395k(a)(2)(F)(i), 1395m(c)(3), 1395x(e),
1395x(f), 1395x(j), 1395x(o), 1395x(p)(4)(A) or (B), paragraphs (15) and
(16) of section 1395x(s), section 1395x(aa)(2), 1395x(cc)(2),
1395x(dd)(2), or 1395x(mm)(1) of this title, as the case may be, are
met, he may, to the extent he deems it appropriate, treat such entity as
meeting the condition or conditions with respect to which he made such
finding. The Secretary may not disclose any accreditation survey (other
than a survey with respect to a home health agency) made and released to
him by the Joint Commission on Accreditation of Hospitals, the American
Osteopathic Association, or any other national accreditation body, of an
entity accredited by such body, except that the Secretary may disclose
such a survey and information related to such a survey to the extent
such survey and information relate to an enforcement action taken by the
Secretary.
(b) Notwithstanding any other provision of this subchapter, if the
Secretary finds that a hospital has significant deficiencies (as defined
in regulations pertaining to health and safety), the hospital shall,
after the date of notice of such finding to the hospital and for such
period as may be prescribed in regulations, be deemed not to meet the
requirements of the numbered paragraphs of section 1395x(e) of this
title.
(Aug. 14, 1935, ch. 531, title XVIII, 1865, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 326, and amended Oct. 30,
1972, Pub. L. 92-603, title II, 234(h), 244(b), 86 Stat. 1413, 1423;
Sept. 3, 1982, Pub. L. 97-248, title I, 122(g)(4), 128(d)(3), 96 Stat.
362, 367; July 18, 1984, Pub. L. 98-369, div. B, title III, 2345(a),
2346(a), 98 Stat. 1096; Oct. 21, 1986, Pub. L. 99-509, title IX,
9305(c)(3), 9320(h)(3), 100 Stat. 1990, 2016; Dec. 22, 1987, Pub. L.
100-203, title IV, 4025(b), 4072(d), 101 Stat. 1330-117, as amended
July 1, 1988, Pub. L. 100-360, title IV, 411(d)(4)(B)(ii), 102 Stat.
774; July 1, 1988, Pub. L. 100-360, title II, 204(c)(3), (d)(3), 102
Stat. 728, 729; Oct. 13, 1988, Pub. L. 100-485, title VI,
608(d)(20)(D), 102 Stat. 2420; Dec. 13, 1989, Pub. L. 101-234, title
II, 201(a), 103 Stat. 1981; Dec. 19, 1989, Pub. L. 101-239, title VI,
6003(g)(3)(C)(iv), 6019(a)-(c), 6115(c), 103 Stat. 2153, 2165, 2166,
2219; Nov. 5, 1990, Pub. L. 101-508, title IV, 4163(c)(3), 104 Stat.
1388-100.)
For contingent effective date of amendment by section 4072(d) of Pub.
L. 100-203, see section 4072(e) of Pub. L. 100-203, set out as an
Effective Date of 1987 Amendment note under section 1395x of this title.
1990 -- Subsec. (a). Pub. L. 101-508 inserted ''1395m(c)(3),'' after
''1395k(a)(2)(F)(i),'' in second sentence.
1989 -- Subsec. (a). Pub. L. 101-239, 6115(c), substituted
''paragraphs (15) and (16)'' for ''paragraphs (14) and (15)''.
Pub. L. 101-239, 6019(b), inserted before period at end '', except
that the Secretary may disclose such a survey and information related to
such a survey to the extent such survey and information relate to an
enforcement action taken by the Secretary''.
Pub. L. 101-239, 6003(g)(3)(C)(iv), substituted ''1395x(dd)(2), or
1395x(mm)(1) of this title'' for ''or 1395x(dd)(2) of this title'' in
third sentence.
Pub. L. 101-234 repealed Pub. L. 100-360, 204(c)(3), (d)(3), and
provided that the provisions of law amended or repealed by such section
are restored or revived as if such section had not been enacted, see
1988 and 1989 Amendment notes.
Subsec. (a)(2). Pub. L. 101-239, 6019(a), designated existing
provisions as subpar. (A), struck out ''(if it is included within a
survey described in section 1395aa(c) of this title)'' after ''such
institution'', inserted '', together with any other information directly
related to the survey as the Secretary may require (including corrective
action plans)'' after ''by such Commission'', and added subpar. (B).
Subsec. (b). Pub. L. 101-239, 6019(c), struck out ''following a
survey made pursuant to section 1395aa(c) of this title'' after ''if the
Secretary finds''.
1988 -- Subsec. (a). Pub. L. 100-360, 411(d)(4)(B)(ii), as amended
by Pub. L. 100-485, 608(d)(20)(D), added Pub. L. 100-203, 4025(b),
see 1987 Amendment note below.
Pub. L. 100-360, 204(d)(3), substituted ''paragraphs (14) and (15)''
for ''paragraphs (13) and (14)'' in third sentence.
Pub. L. 100-360, 204(c)(3), inserted ''1395m(e)(3),'' after
''1395k(a)(2)(F)(i),'' in third sentence.
1987 -- Subsec. (a). Pub. L. 100-203, 4072(d), substituted
''paragraphs (13) and (14)'' for ''paragraphs (12) and (13)'' in
penultimate sentence.
Pub. L. 100-203, 4025(b), as added by Pub. L. 100-360,
411(d)(4)(B)(ii), as amended by Pub. L. 100-485, 608(d)(20)(D),
inserted ''(other than a survey with respect to a home health agency)''
after ''survey'' in last sentence.
1986 -- Subsec. (a). Pub. L. 99-509, 9305(c)(3), inserted '',
requires a discharge planning process (or imposes another requirement
which serves substantially the same purpose)'' after ''the same
purpose)'', and ''clause (A) or (B) of'' after ''comply also with'' in
second sentence.
Pub. L. 99-509, 9320(h)(3), substituted ''paragraphs (12) and (13)''
for ''paragraphs (11) and (12)'' in third sentence.
1984 -- Subsec. (a). Pub. L. 98-369, 2346(a), in provisions
following par. (4), substituted ''section 1395k(a)(2)(F)(i), 1395x(e),
1395x(f), 1395x(j), 1395x(o), 1395x(p)(4)(A) or (B), paragraphs (11) and
(12) of section 1395x(s), section 1395x(aa)(2), 1395x(cc)(2), or
1395x(dd)(2) of this title'' for ''section 1395x(e), (j), (o), or (dd)
of this title'', and substituted ''entity'' for ''institution or
agency'' in two places.
Pub. L. 98-369, 2345(a), struck out ''(on a confidential basis)''
after ''release to the Secretary'' in par. (2), and inserted provision
that the Secretary may not disclose any accreditation survey made and
released to him by the Joint Commission on Accreditation of Hospitals,
the American Osteopathic Association, or any other national
accreditation body, of an entity accredited by such body, in provisions
following par. (4).
1982 -- Subsec. (a). Pub. L. 97-248, 122(g)(4), substituted ''(o),
or (dd)'' for ''or (o)''.
Subsec. (b). Pub. L. 97-248, 128(d)(3), substituted ''a hospital''
for ''an institution'' and ''the hospital'' for ''such institution''.
1972 -- Pub. L. 92-603 designated existing provisions as subsec.
(a), inserted reference to subsec. (b) of this section in opening
provisions, redesignated existing provisions as pars. (1) and (3) and
added pars. (2) and (4) and in provisions following par. (4) inserted
provisions for the imposition of a standard which the Secretary
determines is at least equivalent to the standard promulgated by the
Secretary as described in par. (4), and added subsec. (b).
Amendment by Pub. L. 101-508 applicable to screening mammography
performed on or after Jan. 1, 1991, see section 4163(e) of Pub. L.
101-508, set out as a note under section 1395l of this title.
Section 6019(d) of Pub. L. 101-239 provided that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (amending this section) shall take effect on the date of
the enactment of this Act (Dec. 19, 1989).
''(2) The amendments made by subsection (a) (amending this section)
shall take effect 6 months after the date of the enactment of this
Act.''
Amendment by section 6115(c) of Pub. L. 101-239 applicable to
screening pap smears performed on or after July 1, 1990, see section
6115(d) of Pub. L. 101-239, set out as a note under section 1395x of
this title.
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.
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 204(c)(3), (d)(3) of Pub. L. 100-360 applicable
to screening mammography performed on or after Jan. 1, 1990, see
section 204(e) of Pub. L. 100-360, set out as a note under section
1395m of this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(d)(4)(B)(ii) 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.
Amendment by section 4025(b) of Pub. L. 100-203 applicable with
respect to agreements entered into or renewed on or after Dec. 22,
1987, see section 4025(c) of Pub. L. 100-203, as amended, set out as a
note under section 1395aa of this title.
For contingent effective date of amendment by section 4072(d) of Pub.
L. 100-203, see section 4072(e) of Pub. L. 100-203, set out as a note
under section 1395x of this title.
Amendment by section 9305(c)(3) of Pub. L. 99-509 applicable to
hospitals as of one year after Oct. 21, 1986, see section 9305(c)(4) of
Pub. L. 99-509, set out as a note under section 1395x of this title.
Amendment by section 9320(h)(3) of Pub. L. 99-509 applicable to
services furnished on or after Jan. 1, 1989, with exceptions for
hospitals located in rural areas which meet certain requirements related
to certified registered nurse anesthetists, see section 9320(i), (k) of
Pub. L. 99-509, as amended, set out as notes under section 1395k of
this title.
Section 2345(b) of Pub. L. 98-369 provided that: ''The amendments
made by this section (amending this section) shall become effective on
the date of the enactment of this Act (July 18, 1984), and shall apply
with respect to surveys released to the Secretary on, before, or after
such date.''
Section 2346(b) of Pub. L. 98-369 provided that: ''The amendments
made by this section (amending this section) shall become effective on
the date of the enactment of this Act (July 18, 1984).''
Amendment by section 122(g)(4) 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.
Amendment by section 128(d)(3) of Pub. L. 97-248 effective Sept. 3,
1982, see section 128(e)(3) of Pub. L. 97-248, set out as a note under
section 1395x of this title.
Amendment by section 234(h) of Pub. L. 92-603 applicable with
respect to providers of services for fiscal years beginning after the
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.
/1/ So in original. Probably should be followed by ''and''.
42 USC 1395cc. Agreements with providers of services
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Filing of agreements; eligibility for payment; charges with
respect to items and services
(1) Any provider of services (except a fund designated for purposes
of section 1395f(g) and section 1395n(e) of this title) shall be
qualified to participate under this subchapter and shall be eligible for
payments under this subchapter if it files with the Secretary an
agreement --
(A) not to charge, except as provided in paragraph (2), any
individual or any other person for items or services for which such
individual is entitled to have payment made under this subchapter (or
for which he would be so entitled if such provider of services had
complied with the procedural and other requirements under or pursuant to
this subchapter or for which such provider is paid pursuant to the
provisions of section 1395f(e) of this title),
(B) not to charge any individual or any other person for items or
services for which such individual is not entitled to have payment made
under this subchapter because payment for expenses incurred for such
items or services may not be made by reason of the provisions of
paragraph (1) or (9) of section 1395y(a) of this title, but only if (i)
such individual was without fault in incurring such expenses and (ii)
the Secretary's determination that such payment may not be made for such
items and services was made after the third year following the year in
which notice of such payment was sent to such individual; except that
the Secretary may reduce such three-year period to not less than one
year if he finds such reduction is consistent with the objectives of
this subchapter,
(C) to make adequate provision for return (or other disposition, in
accordance with regulations) of any moneys incorrectly collected from
such individual or other person,
(D) to promptly notify the Secretary of its employment of an
individual who, at any time during the year preceding such employment,
was employed in a managerial, accounting, auditing, or similar capacity
(as determined by the Secretary by regulation) by an agency or
organization which serves as a fiscal intermediary or carrier (for
purposes of part A or part B, or both, of this subchapter) with respect
to the provider,
(E) to release data with respect to patients of such provider upon
request to an organization having a contract with the Secretary under
part B of subchapter XI of this chapter as may be necessary (i) to allow
such organization to carry out its functions under such contract, or
(ii) to allow such organization to carry out similar review functions
under any contract the organization may have with a private or public
agency paying for health care in the same area with respect to patients
who authorize release of such data for such purposes,
(F)(i) in the case of hospitals which provide inpatient hospital
services for which payment may be made under subsection (b), (c), or (d)
of section 1395ww of this title, to maintain an agreement with a
professional standards review organization (if there is such an
organization in existence in the area in which the hospital is located)
or with a utilization and quality control peer review organization which
has a contract with the Secretary under part B of subchapter XI of this
chapter for the area in which the hospital is located, under which the
organization will perform functions under that part with respect to the
review of the validity of diagnostic information provided by such
hospital, the completeness, adequacy, and quality of care provided, the
appropriateness of admissions and discharges, and the appropriateness of
care provided for which additional payments are sought under section
1395ww(d)(5) of this title, with respect to inpatient hospital services
for which payment may be made under part A of this subchapter (and for
purposes of payment under this subchapter, the cost of such agreement to
the hospital shall be considered a cost incurred by such hospital in
providing inpatient services under part A of this subchapter, and (I)
shall be paid directly by the Secretary to such organization on behalf
of such hospital in accordance with a rate per review established by the
Secretary, (II) shall be transferred from the Federal Hospital Insurance
Trust Fund, without regard to amounts appropriated in advance in
appropriation Acts, in the same manner as transfers are made for payment
for services provided directly to beneficiaries, and (III) shall not be
less in the aggregate for a fiscal year than the aggregate amount
expended in fiscal year 1988 for direct and administrative costs
(adjusted for inflation and for any direct or administrative costs
incurred as a result of review functions added with respect to a
subsequent fiscal year) of such reviews),
(ii) in the case of hospitals, rural primary care hospitals, skilled
nursing facilities, and home health agencies, to maintain an agreement
with a utilization and quality control peer review organization (which
has a contract with the Secretary under part B of subchapter XI of this
chapter for the area in which the hospital, facility, or agency is
located) to perform the functions described in paragraph (3)(A),
(G) in the case of hospitals which provide inpatient hospital
services for which payment may be made under subsection (b) or (d) of
section 1395ww of this title, not to charge any individual or any other
person for inpatient hospital services for which such individual would
be entitled to have payment made under part A of this subchapter but for
a denial or reduction of payments under section 1395ww(f)(2) of this
title,
(H) in the case of hospitals which provide services for which payment
may be made under this subchapter and in the case of rural primary care
hospitals which provide rural primary care hospital services, to have
all items and services (other than physicians' services as defined in
regulations for purposes of section 1395y(a)(14) of this title, and
other than services described by section 1395x(s)(2)(K)(i) of this
title, certified nurse-midwife services, qualified psychologist
services, and services of a certified registered nurse anesthetist) (i)
that are furnished to an individual who is a patient of the hospital,
and (ii) for which the individual is entitled to have payment made under
this subchapter, furnished by the hospital or otherwise under
arrangements (as defined in section 1395x(w)(1) of this title) made by
the hospital,
(I) in the case of a hospital or rural primary care hospital --
(i) to adopt and enforce a policy to ensure compliance with the
requirements of section 1395dd of this title and to meet the
requirements of such section,
(ii) to maintain medical and other records related to individuals
transferred to or from the hospital for a period of five years from the
date of the transfer, and
(iii) to maintain a list of physicians who are on call for duty after
the initial examination to provide treatment necessary to stabilize an
individual with an emergency medical condition; /1/
(J) in the case of hospitals which provide inpatient hospital
services for which payment may be made under this subchapter, to be a
participating provider of medical care under any health plan contracted
for under section 1079 or 1086 of title 10, or under section 1713 of
title 38, in accordance with admission practices, payment methodology,
and amounts as prescribed under joint regulations issued by the
Secretary and by the Secretaries of Defense and Transportation, in
implementation of sections 1079 and 1086 of title 10,
(K) not to charge any individual or any other person for items or
services for which payment under this subchapter is denied under section
1320c-3(a)(2) of this title by reason of a determination under section
1320c-3(a)(1)(B) of this title,
(L) in the case of hospitals which provide inpatient hospital
services for which payment may be made under this subchapter, to be a
participating provider of medical care under section 1703 of title 38,
in accordance with such admission practices, and such payment
methodology and amounts, as are prescribed under joint regulations
issued by the Secretary and by the Secretary of Veterans Affairs in
implementation of such section,
(M) in the case of hospitals, to provide to each individual who is
entitled to benefits under part A of this subchapter (or to a person
acting on the individual's behalf), at or about the time of the
individual's admission as an inpatient to the hospital, a written
statement (containing such language as the Secretary prescribes
consistent with this paragraph) which explains --
(i) the individual's rights to benefits for inpatient hospital
services and for post-hospital services under this subchapter,
(ii) the circumstances under which such an individual will and will
not be liable for charges for continued stay in the hospital,
(iii) the individual's right to appeal denials of benefits for
continued inpatient hospital services, including the practical steps to
initiate such an appeal, and
(iv) the individual's liability for payment for services if such a
denial of benefits is upheld on appeal,
and which provides such additional information as the Secretary may
specify,
(N) in the case of hospitals and rural primary care hospitals --
(i) to make available to its patients the directory or directories of
participating physicians (published under section 1395u(h)(4) of this
title) for the area served by the hospital or rural primary care
hospital,
(ii) if hospital personnel (including staff of any emergency or
outpatient department) refer a patient to a nonparticipating physician
for further medical care on an outpatient basis, the personnel must
inform the patient that the physician is a nonparticipating physician
and, whenever practicable, must identify at least one qualified
participating physician who is listed in such a directory and from whom
the patient may receive the necessary services,
(iii) to post conspicuously in any emergency department a sign (in a
form specified by the Secretary) specifying rights of individuals under
section 1395dd of this title with respect to examination and treatment
for emergency medical conditions and women in labor, and
(iv) to post conspicuously (in a form specified by the Secretary)
information indicating whether or not the hospital participates in the
medicaid program under a State plan approved under subchapter XIX of
this chapter, and /2/
(O) in the case of hospitals and skilled nursing facilities, to
accept as payment in full for inpatient hospital and extended care
services that are covered under this subchapter and are furnished to any
individual enrolled with an eligible organization (i) with a
risk-sharing contract under section 1395mm of this title, under section
1395mm(i)(2)(A) of this title (as in effect before February 1, 1985),
under section 1395b-1(a) of this title, or under section 222(a) of the
Social Security Amendments of 1972, and (ii) which does not have a
contract establishing payment amounts for services furnished to members
of the organization the amounts (in the case of hospitals) or limits (in
the case of skilled nursing facilities) that would be made as a payment
in full under this subchapter if the individuals were not so enrolled;
/3/
(P) in the case of home health agencies which provide home health
services to individuals entitled to benefits under this subchapter who
require catheters, catheter supplies, ostomy bags, and supplies related
to ostomy care (described in section 1395x(m)(5) of this title), to
offer to furnish such supplies to such an individual as part of their
furnishing of home health services, and
(Q) in the case of hospitals, skilled nursing facilities, home health
agencies, and hospice programs, to comply with the requirement of
subsection (f) of this section (relating to maintaining written policies
and procedures respecting advance directives).
In the case of a hospital which has an agreement in effect with an
organization described in subparagraph (F), which organization's
contract with the Secretary under part B of subchapter XI of this
chapter is terminated on or after October 1, 1984, the hospital shall
not be determined to be out of compliance with the requirement of such
subparagraph during the six month period beginning on the date of the
termination of that contract.
(2)(A) A provider of services may charge such individual or other
person (i) the amount of any deduction or coinsurance amount imposed
pursuant to section 1395e(a)(1), (a)(3), or (a)(4), section 1395l(b), or
section 1395x(y)(3) of this title with respect to such items and
services (not in excess of the amount customarily charged for such items
and services by such provider), and (ii) an amount equal to 20 per
centum of the reasonable charges for such items and services (not in
excess of 20 per centum of the amount customarily charged for such items
and services by such provider) for which payment is made under part B of
this subchapter or which are durable medical equipment furnished as home
health services (but in the case of items and services furnished to
individuals with end-stage renal disease, an amount equal to 20 percent
of the estimated amounts for such items and services calculated on the
basis established by the Secretary). In the case of items and services
described in section 1395l(c) of this title, clause (ii) of the
preceding sentence shall be applied by substituting for 20 percent the
proportion which is appropriate under such section. A provider of
services may not impose a charge under clause (ii) of the first sentence
of this subparagraph with respect to items and services described in
section 1395x(s)(10)(A) of this title, with respect to items and
services furnished in connection with obtaining a second opinion
required under section 1320c-13(c)(2) of this title (or a third opinion,
if the second opinion was in disagreement with the first opinion), and
with respect to clinical diagnostic laboratory tests for which payment
is made under part B of this subchapter. Notwithstanding the first
sentence of this subparagraph, a home health agency may charge such an
individual or person, with respect to covered items subject to payment
under section 1395m(a) of this title, the amount of any deduction
imposed under section 1395l(b) of this title and 20 percent of the
payment basis described in section 1395m(a)(1)(B) of this title.
(B) Where a provider of services has furnished, at the request of
such individual, items or services which are in excess of or more
expensive than the items or services with respect to which payment may
be made under this subchapter, such provider of services may also charge
such individual or other person for such more expensive items or
services to the extent that the amount customarily charged by it for the
items or services furnished at such request exceeds the amount
customarily charged by it for the items or services with respect to
which payment may be made under this subchapter.
(C) A provider of services may in accordance with its customary
practice also appropriately charge any such individual for any whole
blood (or equivalent quantities of packed red blood cells, as defined
under regulations) furnished him with respect to which a deductible is
imposed under section 1395e(a)(2) of this title, except that (i) any
excess of such charge over the cost to such provider for the blood (or
equivalent quantities of packed red blood cells, as so defined) shall be
deducted from any payment to such provider under this subchapter, (ii)
no such charge may be imposed for the cost of administration of such
blood (or equivalent quantities of packed red blood cells, as so
defined), and (iii) such charge may not be made to the extent such blood
(or equivalent quantities of packed red blood cells, as so defined) has
been replaced on behalf of such individual or arrangements have been
made for its replacement on his behalf. For purposes of this
subparagraph, whole blood (or equivalent quantities of packed red blood
cells, as so defined) furnished an individual shall be deemed replaced
when the provider of services 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
imposed under section 1395e(a)(2) of this title.
(D) Where a provider of services customarily furnishes items or
services which are in excess of or more expensive than the items or
services with respect to which payment may be made under this
subchapter, such provider, notwithstanding the preceding provisions of
this paragraph, may not, under the authority of subparagraph (B)(ii) of
this paragraph, charge any individual or other person any amount for
such items or services in excess of the amount of the payment which may
otherwise be made for such items or services under this subchapter if
the admitting physician has a direct or indirect financial interest in
such provider.
(3)(A) Under the agreement required under paragraph (1)(F)(ii), the
peer review organization must perform functions (other than those
covered under an agreement under paragraph (1)(F)(i)) under the third
sentence of section 1320c-3(a)(4)(A) of this title and under section
1320c-3(a)(14) of this title with respect to services, furnished by the
hospital, rural primary care hospital, facility, or agency involved, for
which payment may be made under this subchapter.
(B) For purposes of payment under this subchapter, the cost of such
an agreement to the hospital, rural primary care hospital, facility, or
agency shall be considered a cost incurred by such hospital, rural
primary care hospital, facility, or agency in providing covered services
under this subchapter and shall be paid directly by the Secretary to the
peer review organization on behalf of such hospital, rural primary care
hospital, facility, or agency in accordance with a schedule established
by the Secretary.
(C) Such payments --
(i) shall be transferred in appropriate proportions from the Federal
Hospital Insurance Trust Fund and from the Federal Supplementary Medical
Insurance Trust Fund, without regard to amounts appropriated in advance
in appropriation Acts, in the same manner as transfers are made for
payment for services provided directly to beneficiaries, and
(ii) shall not be less in the aggregate for a fiscal year --
(I) in the case of hospitals, than the amount specified in paragraph
(1)(F)(i)(III), and
(II) in the case of facilities, rural primary care hospitals, and
agencies, than the amounts the Secretary determines to be sufficient to
cover the costs of such organizations' conducting the activities
described in subparagraph (A) with respect to such facilities, rural
primary care hospitals, or agencies under part B of subchapter XI of
this chapter.
(b) Termination or nonrenewal of agreements
(1) A provider of services may terminate an agreement with the
Secretary under this section at such time and upon such notice to the
Secretary and the public as may be provided in regulations, except that
notice of more than six months shall not be required.
(2) The Secretary may refuse to enter into an agreement under this
section or, upon such reasonable notice to the provider and the public
as may be specified in regulations, may refuse to renew or may terminate
such an agreement after the Secretary --
(A) has determined that the provider fails to comply substantially
with the provisions of the agreement, with the provisions of this
subchapter and regulations thereunder, or with a corrective action
required under section 1395ww(f)(2)(B) of this title,
(B) has determined that the provider fails substantially to meet the
applicable provisions of section 1395x of this title, or
(C) has excluded the provider from participation in a program under
this subchapter pursuant to section 1320a-7 of this title or section
1320a-7a of this title.
(3) A termination of an agreement or a refusal to renew an agreement
under this subsection shall become effective on the same date and in the
same manner as an exclusion from participation under the programs under
this subchapter becomes effective under section 1320a-7(c) of this
title.
(c) Refiling after termination or nonrenewal; agreements with
skilled nursing facilities
(1) Where the Secretary has terminated or has refused to renew an
agreement under this subchapter with a provider of services, such
provider may not file another agreement under this subchapter unless the
Secretary finds that the reason for the termination or nonrenewal has
been removed and that there is reasonable assurance that it will not
recur.
(2) Where the Secretary has terminated or has refused to renew an
agreement under this subchapter with a provider of services, the
Secretary shall promptly notify each State agency which administers or
supervises the administration of a State plan approved under subchapter
XIX of this chapter of such termination or nonrenewal.
(d) Decision to withhold payment for failure to review long-stay
cases
If the Secretary finds that there is a substantial failure to make
timely review in accordance with section 1395x(k) of this title of
long-stay cases in a hospital or skilled nursing facility, he may, in
lieu of terminating his agreement with such hospital or facility, decide
that, with respect to any individual admitted to such hospital or
facility after a subsequent date specified by him, no payment shall be
made under this subchapter for inpatient hospital services (including
inpatient psychiatric hospital services) after the 20th day of a
continuous period of such services or for post-hospital extended care
services after such day of a continuous period of such care as is
prescribed in or pursuant to regulations, as the case may be. Such
decision may be made effective only after such notice to the hospital,
or (in the case of a skilled nursing facility) to the facility and the
hospital or hospitals with which it has a transfer agreement, and to the
public, as may be prescribed by regulations, and its effectiveness shall
terminate when the Secretary finds that the reason therefor has been
removed and that there is reasonable assurance that it will not recur.
The Secretary shall not make any such decision except after reasonable
notice and opportunity for hearing to the institution or agency affected
thereby.
(e) ''Provider of services'' defined
For purposes of this section, the term ''provider of services'' shall
include --
(1) a clinic, rehabilitation agency, or public health agency if, in
the case of a clinic or rehabilitation agency, such clinic or agency
meets the requirements of section 1395x(p)(4)(A) of this title (or meets
the requirements of such section through the operation of section
1395x(g) of this title), or if, in the case of a public health agency,
such agency meets the requirements of section 1395x(p)(4)(B) of this
title (or meets the requirements of such section through the operation
of section 1395x(g) of this title), but only with respect to the
furnishing of outpatient physical therapy services (as therein defined)
or (through the operation of section 1395x(g) of this title) with
respect to the furnishing of outpatient occupational therapy services;
and
(2) a community mental health center (as defined in section
1395x(ff)(3)(B) of this title), but only with respect to the furnishing
of partial hospitalization services (as described in section
1395x(ff)(1) of this title).
(f) Maintenance of written policies and procedures
(1) For purposes of subsection (a)(1)(Q) of this section and sections
1395i-3(c)(2)(E), 1395l(r), 1395mm(c)(8), and 1395bbb(a)(6) of this
title, the requirement of this subsection is that a provider of services
or prepaid or eligible organization (as the case may be) maintain
written policies and procedures with respect to all adult individuals
receiving medical care by or through the provider or organization --
(A) to provide written information to each such individual concerning
--
(i) an individual's rights under State law (whether statutory or as
recognized by the courts of the State) to make decisions concerning such
medical care, including the right to accept or refuse medical or
surgical treatment and the right to formulate advance directives (as
defined in paragraph (3)), and
(ii) the written policies of the provider or organization respecting
the implementation of such rights;
(B) to document in the individual's medical record whether or not the
individual has executed an advance directive;
(C) not to condition the provision of care or otherwise discriminate
against an individual based on whether or not the individual has
executed an advance directive;
(D) to ensure compliance with requirements of State law (whether
statutory or as recognized by the courts of the State) respecting
advance directives at facilities of the provider or organization; and
(E) to provide (individually or with others) for education for staff
and the community on issues concerning advance directives.
Subparagraph (C) shall not be construed as requiring the provision of
care which conflicts with an advance directive.
(2) The written information described in paragraph (1)(A) shall be
provided to an adult individual --
(A) in the case of a hospital, at the time of the individual's
admission as an inpatient,
(B) in the case of a skilled nursing facility, at the time of the
individual's admission as a resident,
(C) in the case of a home health agency, in advance of the individual
coming under the care of the agency,
(D) in the case of a hospice program, at the time of initial receipt
of hospice care by the individual from the program, and
(E) in the case of an eligible organization (as defined in section
1395mm(b) of this title) or an organization provided payments under
section 1395l(a)(1)(A) of this title, at the time of enrollment of the
individual with the organization.
(3) In this subsection, the term ''advance directive'' means a
written instruction, such as a living will or durable power of attorney
for health care, recognized under State law (whether statutory or as
recognized by the courts of the State) and relating to the provision of
such care when the individual is incapacitated.
(g) Penalties for improper billing
Except as permitted under subsection (a)(2) of this section, any
person who knowingly and willfully presents, or causes to be presented,
a bill or request for payment inconsistent with an arrangement under
subsection (a)(1)(H) of this section or in violation of the requirement
for such an arrangement, 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.
(h) Dissatisfaction with determination of Secretary; appeal by
institutions or agencies; single notice and hearing
(1) Except as provided in paragraph (2), an institution or agency
dissatisfied with a determination by the Secretary that it is not a
provider of services or with a determination described in subsection
(b)(2) of this section shall be entitled to a hearing thereon by the
Secretary (after reasonable notice) to the same extent as is provided in
section 405(b) of this title, and to judicial review of the Secretary's
final decision after such hearing as is provided in section 405(g) of
this title.
(2) An institution or agency is not entitled to separate notice and
opportunity for a hearing under both section 1320a-7 of this title and
this section with respect to a determination or determinations based on
the same underlying facts and issues.
(i) Intermediate sanctions for psychiatric hospitals
(1) If the Secretary determines that a psychiatric hospital which has
an agreement in effect under this section no longer meets the
requirements for a psychiatric hospital under this subchapter and
further finds that the hospital's deficiencies --
(A) immediately jeopardize the health and safety of its patients, the
Secretary shall terminate such agreement; or
(B) do not immediately jeopardize the health and safety of its
patients, the Secretary may terminate such agreement, or provide that no
payment will be made under this subchapter with respect to any
individual admitted to such hospital after the effective date of the
finding, or both.
(2) If a psychiatric hospital, found to have deficiencies described
in paragraph (1)(B), has not complied with the requirements of this
subchapter --
(A) within 3 months after the date the hospital is found to be out of
compliance with such requirements, the Secretary shall provide that no
payment will be made under this subchapter with respect to any
individual admitted to such hospital after the end of such 3-month
period, or
(B) within 6 months after the date the hospital is found to be out of
compliance with such requirements, no payment may be made under this
subchapter with respect to any individual in the hospital until the
Secretary finds that the hospital is in compliance with the requirements
of this subchapter.
(Aug. 14, 1935, ch. 531, title XVIII, 1866, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 327, and amended Jan. 2,
1968, Pub. L. 90-248, title I, 129(c)(12), 133(c), 135(b), 81 Stat.
849, 851, 852; Oct. 30, 1972, Pub. L. 92-603, title II, 223(e), (g),
227(d)(2), 229(b), 249A(b)-(d), 278(a)(17), (b)(18), 281(c), 86 Stat.
1394, 1406, 1409, 1427, 1453-1455; Oct. 25, 1977, Pub. L. 95-142,
3(b), 8(b), 13(b)(3), 15(a), 91 Stat. 1178, 1194, 1195, 1198, 1200;
Dec. 13, 1977, Pub. L. 95-210, 2(e), 91 Stat. 1489; June 13, 1978,
Pub. L. 95-292, 4(e), 92 Stat. 315; June 17, 1980, Pub. L. 96-272,
title III, 308(b), 94 Stat. 531; Dec. 5, 1980, Pub. L. 96-499, title
IX, 916(a), 94 Stat. 2623; Dec. 28, 1980, Pub. L. 96-611, 1(b)(4),
94 Stat. 3566; Aug. 13, 1981, Pub. L. 97-35, title XXI, 2153, 95 Stat.
802; Sept. 3, 1982, Pub. L. 97-248, title I, 122(g)(5), (6),
128(a)(5), (d)(4), 144, 96 Stat. 362, 366, 367, 393; Jan. 12, 1983,
Pub. L. 97-448, title III, 309(a)(5), (b)(11), 96 Stat. 2408, 2409;
Apr. 20, 1983, Pub. L. 98-21, title VI, 602(f), (l), 97 Stat. 163, 166;
July 18, 1984, Pub. L. 98-369, div. B, title III, 2303(f), 2315(d),
2321(c), 2323(b)(3), 2335(d), 2347(a), 2348(a), 2354(b)(33), (34), 98
Stat. 1066, 1080, 1084, 1086, 1090, 1096, 1097, 1102; Apr. 7, 1986,
Pub. L. 99-272, title IX, 9121(a), 9122(a), 9401(b)(2)(F), 9402(a),
9403(b), 100 Stat. 164, 167, 199, 200; Oct. 21, 1986, Pub. L. 99-509,
title IX, 9305(b)(1), 9320(h)(2), 9332(e)(1), 9337(c)(2), 9343(c)(2),
(3), 9353(e)(1), 100 Stat. 1989, 2016, 2025, 2034, 2040, 2047; Oct. 22,
1986, Pub. L. 99-514, title XVIII, 1895(b)(5), 100 Stat. 2933; Oct.
28, 1986, Pub. L. 99-576, title II, 233(a), 100 Stat. 3265; Aug. 18,
1987, Pub. L. 100-93, 8(d), 101 Stat. 693; Dec. 22, 1987, Pub. L.
100-203, title IV, 4012(a), 4062(d)(4), 4085(i)(17), (28), 4097(a),
(b), 4212(e)(4), 101 Stat. 1330-60, 1330-109, 1330-133, 1330-140,
1330-213, as amended July 1, 1988, Pub. L. 100-360, title IV,
411(i)(4)(C)(vi), (j)(5), 102 Stat. 790, 791; July 1, 1988, Pub. L.
100-360, title I, 104(d)(5), title II, 201(b), (d), 202(h)(1), title
IV, 411(c)(2)(A)(i), (C), (g)(1)(D), 102 Stat. 689, 702, 718, 772, 782,
as amended Oct. 13, 1988, Pub. L. 100-485, title VI, 608(d)(3)(F),
(19)(A), 102 Stat. 2414, 2419; Oct. 13, 1988, Pub. L. 100-485, title
VI, 608(f)(1), 102 Stat. 2424; Dec. 13, 1989, Pub. L. 101-234, title
I, 101(a), title II, 201(a), title III, 301(b)(4), (d)(1), 103 Stat.
1979, 1981, 1985, 1986; Dec. 19, 1989, Pub. L. 101-239, title VI,
6003(g)(3)(D)(xii), (xiii), 6017, 6018(a), 6020, 6112(e)(3), 103 Stat.
2154, 2165, 2166, 2216; Nov. 5, 1990, Pub. L. 101-508, title IV,
4008(b)(3)(B), (m)(3)(G)((F)), 4153(d)(1), 4157(c)(2), 4162(b)(2),
4206(a), 104 Stat. 1388-44, 1388-54, 1388-84, 1388-89, 1388-96,
1388-115; June 13, 1991, Pub. L. 102-54, 13(q)(3)(F), 105 Stat. 280;
Aug. 6, 1991, Pub. L. 102-83, 5(c)(2), 105 Stat. 406.)
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.
Part B of subchapter XI of this chapter, referred to in subsec.
(a)(1), (3)(C)(ii)(II), is classified to section 1320c et seq. of this
title.
Section 222(a) of the Social Security Amendments of 1972, referred to
in subsec. (a)(1)(O)(i), is section 222(a) of Pub. L. 92-603, which is
set out as a note under section 1395b-1 of this title.
1991 -- Subsec. (a)(1)(J). Pub. L. 102-83 substituted ''section 1713
of title 38'' for ''section 613 of title 38''.
Subsec. (a)(1)(L). Pub. L. 102-83 substituted ''section 1703 of title
38'' for ''section 603 of title 38''.
Pub. L. 102-54 substituted ''Secretary of Veterans Affairs'' for
''Administrator of Veterans' Affairs''.
1990 -- Subsec. (a)(1)(F)(i). Pub. L. 101-508,
4008(m)(3)(G)((F))(i), substituted ''),'' for comma at end.
Subsec. (a)(1)(F)(ii). Pub. L. 101-508, 4008(m)(3)(G)((F))(ii),
substituted ''paragraph (3)(A),'' for ''paragraph (4)(A);''.
Subsec. (a)(1)(H). Pub. L. 101-508, 4157(c)(2), inserted ''services
described by section 1395x(s)(2)(K)(i) of this title, certified
nurse-midwife services, qualified psychologist services, and'' after
''and other than''.
Subsec. (a)(1)(I)(i). Pub. L. 101-508, 4008(b)(3)(B), inserted ''and
to meet the requirements of such section'' after ''section 1395dd of
this title''.
Subsec. (a)(1)(P). Pub. L. 101-508, 4153(d)(1), substituted
''catheters, catheter supplies, ostomy bags, and supplies related to
ostomy care'' for ''ostomy supplies''.
Subsec. (a)(1)(Q). Pub. L. 101-508, 4206(a)(1), added subpar. (Q).
Subsec. (e). Pub. L. 101-508, 4162(b)(2), substituted ''include --
'' and pars. (1) and (2) for ''include a clinic, rehabilitation agency,
or public health agency if, in the case of a clinic or rehabilitation
agency, such clinic or agency meets the requirements of section
1395x(p)(4)(A) of this title (or meets the requirements of such section
through the operation of section 1395x(g) of this title), or if, in the
case of a public health agency, such agency meets the requirements of
section 1395x(p)(4)(B) of this title (or meets the requirements of such
section through the operation of section 1395x(g) of this title), but
only with respect to the furnishing of outpatient physical therapy
services (as therein defined) or (through the operation of section
1395x(g) of this title) with respect to the furnishing of outpatient
occupational therapy services.''
Subsec. (f). Pub. L. 101-508, 4206(a)(2), added subsec. (f).
1989 -- Subsec. (a)(1)(F)(i)(III). Pub. L. 101-234, 301(b)(4),
(d)(1), amended subcl. (III) identically substituting ''fiscal year)''
for ''fiscal year))'' before ''of such reviews,'' at end.
Subsec. (a)(1)(F)(ii). Pub. L. 101-239, 6003(g)(3)(D)(xii)(I),
inserted ''rural primary care hospitals,'' after ''hospitals,''.
Subsec. (a)(1)(H). Pub. L. 101-239, 6003(g)(3)(D)(xii)(II), inserted
''and in the case of rural primary care hospitals which provide rural
primary care hospital services'' after ''payment may be made under this
subchapter''.
Subsec. (a)(1)(I). Pub. L. 101-239, 6018(a)(1), amended subpar. (I)
generally. Prior to amendment, subpar. (I) read as follows: ''in the
case of a hospital and in the case of a rural primary care hospital, to
comply with the requirements of section 1395dd of this title to the
extent applicable,''.
Pub. L. 101-239, 6003(g)(3)(D)(xii)(III), inserted ''and in the case
of a rural primary care hospital'' after ''hospital''.
Subsec. (a)(1)(N). Pub. L. 101-239, 6003(g)(3)(D)(xii)(IV),
substituted ''hospitals and rural primary care hospitals'' for
''hospitals'' in introductory provisions and ''hospital or rural primary
care hospital,'' for ''hospital,'' in cl. (i).
Subsec. (a)(1)(N)(iii), (iv). Pub. L. 101-239, 6018(a)(2), added
cls. (iii) and (iv).
Subsec. (a)(1)(P). Pub. L. 101-239, 6112(e)(3), added subpar. (P).
Subsec. (a)(2)(A). Pub. L. 101-234, 201(a), repealed Pub. L.
100-360, 201(b), (d), 202(h)(1), and provided that the provisions of
law amended or repealed by such sections are restored or revived as if
such sections had not been enacted, see 1988 Amendment notes below.
Subsec. (a)(2)(B). Pub. L. 101-239, 6017, redesignated cl. (i) as
subpar. (B) and struck out cl. (ii) which authorized charges for items
or services more expensive than determined to be necessary and which
have not been requested by the individual to the extent that such costs
in the second fiscal period preceding the fiscal period in which such
charges are imposed exceed necessary costs, under certain circumstances.
Subsec. (a)(3)(A), (B). Pub. L. 101-239, 6003(g)(3)(D)(xiii)(I),
substituted ''hospital, rural primary care hospital,'' for ''hospital,''
wherever appearing.
Subsec. (a)(3)(C)(ii)(II). Pub. L. 101-239, 6003(g)(3)(D)(xiii)(II),
substituted ''facilities, rural primary care hospitals,'' for
''facilities'' in two places.
Subsec. (d). Pub. L. 101-234, 101(a), repealed Pub. L. 100-360,
104(d)(5), and provided that the provisions of law amended or repealed
by such section are restored or revived as if such section had not been
enacted, see 1988 Amendment note below.
Subsec. (i). Pub. L. 101-239, 6020, added subsec. (i).
1988 -- Subsec. (a)(1)(M). Pub. L. 100-360, 411(c)(2)(C)(i), as
added by Pub. L. 100-485, 608(d)(19)(A), struck out ''and'' at end.
Subsec. (a)(1)(N). Pub. L. 100-360, 411(c)(2)(C)(ii), as added by
Pub. L. 100-485, 608(d)(19)(A), substituted '', and'' for period at
end.
Subsec. (a)(1)(O). Pub. L. 100-360, 411(c)(2)(A)(i), substituted
cls. (i) and (ii) for ''with a risk-sharing contract under section
1395mm of this title''.
Subsec. (a)(2)(A). Pub. L. 100-360, 201(d), substituted ''section
1395l(d)(1) of this title'' for ''section 1395l(c) of this title'' in
second sentence.
Pub. L. 100-360, 411(g)(1)(D), substituted ''section 1395m(a)(1)(B)
of this title'' for ''section 1395m(a)(2) of this title'' in last
sentence.
Pub. L. 100-360, 202(h)(1), inserted ''1395m(c),'' after
''1395l(b),'' and ''and in the case of covered outpatient drugs,
applicable coinsurance percent (specified in section 1395m(c)(2)(C) of
this title) of the lesser of the actual charges for the drugs or the
payment limit (established under section 1395m(c)(3) of this title)''
after ''established by the Secretary''.
Pub. L. 100-360, 201(b), inserted at end ''A provider of services
may not impose a charge under the first sentence of this subparagraph
for services for which payment is made to the provider pursuant to
section 1395l(c) of this title (relating to catastrophic benefits).''
Subsec. (a)(3)(C)(ii). Pub. L. 100-360, 411(j)(5), made technical
correction to directory language of Pub. L. 100-203, 4097(b), see 1987
Amendment note below.
Subsec. (d). Pub. L. 100-360, 104(d)(5), as amended by Pub. L.
100-485, 608(d)(3)(F), struck out ''post-hospital'' before ''extended
care services''.
Subsec. (f). Pub. L. 100-485, 608(f)(1), struck out subsec. (f)
which provided for termination or decertification and alternatives
thereto.
Subsec. (g). Pub. L. 100-360, 411(i)(4)(C)(vi), added Pub. L.
100-203, 4085(i)(28), see 1987 Amendment note below.
1987 -- Subsec. (a)(1)(F)(i)(III). Pub. L. 100-203, 4097(a),
substituted ''1988'' for ''1986'' and inserted ''and for any direct or
administrative costs incurred as a result of review functions added with
respect to a subsequent fiscal year'' after ''inflation''.
Subsec. (a)(1)(O). Pub. L. 100-203, 4012(a), added subpar. (O).
Subsec. (a)(2)(A). Pub. L. 100-203, 4062(d)(4), inserted at end
''Notwithstanding the first sentence of this subparagraph, a home health
agency may charge such an individual or person, with respect to covered
items subject to payment under section 1395m(a) of this title, the
amount of any deduction imposed under section 1395l(b) of this title and
20 percent of the payment basis described in section 1395m(a)(2) of this
title.''
Subsec. (a)(3). Pub. L. 100-93, 8(d)(1), redesignated par. (4) as
(3) and struck out former par. (3) which read as follows: ''The
Secretary may refuse to enter into or renew an agreement under this
section with a provider of services if any person who has a direct or
indirect ownership or control interest of 5 percent or more in such
provider, or who is an officer, director, agent, or managing employee
(as defined in section 1320a-5(b) of this title) of such provider, is a
person described in section 1320a-5(a) of this title.''
Subsec. (a)(3)(C)(ii). Pub. L. 100-203, 4097(b), as amended by Pub.
L. 100-360, 411(j)(5), amended cl. (ii) generally. Prior to
amendment, cl. (ii) read as follows: ''shall not be less in the
aggregate for hospitals, facilities, and agencies for a fiscal year than
the amounts the Secretary determines to be sufficient to cover the costs
of such organizations' conducting the activities described in
subparagraph (A) with respect to such hospitals, facilities, or agencies
under part B of subchapter XI of this chapter.''
Subsec. (a)(4). Pub. L. 100-93, 8(d)(1)(B), redesignated par. (4)
as (3).
Subsec. (b). Pub. L. 100-93, 8(d)(2), amended subsec. (b)
generally, substituting pars. (1) to (3) for former pars. (1) to (5).
Subsec. (c)(1). Pub. L. 100-93, 8(d)(3), (4), substituted ''the
Secretary has terminated or has refused to renew an agreement under this
subchapter with a provider of services'' for ''an agreement filed under
this subchapter by a provider of services has been terminated by the
Secretary'' and inserted ''or nonrenewal'' after ''termination''.
Subsec. (c)(2). Pub. L. 100-203, 4212(e)(4), redesignated par. (3)
as (2) and struck out former par. (2) which read as follows: ''In the
case of a skilled nursing facility participating in the programs
established by this subchapter and subchapter XIX of this chapter, the
Secretary may enter into an agreement under this section only if such
facility has been approved pursuant to section 1396i(a) of this title,
and the term of any such agreement shall be in accordance with the
period of approval of eligibility specified by the Secretary pursuant to
such section.''
Subsec. (c)(3). Pub. L. 100-203, 4212(e)(4), redesignated par. (3)
as (2).
Pub. L. 100-93, 8(d)(3), (4), substituted ''the Secretary has
terminated or has refused to renew an agreement under this subchapter
with a provider of services'' for ''an agreement filed under this
subchapter by a provider of services has been terminated by the
Secretary'' and inserted ''or nonrenewal'' after ''termination''.
Subsec. (g). Pub. L. 100-203, 4085(i)(28), as added by Pub. L.
100-360, 411(i)(4)(C)(vi), substituted ''money penalty'' for ''monetary
penalty'' in first sentence and amended second sentence generally.
Prior to amendment, second sentence read as follows: ''Such a penalty
shall be imposed in the same manner as civil monetary penalties are
imposed under section 1320a-7a of this title with respect to actions
described in subsection (a) of that section.''
Pub. L. 100-203, 4085(i)(17), substituted ''inconsistent with an
arrangement under subsection (a)(1)(H) of this section or in violation
of the requirement for such an arrangement'' for ''for a hospital
outpatient service for which payment may be made under part B of this
subchapter and such bill or request violates an arrangement under
subsection (a)(1)(H) of this section''.
Subsec. (h). Pub. L. 100-93, 8(d)(5), added subsec. (h).
1986 -- Subsec. (a)(1)(F). Pub. L. 99-509, 9353(e)(1)(A),
designated existing provisions as cl. (i) and in cl. (i), as so
designated, redesignated former cls. (i) to (iii) as subcls. (I) to
(III), and added cl. (ii).
Pub. L. 99-272, 9402(a), redesignated cl. (iv) as (iii) and in cl.
(iii), as so redesignated, substituted ''1986'' for ''1982'', and struck
out former cl. (iii) which provided that the cost of such agreement to
the hospital shall not be less than amount which reflects the rates per
review established in fiscal year 1982 for both direct and
administrative costs (adjusted for inflation).
Subsec. (a)(1)(H). Pub. L. 99-509, 9343(c)(2), struck out
''inpatient hospital'' after ''hospitals which provide'' and substituted
''a patient'' for ''an inpatient''.
Pub. L. 99-509, 9320(h)(2), inserted '', and other than services of
a certified registered nurse anesthetist'' after ''section 1395y(a)(14)
of this title''.
Subsec. (a)(1)(I). Pub. L. 99-514 redesignated subpar. (I) relating
to agreement not to charge for certain items and services as subpar.
(K).
Pub. L. 99-272, 9403(b), added subpar. (I) relating to agreement
not to charge for certain items or services.
Pub. L. 99-272, 9121(a), added subpar. (I) relating to compliance
with the requirements of section 1395dd of this title.
Subsec. (a)(1)(J). Pub. L. 99-272, 9122(a), added subpar. (J).
Subsec. (a)(1)(K). Pub. L. 99-514 redesignated subpar. (I) relating
to agreement not to charge for certain items and services as subpar.
(K).
Subsec. (a)(1)(L). Pub. L. 99-576 added subpar. (L).
Subsec. (a)(1)(M). Pub. L. 99-509, 9305(b)(1), added subpar. (M).
Subsec. (a)(1)(N). Pub. L. 99-509, 9332(e)(1), added subpar. (N).
Subsec. (a)(2)(A). Pub. L. 99-272, 9401(b)(2)(F), inserted '', with
respect to items and services furnished in connection with obtaining a
second opinion required under section 1320c-13(c)(2) of this title (or a
third opinion, if the second opinion was in disagreement with the first
opinion),'' after ''1395x(s)(10)(A) of this title'' in last sentence.
Subsec. (a)(4). Pub. L. 99-509, 9353(e)(1)(B), added par. (4).
Subsec. (e). Pub. L. 99-509, 9337(c)(2), inserted in second sentence
''(or meets the requirements of such section through the operation of
section 1395x(g) of this title)'' in two places, and inserted ''or
(through the operation of section 1395x(g) of this title) with respect
to the furnishing of outpatient occupational therapy services'' after
''(as therein defined)''.
Subsec. (g). Pub. L. 99-509, 9343(c)(3), added subsec. (g).
1984 -- Subsec. (a)(1)(E). Pub. L. 98-369, 2354(b)(33), inserted a
comma at end.
Subsec. (a)(1)(F). Pub. L. 98-369, 2315(d), substituted ''(b), (c),
or (d)'' for ''(c) or (d)''.
Pub. L. 98-369, 2347(a)(1), substituted ''maintain an agreement with
a professional standards review organization (if there is such an
organization in existence in the area in which the hospital is located)
or with a utilization and quality control peer review organization which
has a contract with the Secretary under part B of subchapter XI of this
chapter for the area in which the hospital is located, under which the
organization'' for ''maintain an agreement with a utilization and
quality control peer review organization (if there is such an
organization which has a contract with the Secretary under part B of
subchapter XI of this chapter for the area in which the hospital is
located) under which the organization''.
Pub. L. 98-369, 2347(a)(2), repealed amendment made by Pub. L.
98-21, 602(l)(1). See 1983 Amendment note below.
Subsec. (a)(2)(A). Pub. L. 98-369, 2303(f), inserted ''and with
respect to clinical diagnostic laboratory tests'' after ''section
1395x(s)(10) of this title''.
Pub. L. 98-369, 2321(c), inserted ''or which are durable medical
equipment furnished as home health services'' after ''part B of this
subchapter''.
Pub. L. 98-369, 2323(b)(3), substituted ''section 1395x(s)(10)(A) of
this title'' for ''section 1395x(s)(10) of this title''.
Subsec. (b)(3). Pub. L. 98-369, 2335(d)(1), substituted ''(including
inpatient psychiatric hospital services)'' for ''(including tuberculosis
hospital services and inpatient psychiatric hospital services)''.
Pub. L. 98-369, 2354(b)(34), realigned margin of par. (3).
Subsec. (b)(4). Pub. L. 98-369, 2348(a), substituted ''more than 30
days after such effective date'' for ''after the calendar year in which
such termination is effective''.
Subsec. (d). Pub. L. 98-369, 2335(d)(2), substituted ''(including
inpatient psychiatric hospital services)'' for ''(including inpatient
tuberculosis hospital services and inpatient psychiatric hospital
services)''.
1983 -- Subsec. (a)(1). Pub. L. 98-21, 602(l)(2), inserted
provision at end of par. (1) that in the case of a hospital which has
an agreement in effect with an organization described in subparagraph
(F), which organization's contract with the Secretary under part B of
subchapter XI terminates on or after October 1, 1984, the hospital shall
not be determined to be out of compliance with the requirement of such
subparagraph during the six month period beginning on the date of the
termination of that contract.
Subsec. (a)(1)(F). Pub. L. 98-21, 602(l)(1), which provided that,
effective Oct. 1, 1984, subpar. (F) is amended by substituting ''(with
an organization'' for ''(if there is such an organization'', was
repealed by Pub. L. 98-369, 2347(a)(2), effective July 18, 1984.
Subsec. (a)(1)(F) to (H). Pub. L. 98-21, 602(f)(1), added subpars.
(F) to (H).
Subsec. (a)(2)(A). Pub. L. 97-448, 309(b)(11), inserted a comma
after ''1395e(a)(1)''.
Pub. L. 97-448, 309(a)(5), amended directory language of Pub. L.
97-248, 122(g)(5), to correct an error, and did not involve any change
in text. See 1982 Amendment note below.
Subsec. (a)(2)(B)(ii). Pub. L. 98-21, 602(f)(2), inserted ''and
except with respect to inpatient hospital costs with respect to which
amounts are payable under section 1395ww(d) of this title'' after
''(except with respect to emergency services)'' in provision preceding
subcl. (I).
1982 -- Subsec. (a)(1)(B). Pub. L. 97-248, 128(d)(4), inserted ''of
section 1395y(a) of this title''.
Subsec. (a)(1)(E). Pub. L. 97-248, 144, added subpar. (E).
Subsec. (a)(2)(A). Pub. L. 97-248, 122(g)(5), as amended by Pub. L.
97-448, 309(a)(5), substituted ''(a)(3), or (a)(4)'' for ''or (a)(3)''.
Subsec. (b). Pub. L. 97-248, 128(a)(5), in provisions preceding par.
(1), struck out ''(and in the case of a skilled nursing facility, prior
to the end of the term specified in subsection (a)(1) of this section)''
after ''may be terminated''.
Subsec. (b)(4)(A). Pub. L. 97-248, 122(g)(6), inserted ''or hospice
care'' after ''home health services''.
1981 -- Subsec. (a)(1). Pub. L. 97-35 struck out provision following
subpar. (D) which provided that an agreement with a skilled nursing
facility be for a term not exceeding 12 months with the exception that
the Secretary could extend the time in specified situations.
1980 -- Subsec. (a)(2)(A). Pub. L. 96-611 inserted provision that a
provider of services may not impose a charge under clause (ii) of the
first sentence of this subparagraph with respect to items and services
described in section 1395x(s)(10) of this title for which payment is
made under part B of this subchapter.
Subsec. (c)(3). Pub. L. 96-272 added par. (3).
Subsec. (f). Pub. L. 96-499 added subsec. (f).
1978 -- Subsec. (a)(2)(A). Pub. L. 95-292 provided for computation
of and charging of coinsurance amounts for items and services furnished
individuals with end stage renal disease on the basis established by the
Secretary.
Subsec. (a)(3). Pub. L. 95-142, 8(b)(1), added par. (3).
Subsec. (b)(2)(G). Pub. L. 95-142, 8(b)(2), added cl. (G).
1977 -- Subsec. (a)(1)(D). Pub. L. 95-142, 15(a), added subpar.
(D).
Subsec. (b)(2)(C). Pub. L. 95-142, 3(b), designated existing
provisions as subcl. (i) and added subcl. (ii).
Subsec. (b)(2)(F). Pub. L. 95-142, 13(b)(3), substituted ''of a
quality which fails to meet professionally recognized standards of
health care'' for ''harmful to individuals or to be of a grossly
inferior quality'', and struck out provisions relating to approval by an
appropriate program review team.
Subsec. (c)(2). Pub. L. 95-210 substituted ''section 1396i(a) of this
title'' for ''section 1396i of this title''.
1972 -- Subsec. (a)(1). Pub. L. 92-603, 227(d)(2), 249A(b),
278(a)(17), (b)(18), 281(c), substituted ''Any provider of services
(except a fund designated for purposes of section 1395f(g) and section
1395n(e) of this title)'' for ''Any provider of services'', ''skilled
nursing facility'' for ''extended care facility'', inserted provision
that the agreement be for a term of not to exceed 12 months with an
allowable extension of 2 months under specified circumstances,
redesignated subpar. (B) as (C) and added subpar. (B).
Subsec. (a)(2)(B). Pub. L. 92-603, 223(e), designated existing
provisions as cl. (i) and added cl. (ii).
Subsec. (a)(2)(C). Pub. L. 92-603, 223(g)(2), substituted ''this
subparagraph'' for ''clause (iii) of the preceding sentence''.
Subsec. (a)(2)(D). Pub. L. 92-603, 223(g)(1), added subpar. (D).
Subsec. (b). Pub. L. 92-603, 229(b), 249A(c), 278(a)(17), inserted
''(and in the case of an extended care facility, prior to the end of the
term specified in subsection (a)(1) of this section)'' in provision
preceding par. (1), in par. (2), added cls. (D) to (F), and in par.
(3), substituted ''(including tuberculosis hospital services and
inpatient psychiatric hospital services) or post-hospital extended care
services, with respect to services furnished after the effective date of
such termination, except that payment may be made for up to thirty days
with respect to inpatient institutional services furnished to any
eligible individual who was admitted to such institution prior to'' for
''(including inpatient tuberculosis hospital services and inpatient
psychiatric hospital services) or post-hospital extended care services,
with respect to such services furnished to any individual who is
admitted to the hospital or extended care facility furnishing such
services on or after'' and substituted ''skilled nursing facility'' for
''extended care facility''.
Subsec. (c). Pub. L. 92-603, 249A(d), designated existing provisions
as par. (1) and added par. (2).
Subsec. (d). Pub. L. 92-603, 278(a)(17), substituted ''skilled
nursing facility'' for ''extended care facility'' and ''a'' for ''an''.
1968 -- Subsec. (a)(2)(A). Pub. L. 90-248, 129(c)(12)(A)(i), (ii),
substituted ''or (a)(3)'' for '', (a)(2), or (a)(4)'' in cl. (i), and
deleted ''or, in the case of outpatient hospital diagnostic services,
for which payment is made under part A'' in cl. (ii).
Subsec. (a)(2)(C). Pub. L. 90-248, 129(c)(12)(B), substituted
''1395e(a)(2)'' for ''1395e(a)(3)''.
Pub. L. 90-248, 135(b), authorized a provider of services to charge
for blood in accordance with its customary practices, included, in
addition to whole blood for which a provider of services may charge,
equivalent quantities of packed red blood cells, and provided that blood
furnished an individual will be deemed replaced when the provider is
given one pint of blood for each pint of blood (or equivalent quantities
of packed red blood cells) furnished the individual to which the three
pint deductible applies.
Subsec. (e). Pub. L. 90-248, 133(c), added subsec. (e).
Section 4008(b)(4) of Pub. L. 101-508 provided that: ''The
amendments made by this subsection (amending this section and section
1395dd of this title) shall apply to actions occurring on or after the
first day of the sixth month beginning after the date of the enactment
of this Act (Nov. 5, 1990).''
Section 4153(d)(2) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall take
effect as if included in the enactment of the Omnibus Budget
Reconiliation (sic) Act of 1989 (Pub. L. 101-239).''
Amendment by section 4157(c)(2) of Pub. L. 101-508 applicable to
services furnished on or after Jan. 1, 1991, see section 4157(d) of
Pub. L. 101-508, set out as a note under section 1395k of this title.
Amendment by section 4162(b)(2) of Pub. L. 101-508 applicable with
respect to partial hospitalization services provided on or after Oct.
1, 1991, see section 4162(c) of Pub. L. 101-508, set out as a note
under section 1395k of this title.
Amendment by section 4206(a) of Pub. L. 101-508 applicable with
respect to services furnished on or after the first day of the first
month beginning more than 1 year after Nov. 5, 1990, see section
4206(e)(1) of Pub. L. 101-508, set out as a note under section 1395i-3
of this title.
Section 6018(b) of Pub. L. 101-239 provided that: ''The amendments
made by subsection (a) (amending this section) shall take effect on the
first day of the first month that begins more than 180 days after the
date of the enactment of this Act (Dec. 19, 1989), without regard to
whether regulations to carry out such amendments have been promulgated
by such date.''
Amendment by section 6112(e)(3) of Pub. L. 101-239 applicable with
respect to items furnished on or after Jan. 1, 1990, see section
6112(e)(4) of Pub. L. 101-239, set out as a note under section 1395m of
this title.
Amendment by section 101(a) of Pub. L. 101-234 effective Jan. 1,
1990, see section 101(d) of Pub. L. 101-234, set out as a note under
section 1395c of this title.
Amendment by section 201(a) of Pub. L. 101-234 effective Jan. 1,
1990, see section 201(c) of Pub. L. 101-234, set out as a note under
section 1320a-7a of this title.
Amendment by section 608(d)(3)(F), (19)(A) of Pub. L. 100-485
effective as if included in the enactment of the Medicare Catastrophic
Coverage Act of 1988, Pub. L. 100-360, and amendment by section
608(f)(1) of Pub. L. 100-485 effective Oct. 13, 1988, see section
608(g)(1), (2) of Pub. L. 100-485, set out as a note under section 704
of this title.
Amendment by section 104(d)(5) of Pub. L. 100-360 effective Jan. 1,
1989, except as otherwise provided, and applicable to inpatient hospital
deductible for 1989 and succeeding years, to care and services furnished
on or after Jan. 1, 1989, to premiums for January 1989 and succeeding
months, and to blood or blood cells furnished on or after Jan. 1, 1989,
see section 104(a) of Pub. L. 100-360, set out as a note under section
1395d of this title.
Amendment by section 202(h)(1) of Pub. L. 100-360 applicable to
items dispensed on or after Jan. 1, 1990, see section 202(m)(1) of Pub.
L. 100-360, set out as a note under section 1395u of this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(c)(2)(C), (g)(1)(D), (i)(4)(C)(vi), (j)(5) 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.
Section 411(c)(2)(A)(ii) of Pub. L. 100-360 provided that: ''The
amendment made by clause (i) (amending this section) shall apply to
admissions occurring on or after the first day of the fourth month
beginning after the date of the enactment of this Act (July 1, 1988).''
Amendment by section 4012(a) of Pub. L. 100-203 applicable to
admissions occurring on or after Apr. 1, 1988, or, if later, the
earliest date the Secretary can provide the information required under
section 4012(c) of Pub. L. 100-203 (42 U.S.C. 1395mm note) in machine
readable form, see section 4012(d) of Pub. L. 100-203, set out as a
note under section 1395mm of this title.
Amendment by section 4062(d)(4) of Pub. L. 100-203 applicable to
covered items (other than oxygen and oxygen equipment) furnished on or
after Jan. 1, 1989, and to oxygen and oxygen equipment furnished on or
after June 1, 1989, see section 4062(e) of Pub. L. 100-203, as amended,
set out as a note under section 1395f of this title.
Section 4085(i)(17) of Pub. L. 100-203 provided that the amendment
made by such section 4085(i)(17) is effective as if included in the
enactment of Pub. L. 99-509.
Section 4097(c) of Pub. L. 100-203 provided that: ''The amendments
made by this section (amending this section) shall apply with respect to
fiscal years beginning on or after October 1, 1988.''
Amendment by section 4212(e)(4) of Pub. L. 100-203 applicable to
nursing facility services furnished on or after Oct. 1, 1990, without
regard to whether regulations implementing such amendment are
promulgated by such date, except as otherwise specifically provided in
section 1396r of this title, with transitional rule, see section
4214(a), (b)(2) of Pub. L. 100-203, as amended, set out as an Effective
Date note under section 1396r of this title.
Amendment by Pub. L. 100-93 effective at end of fourteen-day period
beginning Aug. 18, 1987, and inapplicable to administrative proceedings
commenced before end of such period, see section 15(a) of Pub. L.
100-93, set out as a note under section 1320a-7 of this title.
Section 233(b) of Pub. L. 99-576 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply to inpatient
hospital services provided pursuant to admissions to hospitals occurring
after June 30, 1987.''
Amendment by Pub. L. 99-514 effective, except as otherwise provided,
as if included in enactment of the Consolidated Omnibus Budget
Reconciliation Act of 1985, Pub. L. 99-272, see section 1895(e) of Pub.
L. 99-514, set out as a note under section 162 of Title 26, Internal
Revenue Code.
Section 9305(b)(2) of Pub. L. 99-509 provided that: ''The Secretary
of Health and Human Services shall first prescribe the language required
under section 1866(a)(1)(M) of the Social Security Act (subsec.
(a)(1)(M) of this section) not later than six months after the date of
the enactment of this Act (Oct. 21, 1986). The requirement of such
section shall apply to admissions to hospitals occurring on such date
(not later than 60 days after the date such language is first
prescribed) as the Secretary shall provide.''
Amendment by section 9320(h)(2) of Pub. L. 99-509 applicable to
services furnished on or after Jan. 1, 1989, with exceptions for
hospitals located in rural areas which meet certain requirements related
to certified registered nurse anesthetists, see section 9320(i), (k) of
Pub. L. 99-509, as amended, set out as notes under section 1395k of
this title.
Section 9332(e)(2) of Pub. L. 99-509 provided that: ''The amendment
made by paragraph (1) (amending this section) shall apply to agreements
under section 1866(a) of the Social Security Act (subsec. (a) of this
section) as of October 1, 1987.''
Amendment by section 9337(c)(2) of Pub. L. 99-509 applicable to
expenses incurred for outpatient occupational therapy services furnished
on or after July 1, 1987, see section 9337(e) of Pub. L. 99-509, set
out as a note under section 1395k of this title.
Amendment by section 9343(c)(2), (3) of Pub. L. 99-509 applicable to
services furnished after June 30, 1987, see section 9343(h)(4) of Pub.
L. 99-509, as amended, set out as a note under section 1395l of this
title.
Section 9353(e)(3)(A) of Pub. L. 99-509 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
provider agreements as of October 1, 1987.''
Amendment by section 9121(a) of Pub. L. 99-272 effective on first
day of first month that begins at least 90 days after Apr. 7, 1986, see
section 9121(c) of Pub. L. 99-272, set out as a note under section
1395dd of this title.
Section 9122(b) of Pub. L. 99-272, as amended by Pub. L. 99-514,
title XVIII, 1895(b)(6), Oct. 22, 1986, 100 Stat. 2933, provided
that: ''The amendments made by subsection (a) (amending this section)
shall apply to inpatient hospital services provided pursuant to
admissions to hospitals occurring on or after January 1, 1987.''
Section 9402(c)(1) of Pub. L. 99-272 provided that: ''The
amendments made by subsection (a) (amending this section) shall become
effective on the date of the enactment of this Act (Apr. 7, 1986).''
Amendment by section 9403(b) of Pub. L. 99-272 effective Apr. 7,
1986, see section 9403(c) of Pub. L. 99-272, set out as a note under
section 1320c-3 of this title.
Amendment by section 2303(f) of Pub. L. 98-369 applicable to
clinical diagnostic laboratory tests furnished on or after July 1, 1984,
but not applicable to clinical diagnostic laboratory tests furnished to
inpatients of a provider operating under a waiver granted pursuant to
section 602(k) of Pub. L. 98-21, set out as a note under section 1395y
of this title, see section 2303(j)(1), (3) of Pub. L. 98-369, set out
as a note under section 1395l of this title.
Amendment by section 2315(d) 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 Amendment note under section
1395ww of this title.
Amendment by section 2321(c) of Pub. L. 98-369 applicable to items
and services furnished on or after July 18, 1984, see section 2321(g) of
Pub. L. 98-369, set out as a note under section 1395f of this title.
Amendment by section 2323(b)(3) of Pub. L. 98-369 applicable to
services furnished on or after Sept. 1, 1984, see section 2323(d) of
Pub. L. 98-369, set out as a note under section 1395l of this title.
Amendment by section 2335(d) of Pub. L. 98-369 effective July 18,
1984, see section 2335(g) of Pub. L. 98-369, set out as a note under
section 1395f of this title.
Amendment by section 2347(a) of Pub. L. 98-369 effective July 18,
1984, see section 2347(d) of Pub. L. 98-369, set out as a note under
section 1320c-2 of this title.
Section 2348(b) of Pub. L. 98-369 provided that: ''The amendment
made by this section (amending this section) shall apply to terminations
issued on or after the date of the enactment of this Act (July 18,
1984).''
Amendment by section 2354(b)(33), (34) 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.
Section 602(l) of Pub. L. 98-21, as amended by Pub. L. 98-369, div.
B, title III, 2347(a)(2), July 18, 1984, 98 Stat. 1096, provided that
the amendment made by that section is effective Oct. 1, 1984.
Amendment by section 602(f)(2) of 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.
Subsec. (a)(1)(F) to (H) of this section, as added by section
602(f)(1)(C) of Pub. L. 98-21, effective Oct. 1, 1983, see section
604(a)(2) of Pub. L. 98-21, set out as a note under section 1395ww of
this title.
Amendment by section 309(a)(5) of Pub. L. 97-448 effective as if
originally included in the provision of the Tax Equity and Fiscal
Responsibility Act of 1982, Pub. L. 97-248, to which such amendment
relates, see section 309(c)(1) of Pub. L. 97-448, set out as a note
under section 426 of this title.
Amendment by section 309(b)(11) of 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.
Amendment by section 122(g)(5), (6) 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.
Amendment by section 128(a)(5) of Pub. L. 97-248 effective as if
originally included as part of this section as this section was amended
by the Omnibus Budget Reconciliation Act of 1981, Pub. L. 97-35, see
section 128(e)(2) of Pub. L. 97-248, set out as a note under section
1395x of this title.
Amendment by section 128(d)(4) of Pub. L. 97-248 effective Sept. 3,
1982, see section 128(e)(3) of Pub. L. 97-248, set out as a note under
section 1395x of this title.
Amendment by section 144 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.
Amendment by Pub. L. 96-611 effective July 1, 1981, and applicable
to services furnished on or after that date, see section 2 of Pub. L.
96-611, set out as a note under section 1395l of this title.
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.
Section 2(f) of Pub. L. 95-210 provided that:
''(1) The amendments made by this section (amending this section and
sections 1396a, 1396d, and 1396i of this title) shall (except as
otherwise provided in paragraph (2)) apply to medical assistance
provided, under a State plan approved under title XIX of the Social
Security Act (subchapter XIX of this chapter), on and after the first
day of the first calendar quarter that begins more than six months after
the date of enactment of this Act (Dec. 13, 1977).
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (subchapter XIX of this chapter) which
the Secretary determines requires State legislation in order for the
plan to meet the additional requirements imposed by the amendments made
by this section, the State plan shall not be regarded as failing to
comply with the requirements of such title (subchapter) solely on the
basis of its failure to meet these additional requirements before the
first day of the first calendar quarter beginning after the close of the
first regular session of the State legislature that begins after the
date of enactment of this Act (Dec. 13, 1977).''
Amendment by section 3(b) of Pub. L. 95-142 effective Oct. 25,
1977, see section 3(e) of Pub. L. 95-142, set out as an Effective Date
note under section 1320a-3 of this title.
Amendment by section 8(b) of Pub. L. 95-142 (amending this section)
applicable with respect to contracts, agreements, etc., made on and
after first day of fourth month beginning after Oct. 25, 1977, see
section 8(e) of Pub. L. 95-142, set out as an Effective Date note under
section 1320a-5 of this title.
Amendment by section 13(b)(3) of Pub. L. 95-142 effective Oct. 25,
1977, see section 13(c) of Pub. L. 95-142, set out as a note under
section 1395y of this title.
Section 15(b) of Pub. L. 95-142 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply with respect
to agreements entered into or renewed on and after the date of enactment
of this Act (Oct. 25, 1977).''
Amendment by section 223(e), (g) of Pub. L. 92-603 effective with
respect to accounting periods beginning after Dec. 31, 1972, see
section 223(h) of Pub. L. 92-603, set out as a note under section 1395x
of this title.
Amendment by section 227(d)(2) of Pub. L. 92-603 applicable with
respect to accounting periods beginning after June 30, 1973, see section
227(g) of Pub. L. 92-603, set out as a note under section 1395x of this
title.
Section 249A(e) of Pub. L. 92-603 provided that: ''The provisions
of this section (enacting section 1396 of this title and amending this
section) shall be effective with respect to agreements filed with the
Secretary under section 1866 of the Social Security Act (this section)
by skilled nursing facilities (as defined in section 1861(j) of such Act
(section 1395x(j) of this title)) before, on, or after the date of
enactment of this Act (Oct. 30, 1972), but accepted by him on or after
such date.''
Amendment by section 281(c) of Pub. L. 92-603 applicable in the case
of notices sent to individuals after 1968, see section 281(g) of Pub.
L. 92-603, set out as a note under section 1395gg of this title.
Amendment by section 129(c)(12) 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.
Amendment by section 133(c) of Pub. L. 90-248 applicable with
respect to services furnished after June 30, 1968, see section 133(g) of
Pub. L. 90-248, set out as a note under section 1395k of this title.
Amendment by section 135(b) of Pub. L. 90-248 applicable with
respect to payment for blood (or packed red blood cells) furnished an
individual after Dec. 31, 1967, see section 135(d) of Pub. L. 90-248,
set out as a note under section 1395e of this title.
Section 4206(c) of Pub. L. 101-508 provided that: ''Nothing in
subsections (a) and (b) (amending this section and sections 1395l and
1395mm of this title) shall be construed to prohibit the application of
a State law which allows for an objection on the basis of conscience for
any health care provider or any agent of such provider which, as a
matter of conscience, cannot implement an advance directive.''
Section 233(c) of Pub. L. 99-576 provided that:
''(1) The Secretary of Health and Human Services shall periodically
submit to the Congress a report on the number of hospitals that have
terminated or failed to renew an agreement under section 1866 of the
Social Security Act (this section) as a result of the additional
conditions imposed under the amendments made by subsection (a) (amending
this section).
''(2) Not later than October 1, 1987, the Administrator of Veterans'
Affairs shall submit to the Committees on Veterans' Affairs of the
Senate and House of Representatives a report regarding implementation of
this section (amending this section). Thereafter, the Administrator
shall notify such committees if any hospital terminates or fails to
renew an agreement described in paragraph (1) for the reasons described
in that paragraph.''
Section 9122(d) of Pub. L. 99-272 provided that: ''The Secretary of
Health and Human Services shall report to Congress periodically on the
number of hospitals that have terminated or failed to renew an agreement
under section 1866 of the Social Security Act (this section) as a result
of the additional conditions imposed under the amendments made by
subsection (a) (amending this section).''
Section 2347(b) of Pub. L. 98-369 provided that: ''Notwithstanding
section 604(a)(2) of the Social Security Amendments of 1983 (section
604(a)(2) of Pub. L. 98-21, set out as an Effective Date of 1983
Amendment note under section 1395ww of this title), the requirement that
a hospital maintain an agreement with a utilization and quality control
peer review organization, as contained in section 1866(a)(1)(F) of the
Social Security Act (subsec. (a)(1)(F) of this section), shall become
effective on November 15, 1984.''
For authority to waive the requirements of subsec. (a)(1)(H) of this
section for any cost period prior to Oct. 1, 1986, where immediate
compliance would threaten the stability of patient care, see section
602(k) of Pub. L. 98-21, set out as a note under section 1395y of this
title.
Section 119 of Pub. L. 97-248 provided that:
''(a) The Secretary of Health and Human Services shall undertake an
initiative to improve medical review by intermediaries and carriers
under title XVIII of the Social Security Act (this subchapter) and to
encourage similar review efforts by private insurers and other private
entities. The initiative shall include the development of specific
standards for measuring the performance of such intermediaries and
carriers with respect to the identification and reduction of unnecessary
utilization of health services.
''(b) Where such review activity results in the denial of payment to
providers of services under title XVIII of the Social Security Act (this
subchapter), such providers shall be prohibited, in accordance with
sections 1866 and 1879 of such title (this section and section 1395pp of
this title), from collecting any payments from beneficiaries unless
otherwise provided under such title.''
Deemed To Be for Specified Term Ending Dec. 31, 1973
Section 249A(f) of Pub. L. 92-603 provided that: ''Notwithstanding
any other provision of law, any agreement, filed by a skilled nursing
facility (as defined in section 1861(j) of the Social Security Act
(section 1395x(j) of this title)) with the Secretary under section 1866
of such Act (this section) and accepted by him prior to the date of
enactment of this Act (Oct. 30, 1972), which was in effect on such date
shall be deemed to be for a specified term ending on December 31,
1973.''
/1/ So in original. The semicolon probably should be a comma.
/2/ So in original. The word ''and'' probably should not appear.
/3/ So in original. The semicolon probably should be a comma.
42 USC 1395dd. Examination and treatment for emergency medical
conditions and women in labor
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Medical screening requirement
In the case of a hospital that has a hospital emergency department,
if any individual (whether or not eligible for benefits under this
subchapter) comes to the emergency department and a request is made on
the individual's behalf for examination or treatment for a medical
condition, the hospital must provide for an appropriate medical
screening examination within the capability of the hospital's emergency
department, including ancillary services routinely available to the
emergency department, to determine whether or not an emergency medical
condition (within the meaning of subsection (e)(1) of this section)
exists.
(b) Necessary stabilizing treatment for emergency medical conditions
and labor
(1) In general
If any individual (whether or not eligible for benefits under this
subchapter) comes to a hospital and the hospital determines that the
individual has an emergency medical condition, the hospital must provide
either --
(A) within the staff and facilities available at the hospital, for
such further medical examination and such treatment as may be required
to stabilize the medical condition, or
(B) for transfer of the individual to another medical facility in
accordance with subsection (c) of this section.
(2) Refusal to consent to treatment
A hospital is deemed to meet the requirement of paragraph (1)(A) with
respect to an individual if the hospital offers the individual the
further medical examination and treatment described in that paragraph
and informs the individual (or a person acting on the individual's
behalf) of the risks and benefits to the individual of such examination
and treatment, but the individual (or a person acting on the
individual's behalf) refuses to consent to the examination and
treatment. The hospital shall take all reasonable steps to secure the
individual's (or person's) written informed consent to refuse such
examination and treatment.
(3) Refusal to consent to transfer
A hospital is deemed to meet the requirement of paragraph (1) with
respect to an individual if the hospital offers to transfer the
individual to another medical facility in accordance with subsection (c)
of this section and informs the individual (or a person acting on the
individual's behalf) of the risks and benefits to the individual of such
transfer, but the individual (or a person acting on the individual's
behalf) refuses to consent to the transfer. The hospital shall take all
reasonable steps to secure the individual's (or person's) written
informed consent to refuse such transfer.
(c) Restricting transfers until individual stabilized
(1) Rule
If an individual at a hospital has an emergency medical condition
which has not been stabilized (within the meaning of subsection
(e)(3)(B) of this section), the hospital may not transfer the individual
unless --
(A)(i) the individual (or a legally responsible person acting on the
individual's behalf) after being informed of the hospital's obligations
under this section and of the risk of transfer, in writing requests
transfer to another medical facility,
(ii) a physician (within the meaning of section 1395x(r)(1) of this
title) has signed a certification that /1/ based upon the information
available at the time of transfer, the medical benefits reasonably
expected from the provision of appropriate medical treatment at another
medical facility outweigh the increased risks to the individual and, in
the case of labor, to the unborn child from effecting the transfer, or
(iii) if a physician is not physically present in the emergency
department at the time an individual is transferred, a qualified medical
person (as defined by the Secretary in regulations) has signed a
certification described in clause (ii) after a physician (as defined in
section 1395x(r)(1) of this title), in consultation with the person, has
made the determination described in such clause, and subsequently
countersigns the certification; and
(B) the transfer is an appropriate transfer (within the meaning of
paragraph (2)) to that facility.
A certification described in clause (ii) or (iii) of subparagraph (A)
shall include a summary of the risks and benefits upon which the
certification is based.
(2) Appropriate transfer
An appropriate transfer to a medical facility is a transfer --
(A) in which the transferring hospital provides the medical treatment
within its capacity which minimizes the risks to the individual's health
and, in the case of a woman in labor, the health of the unborn child;
(B) in which the receiving facility --
(i) has available space and qualified personnel for the treatment of
the individual, and
(ii) has agreed to accept transfer of the individual and to provide
appropriate medical treatment;
(C) in which the transferring hospital sends to the receiving
facility all medical records (or copies thereof), related to the
emergency condition for which the individual has presented, available at
the time of the transfer, including records related to the individual's
emergency medical condition, observations of signs or symptoms,
preliminary diagnosis, treatment provided, results of any tests and the
informed written consent or certification (or copy thereof) provided
under paragraph (1)(A), and the name and address of any on-call
physician (described in subsection (d)(1)(C) of this section) who has
refused or failed to appear within a reasonable time to provide
necessary stabilizing treatment;
(D) in which the transfer is effected through qualified personnel and
transportation equipment, as required including the use of necessary and
medically appropriate life support measures during the transfer; and
(E) which meets such other requirements as the Secretary may find
necessary in the interest of the health and safety of individuals
transferred.
(d) Enforcement
(1) Civil money penalties
(A) A participating hospital that negligently violates a requirement
of this section is subject to a civil money penalty of not more than
$50,000 (or not more than $25,000 in the case of a hospital with less
than 100 beds) for each such violation. The provisions of section
1320a-7a of this title (other than subsections (a) and (b)) shall apply
to a civil money penalty under this subparagraph in the same manner as
such provisions apply with respect to a penalty or proceeding under
section 1320a-7a(a) of this title.
(B) Subject to subparagraph (C), any physician who is responsible for
the examination, treatment, or transfer of an individual in a
participating hospital, including a physician on-call for the care of
such an individual, and who negligently violates a requirement of this
section, including a physician who --
(i) signs a certification under subsection (c)(1)(A) of this section
that the medical benefits reasonably to be expected from a transfer to
another facility outweigh the risks associated with the transfer, if the
physician knew or should have known that the benefits did not outweigh
the risks, or
(ii) misrepresents an individual's condition or other information,
including a hospital's obligations under this section,
is subject to a civil money penalty of not more than $50,000 for each
such violation and, if the violation is is /2/ gross and flagrant or is
repeated, to exclusion from participation in this subchapter and State
health care programs. The provisions of section 1320a-7a of this title
(other than the first and second sentences of subsection (a) and
subsection (b)) shall apply to a civil money penalty and exclusion under
this subparagraph in the same manner as such provisions apply with
respect to a penalty, exclusion, or proceeding under section 1320a-7a(a)
of this title.
(C) If, after an initial examination, a physician determines that the
individual requires the services of a physician listed by the hospital
on its list of on-call physicians (required to be maintained under
section 1395cc(a)(1)(I) of this title) and notifies the on-call
physician and the on-call physician fails or refuses to appear within a
reasonable period of time, and the physician orders the transfer of the
individual because the physician determines that without the services of
the on-call physician the benefits of transfer outweigh the risks of
transfer, the physician authorizing the transfer shall not be subject to
a penalty under subparagraph (B). However, the previous sentence shall
not apply to the hospital or to the on-call physician who failed or
refused to appear.
(2) Civil enforcement
(A) Personal harm
Any individual who suffers personal harm as a direct result of a
participating hospital's violation of a requirement of this section may,
in a civil action against the participating hospital, obtain those
damages available for personal injury under the law of the State in
which the hospital is located, and such equitable relief as is
appropriate.
(B) Financial loss to other medical facility
Any medical facility that suffers a financial loss as a direct result
of a participating hospital's violation of a requirement of this section
may, in a civil action against the participating hospital, obtain those
damages available for financial loss, under the law of the State in
which the hospital is located, and such equitable relief as is
appropriate.
(C) Limitations on actions
No action may be brought under this paragraph more than two years
after the date of the violation with respect to which the action is
brought.
(3) Consultation with peer review organizations
In considering allegations of violations of the requirements of this
section in imposing sanctions under paragraph (1), the Secretary shall
request the appropriate utilization and quality control peer review
organization (with a contract under part B of subchapter XI of this
chapter) to assess whether the individual involved had an emergency
medical condition which had not been stabilized, and provide a report on
its findings. Except in the case in which a delay would jeopardize the
health or safety of individuals, the Secretary shall request such a
review before effecting a sanction under paragraph (1) and shall provide
a period of at least 60 days for such review.
(e) Definitions
In this section:
(1) The term ''emergency medical condition'' means --
(A) a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that the absence of
immediate medical attention could reasonably be expected to result in --
(i) placing the health of the individual (or, with respect to a
pregnant woman, the health of the woman or her unborn child) in serious
jeopardy,
(ii) serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part; or
(B) with respect to a pregnant women /3/ who is having contractions
--
(i) that there is inadequate time to effect a safe transfer to
another hospital before delivery, or
(ii) that transfer may pose a threat to the health or safety of the
woman or the unborn child.
(2) The term ''participating hospital'' means hospital that has
entered into a provider agreement under section 1395cc of this title.
(3)(A) The term ''to stabilize'' means, with respect to an emergency
medical condition described in paragraph (1)(A), to provide such medical
treatment of the condition as may be necessary to assure, within
reasonable medical probability, that no material deterioration of the
condition is likely to result from or occur during the transfer of the
individual from a facility, or, with respect to an emergency medical
condition described in paragraph (1)(B), to deliver (including the
placenta).
(B) The term ''stabilized'' means, with respect to an emergency
medical condition described in paragraph (1)(A), that no material
deterioration of the condition is likely, within reasonable medical
probability, to result from or occur during the transfer of the
individual from a facility, or, with respect to an emergency medical
condition described in paragraph (1)(B), that the woman has delivered
(including the placenta).
(4) The term ''transfer'' means the movement (including the
discharge) of an individual outside a hospital's facilities at the
direction of any person employed by (or affiliated or associated,
directly or indirectly, with) the hospital, but does not include such a
movement of an individual who (A) has been declared dead, or (B) leaves
the facility without the permission of any such person.
(5) The term ''hospital'' includes a rural primary care hospital (as
defined in section 1395x(mm)(1) of this title).
(f) Preemption
The provisions of this section do not preempt any State or local law
requirement, except to the extent that the requirement directly
conflicts with a requirement of this section.
(g) Nondiscrimination
A participating hospital that has specialized capabilities or
facilities (such as burn units, shock-trauma units, neonatal intensive
care units, or (with respect to rural areas) regional referral centers
as identified by the Secretary in regulation) shall not refuse to accept
an appropriate transfer of an individual who requires such specialized
capabilities or facilities if the hospital has the capacity to treat the
individual.
(h) No delay in examination or treatment
A participating hospital may not delay provision of an appropriate
medical screening examination required under subsection (a) of this
section or further medical examination and treatment required under
subsection (b) of this section in order to inquire about the
individual's method of payment or insurance status.
(i) Whistleblower protections
A participating hospital may not penalize or take adverse action
against a qualified medical person described in subsection
(c)(1)(A)(iii) of this section or a physician because the person or
physician refuses to authorize the transfer of an individual with an
emergency medical condition that has not been stabilized or against any
hospital employee because the employee reports a violation of a
requirement of this section.
(Aug. 14, 1935, ch. 531, title XVIII, 1867, as added Apr. 7, 1986,
Pub. L. 99-272, title IX, 9121(b), 100 Stat. 164, and amended Oct. 21,
1986, Pub. L. 99-509, title IX, 9307(c)(4), 100 Stat. 1996; Oct. 22,
1986, Pub. L. 99-514, title XVIII, 1895(b)(4), 100 Stat. 2933; Dec.
22, 1987, Pub. L. 100-203, title IV, 4009(a)(1), formerly 4009(a)(1),
(2), 101 Stat. 1330-56, 1330-57; July 1, 1988, Pub. L. 100-360, title
IV, 411(b)(8)(A)(i), 102 Stat. 772; Oct. 13, 1988, Pub. L. 100-485,
title VI, 608(d)(18)(E), 102 Stat. 2419; Dec. 19, 1989, Pub. L.
101-239, title VI, 6003(g)(3)(D)(xiv), 6211(a)-(h), 103 Stat. 2154,
2245-2248; Nov. 5, 1990, Pub. L. 101-508, title IV,
4008(b)(1)-(3)(A), 4027(4207)(a)(1)(A), (2), (3), (k)(3), 104 Stat.
1388-44, 1388-117, 1388-124.)
Part B of subchapter XI of this chapter, referred to in subsec.
(d)(3), is classified to section 1320c et seq. of this title.
A prior section 1395dd, act Aug. 14, 1935, ch. 531, title XVIII,
1867, as added July 30, 1965, Pub. L. 89-97, title I, 102(a), 79 Stat.
329, and amended Jan. 2, 1968, Pub. L. 90-248, title I, 164(a), 81
Stat. 873; Oct. 30, 1972, Pub. L. 92-603, title II, 288, 86 Stat.
1457, which related to creation, composition, meetings, and functions of
the Health Insurance Benefits Advisory Council and the appointment of a
Chairman and members thereto, and qualifications, terms of office,
compensation, and reimbursement of travel expenses of members, was
repealed by Pub. L. 98-369, div. B, title III, 2349(a), July 18,
1984, 98 Stat. 1097, eff. July 18, 1984.
1990 -- Subsec. (c)(2)(C). Pub. L. 101-508, 4008(b)(3)(A)(iii),
substituted ''subsection (d)(1)(C)'' for ''subsection (d)(2)(C)''.
Subsec. (d)(1). Pub. L. 101-508, 4008(b)(3)(A)(i), (ii),
redesignated par. (2) as (1) and struck out former par. (1) which read
as follows: ''If a hospital knowingly and willfully, or negligently,
fails to meet the requirements of this section, such hospital is subject
to --
''(A) termination of its provider agreement under this subchapter in
accordance with section 1395cc(b) of this title, or
''(B) at the option of the Secretary, suspension of such agreement
for such period of time as the Secretary determines to be appropriate,
upon reasonable notice to the hospital and to the public.''
Subsec. (d)(1)(B). Pub. L. 101-508, 4027(4207)(a)(2), (3), which
directed amendment of par. (2)(B) by substituting ''negligently'' for
''knowingly'' and ''is gross and flagrant or is repeated'' for ''knowing
and willful or negligent'', was executed by making the substitutions in
par. (1)(B) to reflect the probable intent of Congress and the
intervening redesignation of par. (2) as (1) by Pub. L. 101-508,
4008(b)(3)(A)(ii). See above.
Subsec. (d)(2). Pub. L. 101-508, 4008(b)(3)(A)(ii), redesignated
par. (3) as (2). Former par. (2) redesignated (1).
Subsec. (d)(2)(A). Pub. L. 101-508, 4008(b)(1), (2), substituted
''negligently'' for ''knowingly'' and inserted ''(or not more than
$25,000 in the case of a hospital with less than 100 beds)'' after
''$50,000''.
Subsec. (d)(3). Pub. L. 101-508, 4027(4207)(a)(1)(A), added par.
(3). Former par. (3) redesignated (2).
Subsec. (i). Pub. L. 101-508, 4027(4207)(k)(3), amended subsec. (i)
generally. Prior to amendment, subsec. (i) read as follows: ''A
participating hospital may not penalize or take adverse action against a
physician because the physician refuses to authorize the transfer of an
individual with an emergency medical condition that has not been
stabilized.''
1989 -- Pub. L. 101-239, 6211(h)(2)(A), struck out ''active''
before ''labor'' in section catchline.
Subsec. (a). Pub. L. 101-239, 6211(h)(2)(B), which directed the
amendment of subsec. (a) by striking out ''or to determine if the
individual is in active labor (within the meaning of section (e)(2) of
this section)'' was executed by striking out ''or to determine if the
individual is in active labor (within the meaning of subsection (e)(2)
of this section)'' after ''exists''.
Pub. L. 101-239, 6211(a), substituted ''hospital's emergency
department, including ancillary services routinely available to the
emergency department,'' for ''hospital's emergency department''.
Subsec. (b). Pub. L. 101-239, 6211(h)(2)(C), struck out ''active''
before ''labor'' in heading.
Subsec. (b)(1). Pub. L. 101-239, 6211(h)(2)(D)(i), struck out ''or
is in active labor'' after ''emergency medical condition'' in
introductory provisions.
Subsec. (b)(1)(A). Pub. L. 101-239, 6211(h)(2)(D)(ii), struck out
''or to provide for treatment of the labor'' after ''stabilize the
medical condition''.
Subsec. (b)(2). Pub. L. 101-239, 6211(b)(1), inserted ''and informs
the individual (or a person acting on the individual's behalf) of the
risks and benefits to the individual of such examination and
treatment,'' after ''in that paragraph'', substituted ''and treatment.''
for ''or treatment.'', and inserted at end ''The hospital shall take all
reasonable steps to secure the individual's (or person's) written
informed consent to refuse such examination and treatment.''
Subsec. (b)(3). Pub. L. 101-239, 6211(b)(2), inserted ''and informs
the individual (or a person acting on the individual's behalf) of the
risks and benefits to the individual of such transfer,'' after
''subsection (c) of this section'' and inserted at end ''The hospital
shall take all reasonable steps to secure the individual's (or person's)
written informed consent to refuse such transfer.''
Subsec. (c). Pub. L. 101-239, 6211(g)(1)(A), substituted
''individual'' for ''patient'' in heading.
Subsec. (c)(1). Pub. L. 101-239, 6211(c)(4), (g)(1)(B), (h)(2)(E),
in introductory provisions, substituted ''an individual'' for ''a
patient'', ''subsection (e)(3)(B) of this section)'' for ''subsection
(e)(4)(B) of this section) or is in active labor'', and ''the
individual'' for ''the patient'', and inserted at end ''A certification
described in clause (ii) or (iii) of subparagraph (A) shall include a
summary of the risks and benefits upon which the certification is
based.''
Subsec. (c)(1)(A)(i). Pub. L. 101-239, 6211(c)(1), (g)(1)(B),
substituted ''the individual'' for ''the patient'', ''the individual's
behalf'' for ''the patient's behalf'', and ''after being informed of the
hospital's obligations under this section and of the risk of transfer,
in writing requests transfer to another medical facility'' for
''requests that the transfer be effected''.
Subsec. (c)(1)(A)(ii). Pub. L. 101-239, 6211(c)(2)(B), (3),
(g)(1)(B), substituted ''has signed a certification that based upon the
information available at the time of transfer'' for '', or other
qualified medical personnel when a physician is not readily available in
the emergency department, has signed a certification that, based upon
the reasonable risks and benefits to the patient, and based upon the
information available at the time'' and ''individual and, in the case of
labor, to the unborn child'' for ''individual's medical condition''.
Subsec. (c)(1)(A)(iii). Pub. L. 101-239, 6211(c)(2)(A), (C), (D),
added cl. (iii).
Subsec. (c)(2)(A). Pub. L. 101-239, 6211(c)(5), added subpar. (A).
Former subpar. (A) redesignated (B).
Subsec. (c)(2)(B). Pub. L. 101-239, 6211(c)(5)(A), (g)(1)(B),
redesignated subpar. (A) as (B) and substituted ''the individual'' for
''the patient'' in cls. (i) and (ii). Former subpar. (B) redesignated
(C).
Subsec. (c)(2)(C). Pub. L. 101-239, 6211(c)(5)(A), (d), redesignated
subpar. (B) as (C) and substituted ''sends to'' for ''provides'' and
''all medical records (or copies thereof), related to the emergency
condition for which the individual has presented, available at the time
of the transfer, including records related to the individual's emergency
medical condition, observations of signs or symptoms, preliminary
diagnosis, treatment provided, results of any tests and the informed
written consent or certification (or copy thereof) provided under
paragraph (1)(A), and the name and address of any on-call physician
(described in subsection (d)(2)(C) of this section) who has refused or
failed to appear within a reasonable time to provide necessary
stabilizing treatment'' for ''with appropriate medical records (or
copies thereof) of the examination and treatment effected at the
transferring hospital''. Former subpar. (C) redesignated (D).
Subsec. (c)(2)(D). Pub. L. 101-239, 6211(c)(5)(A), redesignated
subpar. (C) as (D). Former subpar. (D) redesignated (E).
Subsec. (c)(2)(E). Pub. L. 101-239, 6211(c)(5)(A), (g)(1)(B),
redesignated subpar. (D) as (E) and substituted ''individuals'' for
''patients''.
Subsec. (d)(2)(B). Pub. L. 101-239, 6211(e)(1), amended subpar. (B)
generally. Prior to amendment, subpar. (B) read as follows: ''The
responsible physician in a participating hospital with respect to the
hospital's violation of a requirement of this subsection is subject to
the sanctions described in section 1395u(j)(2) of this title, except
that, for purposes of this subparagraph, the civil money penalty with
respect to each violation may not exceed $50,000, rather than $2,000.''
Subsec. (d)(2)(C). Pub. L. 101-239, 6211(e)(2), added subpar. (C)
and struck out former subpar. (C) which read as follows: ''As used in
this paragraph, the term 'responsible physician' means, with respect to
a hospital's violation of a requirement of this section, a physician who
--
''(i) is employed by, or under contract with, the participating
hospital, and
''(ii) acting as such an employee or under such a contract, has
professional responsibility for the provision of examinations or
treatments for the individual, or transfers of the individual, with
respect to which the violation occurred.''
Subsec. (e)(1). Pub. L. 101-239, 6211(h)(1)(A), substituted ''means
-- '' and subpars. (A) and (B) for ''means a medical condition
manifesting itself by acute symptoms of sufficient severity (including
severe pain) such that the absence of immediate medical attention could
reasonably be expected to result in --
''(A) placing the patient's health in serious jeopardy,
''(B) serious impairment to bodily functions, or
''(C) serious dysfunction of any bodily organ or part.''
Subsec. (e)(2). Pub. L. 101-239, 6211(h)(1)(B), (E), redesignated
par. (3) as (2) and struck out former par. (2) which defined ''active
labor''.
Subsec. (e)(3). Pub. L. 101-239, 6211(h)(1)(E), redesignated par.
(4) as (3). Former par. (3) redesignated (2).
Subsec. (e)(4). Pub. L. 101-239, 6211(h)(1)(E), redesignated par.
(5) as (4). Former par. (4) redesignated (3).
Subsec. (e)(4)(A). Pub. L. 101-239, 6211(h)(1)(C), substituted
''emergency medical condition described in paragraph (1)(A)'' for
''emergency medical condition'', ''likely to result from or occur
during'' for ''likely to result from'', and ''from a facility, or, with
respect to an emergency medical condition described in paragraph (1)(B),
to deliver (including the placenta)'' for ''from a facility''.
Subsec. (e)(4)(B). Pub. L. 101-239, 6211(h)(1)(D), inserted
''described in paragraph (1)(A)'' after ''emergency medical condition'',
''or occur during'' after ''to result from'', and '', or, with respect
to an emergency medical condition described in paragraph (1)(B), that
the woman has delivered (including the placenta)'' after ''from a
facility''.
Subsec. (e)(5). Pub. L. 101-239, 6211(h)(1)(E), redesignated par.
(6) as (5). Former par. (5) redesignated (4).
Pub. L. 101-239, 6211(g)(2), substituted ''an individual'' for ''a
patient'' in two places.
Subsec. (e)(6). Pub. L. 101-239, 6211(h)(1)(E), redesignated par.
(6) as (5).
Pub. L. 101-239, 6003(g)(3)(D)(xiv), added par. (6).
Subsecs. (g) to (i). Pub. L. 101-239, 6211(f), added subsecs. (g)
to (i).
1988 -- Subsec. (d)(1). Pub. L. 100-360, 411(b)(8)(A)(i), amended
Pub. L. 100-203, 4009(a)(2), see 1987 Amendment note below.
Subsec. (d)(2). Pub. L. 100-360, 411(b)(8)(A)(i), as amended by Pub.
L. 100-485, 608(d)(18)(E), amended Pub. L. 100-203, 4009(a)(1), see
1987 Amendment note below.
1987 -- Subsec. (d)(1). Pub. L. 100-203, 4009(a)(2), which directed
insertion of a provision related to imposing the sanction described in
section 1395u(j)(2)(A) of this title, was amended generally by Pub. L.
100-360, 411(b)(8)(A)(i), so that it does not amend par. (1).
Subsec. (d)(2). Pub. L. 100-203, 4009(a)(1), as amended by Pub. L.
100-360, 411(b)(8)(A)(i), as amended by Pub. L. 100-485,
608(d)(18)(E), substituted subpars. (A) and (B) for ''In addition to
the other grounds for imposition of a civil money penalty under section
1320a-7a(a) of this title, a participating hospital that knowingly
violates a requirement of this section and the responsible physician in
the hospital with respect to such a violation are each subject, under
that section, to a civil money penalty of not more than $25,000 for each
such violation.'', designated second sentence as subpar. (C),
substituted ''this paragraph'' for ''the previous sentence'', and
redesignated former subpars. (A) and (B) as cls. (i) and (ii),
respectively, of subpar. (C).
1986 -- Subsec. (b)(2), (3). Pub. L. 99-509 struck out ''legally
responsible'' after ''individual (or a''.
Subsec. (e)(3). Pub. L. 99-514 struck out ''and has, under the
agreement, obligated itself to comply with the requirements of this
section'' after ''section 1395cc of this title''.
Amendment by section 4008(b)(1)-(3)(A) of Pub. L. 101-508 applicable
to actions occurring on or after the first day of the sixth month
beginning after Nov. 5, 1990, see section 4008(b)(4) of Pub. L.
101-508, set out as a note under section 1395cc of this title.
Amendment by section 4027(4207)(a)(1)(A) of Pub. L. 101-508
effective on the first day of the first month beginning more than 60
days after Nov. 5, 1990, see section 4027(4207)(a)(1)(C) of Pub. L.
101-508, set out as a note under section 1320c-3 of this title.
Section 4027(4207)(a)(4) of Pub. L. 101-508 provided that: ''The
amendments made by this subsection (amending this section and section
1320c-3 of this title) shall apply to actions occurring on or after the
first day of the sixth month beginning after the date of the enactment
of this Act (Nov. 5, 1990).''
Section 6211(i) of Pub. L. 101-239 provided that: ''The amendments
made by this section (amending this section) shall take effect on the
first day of the first month that begins more than 180 days after the
date of the enactment of this Act (Dec. 19, 1989), without regard to
whether regulations to carry out such amendments have been promulgated
by such date.''
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
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.
Section 4009(a)(2), formerly 4009(a)(3), of Pub. L. 100-203, as
redesignated by Pub. L. 100-360, title IV, 411(b)(8)(A)(ii), July 1,
1988, 102 Stat. 772, provided that: ''The amendments made by this
subsection (amending this section) shall apply to actions occurring on
or after the date of the enactment of this Act (Dec. 22, 1987).''
Amendment by Pub. L. 99-514 effective, except as otherwise provided,
as if included in enactment of the Consolidated Omnibus Budget
Reconciliation Act of 1985, Pub. L. 99-272, see section 1895(e) of Pub.
L. 99-514, set out as a note under section 162 of Title 26, Internal
Revenue Code.
Section 9121(c) of Pub. L. 99-272 provided that: ''The amendments
made by this section (enacting this section and amending section 1395cc
of this title) shall take effect on the first day of the first month
that begins at least 90 days after the date of the enactment of this Act
(Apr. 7, 1986).''
Section 4008(c) of Pub. L. 101-508 provided that:
''(1) Study. -- The Secretary of Health and Human Services (acting
through the Inspector General of the Department of Health and Human
Services) shall conduct a study of the effect of State laws prohibiting
the employment of physicians by hospitals on the availability and
accessibility of trauma and emergency care services, and shall include
in such study an analysis of the effect of such laws on the ability of
hospitals to meet the requirements of section 1867 of the Social
Security Act (this section) relating to the examination and treatment of
individuals with an emergency medical condition and women in labor.
''(2) Report. -- By not later than 1 year after the date of the
enactment of this Act (Nov. 5, 1990), the Secretary shall submit a
report to Congress on the study conducted under paragraph (1).''
/1/ So in original. Probably should be followed by a comma.
/2/ So in original.
/3/ So in original. Probably should be ''woman''.
42 USC 1395ee. Practicing Physicians Advisory Council
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Appointment
The Secretary shall appoint, based upon nominations submitted by
medical organizations representing physicians, a Practicing Physicians
Advisory Council (in this section referred to as the ''Council'') to be
composed of 15 physicians, each of whom has submitted at least 250
claims for physicians' services under this subchapter in the previous
year. At least 11 of the members of the Council shall be physicians
described in section 1395x(r)(1) of this title and the members of the
Council shall include both participating and nonparticipating physicians
and physicians practicing in rural areas and underserved urban areas.
(b) Meetings
The Council shall meet once during each calendar quarter to discuss
certain proposed changes in regulations and carrier manual instructions
related to physician services identified by the Secretary. To the
extent feasible and consistent with statutory deadlines, such
consultation shall occur before the publication of such proposed
changes.
(c) Reimbursement of expenses
Members of the Council shall be entitled to receive reimbursement of
expenses and per diem in lieu of subsistence in the same manner as other
members of advisory councils appointed by the Secretary are provided
such reimbursement and per diem under this subchapter.
(Aug. 14, 1935, ch. 531, title XVIII, 1868, as added Nov. 5, 1990,
Pub. L. 101-508, title IV, 4112, 104 Stat. 1388-64.)
A prior section 1395ee, act Aug. 14, 1935, ch. 531, title XVIII,
1868, as added July 30, 1965, Pub. L. 89-97, title I, 102(a), 79 Stat.
329, which provided for creation of a National Medical Review
Committee, functions of such Committee, including submission of annual
reports to the Secretary and Congress, employment of technical
assistance, and for availability of assistance and data, was repealed by
Pub. L. 90-248, title I, 164(c), Jan. 2, 1968, 81 Stat. 874.
Advisory councils established after Jan. 5, 1973, to terminate not
later than the expiration of the 2-year period beginning on the date of
their establishment, unless, in the case of a council established by the
President or an officer of the Federal Government, such council is
renewed by appropriate action prior to the expiration of such 2-year
period, or in the case of a council established by Congress, its
duration is otherwise provided by law. See sections 3(2) and 14 of Pub.
L. 92-463, Oct. 6, 1972, 86 Stat. 770, 776, set out in the Appendix
to Title 5, Government Organization and Employees.
42 USC 1395ff. Determinations of Secretary
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Entitlement to and amount of benefits
The determination of whether an individual is entitled to benefits
under part A or part B of this subchapter, and the determination of the
amount of benefits under part A or part B of this subchapter, and any
other determination with respect to a claim for benefits under part A of
this subchapter or a claim for benefits with respect to home health
services under part B of this subchapter shall be made by the Secretary
in accordance with regulations prescribed by him.
(b) Appeal by individuals; provider representation of beneficiaries
(1) Any individual dissatisfied with any determination under
subsection (a) of this section as to --
(A) whether he meets the conditions of section 426 or section 426a of
this title, or
(B) whether he is eligible to enroll and has enrolled pursuant to the
provisions of part B of this subchapter or section 1395i-2 of this
title,
(C) the amount of benefits under part A or part B of this subchapter
(including a determination where such amount is determined to be zero),
or
(D) any other denial (other than under part B of subchapter XI of
this chapter) of a claim for benefits under part A of this subchapter or
a claim for benefits with respect to home health services under part B
of this subchapter,
shall be entitled to a hearing thereon by the Secretary to the same
extent as is provided in section 405(b) of this title and to judicial
review of the Secretary's final decision after such hearing as is
provided in section 405(g) of this title. Sections 406(a), 1302, and
1395hh of this title shall not be construed as authorizing the Secretary
to prohibit an individual from being represented under this subsection
by a person that furnishes or supplies the individual, directly or
indirectly, with services or items solely on the basis that the person
furnishes or supplies the individual with such a service or item. Any
person that furnishes services or items to an individual may not
represent an individual under this subsection with respect to the issue
described in section 1395pp(a)(2) of this title unless the person has
waived any rights for payment from the beneficiary with respect to the
services or items involved in the appeal. If a person furnishes
services or items to an individual and represents the individual under
this subsection, the person may not impose any financial liability on
such individual in connection with such representation.
(2) Notwithstanding paragraph (1)(C) and (1)(D), in the case of a
claim arising --
(A) under part A of this subchapter, a hearing shall not be available
to an individual under paragraph (1)(C) and (1)(D) if the amount in
controversy is less than $100 and judicial review shall not be available
to the individual under that paragraph if the amount in controversy is
less than $1,000; or
(B) under part B of this subchapter, a hearing shall not be available
to an individual under paragraph (1)(C) and (1)(D) if the amount in
controversy is less than $500 and judicial review shall not be available
to the individual under that paragraph if the aggregate amount in
controversy is less than $1,000.
In determining the amount in controversy, the Secretary, under
regulations, shall allow two or more claims to be aggregated if the
claims involve the delivery of similar or related services to the same
individual or involve common issues of law and fact arising from
services furnished to two or more individuals.
(3) Review of any national coverage determination under section
1395y(a)(1) of this title respecting whether or not a particular type or
class of items or services is covered under this subchapter shall be
subject to the following limitations:
(A) Such a determination shall not be reviewed by any administrative
law judge.
(B) Such a determination shall not be held unlawful or set aside on
the ground that a requirement of section 553 of title 5 or section
1395hh(b) of this title, relating to publication in the Federal Register
or opportunity for public comment, was not satisfied.
(C) In any case in which a court determines that the record is
incomplete or otherwise lacks adequate information to support the
validity of the determination, it shall remand the matter to the
Secretary for additional proceedings to supplement the record and the
court may not determine that an item or service is covered except upon
review of the supplemented record.
(4) A regulation or instruction which relates to a method for
determining the amount of payment under part B of this subchapter and
which was initially issued before January 1, 1981, shall not be subject
to judicial review.
(5) In an administrative hearing pursuant to paragraph (1), where the
moving party alleges that there are no material issues of fact in
dispute, the administrative law judge shall make an expedited
determination as to whether any such facts are in dispute and, if not,
shall determine the case expeditiously.
(Aug. 14, 1935, ch. 531, title XVIII, 1869, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 330, and amended Oct. 30,
1972, Pub. L. 92-603, title II, 299O(a), 86 Stat. 1464; July 18, 1984,
Pub. L. 98-369, div. B, title III, 2354(b)(35), 98 Stat. 1102; Oct.
21, 1986, Pub. L. 99-509, title IX, 9313(a)(1), (b)(1), 9341(a)(1),
100 Stat. 2002, 2037; Aug. 18, 1987, Pub. L. 100-93, 8(e), 101 Stat.
694; Dec. 22, 1987, Pub. L. 100-203, title IV, 4082(a), (b),
4085(i)(18), (19), 101 Stat. 1330-128, 1330-133.)
Parts A and B of this subchapter, referred to in subsecs. (a) and
(b), are classified to sections 1395c et seq. and 1395j et seq.,
respectively, of this title.
Part B of subchapter XI of this chapter, referred to in subsec.
(b)(1)(D), is classified to section 1320c et seq. of this title.
1987 -- Subsec. (a). Pub. L. 100-203, 4085(i)(18), inserted ''or a
claim for benefits with respect to home health services under part B of
this subchapter'' before ''shall''.
Subsec. (b)(2). Pub. L. 100-203, 4085(i)(19), inserted ''and
(1)(D)'' after ''paragraph (1)(C)'' in two places.
Subsec. (b)(3)(B). Pub. L. 100-203, 4082(a), substituted ''section
553'' for ''chapter 5''.
Subsec. (b)(5). Pub. L. 100-203, 4082(b), added par. (5).
Subsec. (c). Pub. L. 100-93 struck out subsec. (c) which read as
follows: ''Any institution or agency dissatisfied with any
determination by the Secretary that it is not a provider of services, or
with any determination described in section 1395cc(b)(2) of this title,
shall be entitled to a hearing thereon by the Secretary (after
reasonable notice and opportunity for hearing) to the same extent as is
provided in section 405(b) of this title, and to judicial review of the
Secretary's final decision after such hearing as is provided in section
405(g) of this title.''
1986 -- Subsec. (a). Pub. L. 99-509, 9341(a)(1)(A), inserted ''or
part B'' after ''amount of benefits under part A''.
Pub. L. 99-509, 9313(b)(1)(A), inserted ''and any other
determination with respect to a claim for benefits under part A of this
subchapter'' before ''shall''.
Subsec. (b)(1). Pub. L. 99-509, 9313(a)(1), in concluding
provisions, inserted at end ''Sections 406(a), 1302, and 1395hh of this
title shall not be construed as authorizing the Secretary to prohibit an
individual from being represented under this subsection by a person that
furnishes or supplies the individual, directly or indirectly, with
services or items solely on the basis that the person furnishes or
supplies the individual with such a service or item. Any person that
furnishes services or items to an individual may not represent an
individual under this subsection with respect to the issue described in
section 1395pp(a)(2) of this title unless the person has waived any
rights for payment from the beneficiary with respect to the services or
items involved in the appeal. If a person furnishes services or items
to an individual and represents the individual under this subsection,
the person may not impose any financial liability on such individual in
connection with such representation.''
Subsec. (b)(1)(C). Pub. L. 99-509, 9341(a)(1)(B), inserted ''or part
B''.
Subsec. (b)(1)(D). Pub. L. 99-509, 9313(b)(1)(B), added subpar.
(D).
Subsec. (b)(2). Pub. L. 99-509, 9341(a)(1)(C), amended par. (2)
generally. Prior to amendment, par. (2) read as follows:
''Notwithstanding the provisions of subparagraph (C) of paragraph (1) of
this subsection, a hearing shall not be available to an individual by
reason of such subparagraph (C) if the amount in controversy is less
than $100; nor shall judicial review be available to an individual by
reason of such subparagraph (C) if the amount in controversy is less
than $1,000.''
Subsec. (b)(3), (4). Pub. L. 99-509, 9341(a)(1)(D), added pars.
(3) and (4).
1984 -- Subsec. (b)(1)(B). Pub. L. 98-369 struck out the comma
before ''or section 1395i-2'' and struck out '', or section 1819'' after
''section 1395i-2 of this title''.
1972 -- Subsec. (b). Pub. L. 92-603 redesignated existing provisions
as par. (1), generally amended conditions under which a dissatisfied
individual shall be entitled to a hearing by Secretary and to judicial
review of final decision of Secretary after such hearing, and added par.
(2).
Section 4082(e)(1), (2) of Pub. L. 100-203 provided that:
''(1) The amendment made by subsection (a) (amending this section)
shall take effect on the date of the enactment of this Act (Dec. 22,
1987).
''(2) The amendment made by subsection (b) (amending this section)
shall apply to requests for hearings filed after the end of the 60-day
period beginning on the date of the enactment of this Act.''
Amendment by Pub. L. 100-93 effective at end of fourteen-day period
beginning Aug. 18, 1987, and inapplicable to administrative proceedings
commenced before end of such period, see section 15(a) of Pub. L.
100-93, set out as a note under section 1320a-7 of this title.
Section 9313(b)(2) of Pub. L. 99-509 provided that: ''The
amendments made by this subsection (amending this section) take effect
on the date of the enactment of this Act (Oct. 21, 1986).''
Section 9341(b) of Pub. L. 99-509 provided that: ''The amendments
made by subsection (a) (amending this section and sections 1395u and
1395pp of this title) shall apply to items and services furnished on or
after January 1, 1987.''
Amendment by Pub. L. 98-369 effective July 18, 1984, but not to be
construed as changing or affecting any right, liability, status, or
interpretation which existed (under the provisions of law involved)
before that date, see section 2354(e)(1) of Pub. L. 98-369, set out as
a note under section 1320a-1 of this title.
Section 299O(b) of Pub. L. 92-603 provided that:
''(1) The provisions of subparagraphs (A) and (B) of section
1869(b)(1) of the Social Security Act (subsec. (b)(1)(A), (B) of this
section), as amended by subsection (a) of this section, shall be
effective on the date of enactment of this Act (Oct. 30, 1972).
''(2) The provisions of paragraph (2) and subparagraph (C) of
paragraph (1) of section 1869(b) of the Social Security Act (subsec.
(b)(1)(C) and (b)(2) of this section), as amended by subsection (a) of
this section, shall be effective with respect to any claims under part A
of title XVIII of such Act (part A of this subchapter), filed --
''(A) in or after the month in which this Act is enacted (Oct.
1972), or
''(B) before the month in which this Act is enacted (Oct. 1972), but
only if a civil action with respect to a final decision of the Secretary
of Health, Education, and Welfare on such claim has not been commenced
under such section 1869(b) (subsec. (b) of this section) before such
month.''
Pub. L. 101-508, title IV, 4113, Nov. 5, 1990, 104 Stat. 1388-64,
provided that: ''The Secretary of Health and Human Services shall carry
out a study of the effects of permitting the aggregation of claims that
involve common issues of law and fact furnished in the same carrier area
to two or more individuals by two or more physicians within the same
12-month period for purposes of appeals provided for under section
1869(b)(2) (subsec. (b)(2) of this section). Such study shall be
conducted in at least four carrier areas. The Secretary shall report on
the results of such study and any recommendations to the Committee on
Finance of the Senate and the Committees on Energy and Commerce and Ways
and Means of the House of Representatives by December 31, 1992.''
Section 4037 of Pub. L. 100-203 provided that:
''(a) Maintaining Current System for Hearings and Appeals. -- Any
hearing conducted under section 1869(b)(1) of the Social Security Act
(subsec. (b)(1) of this section) prior to the earliest of the date on
which the Secretary of Health and Human Services submits the report
required to be submitted by the Secretary under subsection (b)(1) or
September 1 shall be conducted by Administrative Law Judges of the
Office of Hearings and Appeals of the Social Security Administration in
the same manner as are hearings conducted under section 205(b)(1) of
such Act (section 405(b)(1) of this title).
''(b) Study and Report on Use of Telephone Hearings. --
''(1) The Secretary of Health and Human Services and the Comptroller
General of the United States shall each conduct a study on holding
hearings under section 1869(b)(1) of the Social Security Act (subsec.
(b)(1) of this section) by telephone and shall each report the results
of the study not later than 6 months after the date of enactment of this
Act (Dec. 22, 1987).
''(2) The studies under paragraph (1) shall focus on whether
telephone hearings allow for a full and fair evidentiary hearing, in
general, or with respect to any particular category of claims and shall
examine the possible improvements to the hearing process (such as
cost-effectiveness, convenience to the claimant, and reduction in time
under the process) resulting from the use of such hearings as compared
to the adoption of other changes to the process (such as expansions in
staff and resources).''
42 USC 1395gg. Overpayment on behalf of individuals and settlement of
claims for benefits on behalf of deceased individuals
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Payments to providers of services or other person regarded as
payment to individuals
Any payment under this subchapter to any provider of services or
other person with respect to any items or services furnished any
individual shall be regarded as a payment to such individual.
(b) Incorrect payments on behalf of individuals; payment adjustment
Where --
(1) more than the correct amount is paid under this subchapter to a
provider of services or other person for items or services furnished an
individual and the Secretary determines (A) that, within such period as
he may specify, the excess over the correct amount cannot be recouped
from such provider of services or other person, or (B) that such
provider of services or other person was without fault with respect to
the payment of such excess over the correct amount, or
(2) any payment has been made under section 1395f(e) of this title to
a provider of services or other person for items or services furnished
an individual,
proper adjustments shall be made, under regulations prescribed (after
consultation with the Railroad Retirement Board) by the Secretary, by
decreasing subsequent payments --
(3) to which such individual is entitled under subchapter II of this
chapter or under the Railroad Retirement Act of 1974 (45 U.S.C. 231 et
seq.), as the case may be, or
(4) if such individual dies before such adjustment has been
completed, to which any other individual is entitled under subchapter II
of this chapter or under the Railroad Retirement Act of 1974 (45 U.S.C.
231 et seq.), as the case may be, with respect to the wages and
self-employment income or the compensation constituting the basis of the
benefits of such deceased individual under subchapter II of this
chapter.
As soon as practicable after any adjustment under paragraph (3) or
(4) is determined to be necessary, the Secretary, for purposes of this
section, section 1395i(g) of this title, and section 1395t(f) of this
title, shall certify (to the Railroad Retirement Board if the adjustment
is to be made by decreasing subsequent payments under the Railroad
Retirement Act of 1974 (45 U.S.C. 231 et seq.)) the amount of the
overpayment as to which the adjustment is to be made. For purposes of
clause (B) of paragraph (1), such provider of services or such other
person shall, in the absence of evidence to the contrary, be deemed to
be without fault if the Secretary's determination that more than such
correct amount was paid was made subsequent to the third year following
the year in which notice was sent to such individual that such amount
had been paid; except that the Secretary may reduce such three-year
period to not less than one year if he finds such reduction is
consistent with the objectives of this subchapter.
(c) Exception to subsection (b) payment adjustment
There shall be no adjustment as provided in subsection (b) of this
section (nor shall there be recovery) in any case where the incorrect
payment has been made (including payments under section 1395f(e) of this
title) with respect to an individual who is without fault or where the
adjustment (or recovery) would be made by decreasing payments to which
another person who is without fault is entitled as provided in
subsection (b)(4) of this section, if such adjustment (or recovery)
would defeat the purposes of subchapter II or subchapter XVIII of this
chapter or would be against equity and good conscience. Adjustment or
recovery of an incorrect payment (or only such part of an incorrect
payment as the Secretary determines to be inconsistent with the purposes
of this subchapter) against an individual who is without fault shall be
deemed to be against equity and good conscience if (A) the incorrect
payment was made for expenses incurred for items or services for which
payment may not be made under this subchapter by reason of the
provisions of paragraph (1) or (9) of section 1395y(a) of this title and
(B) if the Secretary's determination that such payment was incorrect was
made subsequent to the third year following the year in which notice of
such payment was sent to such individual; except that the Secretary may
reduce such three-year period to not less than one year if he finds such
reduction is consistent with the objectives of this subchapter.
(d) Liability of certifying or disbursing officer for failure to
recoup
No certifying or disbursing officer shall be held liable for any
amount certified or paid by him to any provider of services or other
person where the adjustment or recovery of such amount is waived under
subsection (c) of this section or where adjustment under subsection (b)
of this section is not completed prior to the death of all persons
against whose benefits such adjustment is authorized.
(e) Settlement of claims for benefits under this subchapter on behalf
of deceased individuals
If an individual, who received services for which payment may be made
to such individual under this subchapter, dies, and payment for such
services was made (other than under this subchapter), and the individual
died before any payment due him under this subchapter with respect to
such services was completed, payment of the amount due (including the
amount of any unnegotiated checks) shall be made --
(1) if the payment for such services was made (before or after such
individual's death) by a person other than the deceased individual, to
the person or persons determined by the Secretary under regulations to
have paid for such services, or if the payment for such services was
made by the deceased individual before his death, to the legal
representative of the estate of such deceased individual, if any;
(2) if there is no person who meets the requirements of paragraph
(1), to the person, if any, who is determined by the Secretary to be the
surviving spouse of the deceased individual and who was either living in
the same household with the deceased at the time of his death or was,
for the month in which the deceased individual died, entitled to a
monthly benefit on the basis of the same wages and self-employment
income as was the deceased individual;
(3) if there is no person who meets the requirements of paragraph (1)
or (2), or if the person who meets such requirements dies before the
payment due him under this subchapter is completed, to the child or
children, if any, of the deceased individual who were, for the month in
which the deceased individual died, entitled to monthly benefits on the
basis of the same wages and self-employment income as was the deceased
individual (and, in case there is more than one such child, in equal
parts to each such child);
(4) if there is no person who meets the requirements of paragraph
(1), (2), or (3), or if each person who meets such requirements dies
before the payment due him under this subchapter is completed, to the
parent or parents, if any, of the deceased individual who were, for the
month in which the deceased individual died, entitled to monthly
benefits on the basis of the same wages and self-employment income as
was the deceased individual (and, in case there is more than one such
parent, in equal parts to each such parent);
(5) if there is no person who meets the requirements of paragraph
(1), (2), (3), or (4), or if each person who meets such requirements
dies before the payment due him under this subchapter is completed, to
the person, if any, determined by the Secretary to be the surviving
spouse of the deceased individual;
(6) if there is no person who meets the requirements of paragraph
(1), (2), (3), (4), or (5), or if each person who meets such
requirements dies before the payment due him under this subchapter is
completed, to the person or persons, if any, determined by the Secretary
to be the child or children of the deceased individual (and, in case
there is more than one such child, in equal parts to each such child);
(7) if there is no person who meets the requirements of paragraph
(1), (2), (3), (4), (5), or (6), or if each person who meets such
requirements dies before the payment due him under this subchapter is
completed, to the parent or parents, if any, of the deceased individual
(and, in case there is more than one such parent, in equal parts to each
such parent); or
(8) if there is no person who meets the requirements of paragraph
(1), (2), (3), (4), (5), (6), or (7), or if each person who meets such
requirements dies before the payment due him under this subchapter is
completed, to the legal representatives of the estate of the deceased
individual, if any.
(f) Settlement of claims for section 1395k benefits on behalf of
deceased individuals
If an individual who received medical and other health services for
which payment may be made under section 1395k(a)(1) of this title dies,
and no assignment of the right to payment for such services was made by
such individual before his death, and payment for such services has not
been made --
(1) if the person or persons who furnished the services agree to the
terms of assignment specified in section 1395u(b)(3)(B)(ii) of this
title with respect to the services, payment for such services shall be
made to such person or persons, and
(2) if the person or persons who furnished the services do not agree
to the terms of assignment specified in section 1395u(b)(3)(B)(ii) of
this title with respect to the services, payment for such services shall
be made on the basis of an itemized bill to the person who has agreed to
assume the legal obligation to make payment for such services and files
a request for payment (with such accompanying evidence of such legal
obligation as may be required in regulations),
but only in such amount and subject to such conditions as would be
applicable if the individual who received the services had not died.
(g) Refund of premiums for deceased individuals
If an individual, who is enrolled under section 1395i-2(c) of this
title or under section 1395p of this title, dies, and premiums with
respect to such enrollment have been received with respect to such
individual for any month after the month of his death, such premiums
shall be refunded to the person or persons determined by the Secretary
under regulations to have paid such premiums or if payment for such
premiums was made by the deceased individual before his death, to the
legal representative of the estate of such deceased individual, if any.
If there is no person who meets the requirements of the preceding
sentence such premiums shall be refunded to the person or persons in the
priorities specified in paragraphs (2) through (7) of subsection (e) of
this section.
(Aug. 14, 1935, ch. 531, title XVIII, 1870, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 331, and amended Jan. 2,
1968, Pub. L. 90-248, title I, 154(b), (c), 81 Stat. 862; Oct. 30,
1972, Pub. L. 92-603, title II, 261(a), 266, 281(a), (b), 86 Stat.
1448, 1450, 1454, 1455; Oct. 16, 1974, Pub. L. 93-445, title III, 309,
88 Stat. 1358; Dec. 5, 1980, Pub. L. 96-499, title IX, 954(a), 94
Stat. 2647; Sept. 3, 1982, Pub. L. 97-248, title I, 128(d)(1), 96
Stat. 367; Dec, 22, 1987, Pub. L. 100-203, title IV, 4039(h)(7),
4096(a)(2), 101 Stat. 1330-139, as amended July 1, 1988, Pub. L.
100-360, title IV, 411(e)(3), 102 Stat. 776; July 1, 1988, Pub. L.
100-360, title IV, 411(j)(4)(B), 102 Stat. 791.)
The Railroad Retirement Act of 1974, referred to in subsec. (b), is
title I of Pub. L. 93-445, Oct. 16, 1974, 88 Stat. 1305, and is
classified generally to subchapter IV ( 231 et seq.) of chapter 9 of
Title 45, Railroads. Such title I completely amended and revised the
Railroad Retirement Act of 1937 (approved June 24, 1937, ch. 382, 50
Stat. 307), and as thus amended and revised, the 1937 Act was
redesignated the Railroad Retirement Act of 1974. Previously, the 1937
Act had completely amended and revised the Railroad Retirement Act of
1935 (approved Aug. 29, 1935, ch. 812, 49 Stat. 967). Section 201 of the
1937 Act provided that the 1935 Act, as in force prior to amendment by
the 1937 Act, may be cited as the Railroad Retirement Act of 1935; and
that the 1935 Act, as amended by the 1937 Act may be cited as the
Railroad Retirement Act of 1937. The Railroad Retirement Acts of 1935
and 1937 were classified to subchapter II ( 215 et seq.) and subchapter
III ( 228a et seq.), respectively, of chapter 9 of Title 45.
1988 -- Pub. L. 100-360, 411(e)(3), added Pub. L. 100-203,
4039(h)(7), see 1987 Amendment note below.
Subsec. (f)(1), (2). Pub. L. 100-360, 411(j)(4)(B), substituted
''of assignment specified in'' for ''specified in subclauses (I) and
(II) of''.
1987 -- Pub. L. 100-203, 4039(h)(7), as added by Pub. L. 100-360,
411(e)(3), amended section catchline generally.
Subsec. (f)(1), (2). Pub. L. 100-203, 4096(a)(2), substituted ''to
the terms specified in subclauses (I) and (II) of section
1395u(b)(3)(B)(ii) of this title with respect to the services'' for
''that the reasonable charge is the full charge for the services''.
1982 -- Subsec. (c). Pub. L. 97-248 substituted ''section 1395y(a)''
for ''section 1395y''.
1980 -- Subsec. (f). Pub. L. 96-499 amended subsec. (f) generally,
inserting provision for payments to providers of medical and other
health services where the person or persons furnishing the services did
not agree that the reasonable charge was the full charge for such
services.
1974 -- Subsec. (b). Pub. L. 93-445 substituted ''Railroad
Retirement Act of 1974'' for ''Railroad Retirement Act of 1937'',
wherever appearing.
1972 -- Subsec. (b). Pub. L. 92-603, 281(a), required that provider
of services or other person be without fault with respect to payment of
excess over correct amount as prerequisite to adjustment or recovery of
incorrect payments.
Subsec. (c). Pub. L. 92-603, 261(a), 281(b), substituted ''or where
the adjustment (or recovery) would be made by decreasing payments to
which another person who is without fault is entitled as provided in
subsection (b)(4) of this section, if'' for ''and where'', inserted
reference to subchapter XVIII of this chapter, and inserted provisions
covering the adjustment or recovery of incorrect payments against
individuals who are without fault.
Subsec. (g). Pub. L. 92-603, 266, added subsec. (g).
1968 -- Pub. L. 90-248, 154(b), provided for settlement of claims
for benefits on behalf of deceased individuals in section catchline.
Subsecs. (e), (f). Pub. L. 90-248, 154(c), added subsecs. (e) and
(f).
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.
Amendment by section 4096(a)(2) of Pub. L. 100-203 applicable to
services furnished on or after Jan. 1, 1988, see section 4096(d) of
Pub. L. 100-203, set out as a note under section 1320c-3 of this title.
Amendment by Pub. L. 97-248 effective Sept. 3, 1982, see section
128(e)(3) of Pub. L. 97-248, set out as a note under section 1395x of
this title.
Section 954(b) of Pub. L. 96-499 provided that: ''The amendment
made by this section (amending this section) shall apply only to claims
filed on or after January 1, 1981.''
Amendment by Pub. L. 93-445 effective Jan. 1, 1975, see section 603
of Pub. L. 93-445, set out as a note under section 402 of this title.
Section 261(b) of Pub. L. 92-603 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply with respect
to waiver actions considered after the date of the enactment of this Act
(Oct. 30, 1972).''
Section 281(g) of Pub. L. 92-603 provided that: ''The provisions of
subsection (a)(1) (amending this section) shall apply with respect to
notices of payment sent to individuals after the date of enactment of
this Act (Oct. 30, 1972). The provisions of subsections (a)(2), (b),
(c), and (d) (amending this section and sections 1395u and 1395cc of
this title) shall apply in the case of notices sent to individuals after
1968. The provisions of subsections (e) and (f) (amending sections
1395f and 1395n of this title) shall apply in the case of services
furnished (or deemed to have been furnished) after 1970.''
Pub. L. 101-239, title VI, 6109, Dec. 19, 1989, 103 Stat. 2213,
provided that: ''In the case where more than the correct amount may
have been paid to a physician or individual under part B of title XVIII
of the Social Security Act (part B of this subchapter) with respect to
services furnished during the period beginning on July 1, 1985, and
ending on March 31, 1986, as a result of a carrier's establishing
statewide fees for certain procedure codes while the carrier was in the
process of implementing the national common procedure coding system of
the Health Care Financing Administration, the provisions of section
1870(c) of the Social Security Act (subsec. (c) of this section) shall
apply, without the need for affirmative action by such a physician or
individual, so as to prevent any recoupment, or other decrease in
subsequent payments, to the physician or individual. The previous
sentence shall apply to claims for items and services which were
reopened by carriers on or after July 31, 1987.''
42 USC 1395hh. Regulations
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Authority to prescribe regulations; ineffectiveness of
substantive rules not promulgated by regulation
(1) The Secretary shall prescribe such regulations as may be
necessary to carry out the administration of the insurance programs
under this subchapter. When used in this subchapter, the term
''regulations'' means, unless the context otherwise requires,
regulations prescribed by the Secretary.
(2) No rule, requirement, or other statement of policy (other than a
national coverage determination) that establishes or changes a
substantive legal standard governing the scope of benefits, the payment
for services, or the eligibility of individuals, entities, or
organizations to furnish or receive services or benefits under this
subchapter shall take effect unless it is promulgated by the Secretary
by regulation under paragraph (1).
(b) Notice of proposed regulations; public comment
(1) Except as provided in paragraph (2), before issuing in final form
any regulation under subsection (a) of this section, the Secretary shall
provide for notice of the proposed regulation in the Federal Register
and a period of not less than 60 days for public comment thereon.
(2) Paragraph (1) shall not apply where --
(A) a statute specifically permits a regulation to be issued in
interim final form or otherwise with a shorter period for public
comment,
(B) a statute establishes a specific deadline for the implementation
of a provision and the deadline is less than 150 days after the date of
the enactment of the statute in which the deadline is contained, or
(C) subsection (b) of section 553 of title 5 does not apply pursuant
to subparagraph (B) of such subsection.
(c) Publication of certain rules; public inspection; changes in
data collection and retrieval
(1) The Secretary shall publish in the Federal Register, not less
frequently than every 3 months, a list of all manual instructions,
interpretative rules, statements of policy, and guidelines of general
applicability which --
(A) are promulgated to carry out this subchapter, but
(B) are not published pursuant to subsection (a)(1) of this section
and have not been previously published in a list under this subsection.
(2) Effective June 1, 1988, each fiscal intermediary and carrier
administering claims for extended care, post-hospital extended care,
home health care, and durable medical equipment benefits under this
subchapter shall make available to the public all interpretative
materials, guidelines, and clarifications of policies which relate to
payments for such benefits.
(3) The Secretary shall to the extent feasible make such changes in
automated data collection and retrieval by the Secretary and fiscal
intermediaries with agreements under section 1395h of this title as are
necessary to make easily accessible for the Secretary and other
appropriate parties a data base which fairly and accurately reflects the
provision of extended care, post-hospital extended care and home health
care benefits pursuant to this subchapter, including such categories as
benefit denials, results of appeals, and other relevant factors, and
selectable by such categories and by fiscal intermediary, service
provider, and region.
(Aug. 14, 1935, ch. 531, title XVIII, 1871, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a) 79 Stat. 331, and amended Oct. 21,
1986, Pub. L. 99-509, title IX, 9321(e)(1), 100 Stat. 2017; Dec. 22,
1987, Pub. L. 100-203, title IV, 4035(b), (c), 101 Stat. 1330-78.)
1987 -- Subsec. (a). Pub. L. 100-203, 4035(b), designated existing
provisions as par. (1) and added par. (2).
Subsec. (c). Pub. L. 100-203, 4035(c), added subsec. (c).
1986 -- Pub. L. 99-509 designated existing provisions as subsec.
(a) and added subsec. (b).
Amendment by Pub. L. 100-203 effective Dec. 22, 1987, and
applicable to budgets for fiscal years beginning with fiscal year 1989,
see section 4035(a)(3) of Pub. L. 100-203, set out as a note under
section 1395h of this title.
Section 9321(e)(3)(A) of Pub. L. 99-509 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
notices of proposed rulemaking issued after the date of the enactment of
this Act (Oct. 21, 1986).''
Pub. L. 101-508, title IV, 4027(4207)(j), Nov. 5, 1990, 104 Stat.
1388-124, provided that: ''The Secretary of Health and Human Services
shall issue such regulations (on an interim or other basis) as may be
necessary to implement this title and the amendments made by this title
(see Tables for classification).''
Section 4039(g) of title IV of Pub. L. 100-203 provided that: ''The
Secretary of Health and Human Services shall issue such regulations (on
an interim or other basis) as may be necessary to implement this
subtitle and the amendments made by this subtitle (subtitle A (
4001-4097) of title IV of Pub. L. 100-203, see Tables for
classification).''
42 USC 1395ii. Application of certain provisions of subchapter II
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
The provisions of sections 406 and 416(j) of this title, and of
subsections (a), (d), (e), (h), (i), (j), (k), and (l) of section 405 of
this title, shall also apply with respect to this subchapter to the same
extent as they are applicable with respect to subchapter II of this
chapter.
(Aug. 14, 1935, ch. 531, title XVIII, 1872, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 332, and amended Oct. 30,
1972, Pub. L. 92-603, title II, 242(a), 86 Stat. 1419; July 18, 1984,
Pub. L. 98-369, div. B, title III, 2354(b)(36), 98 Stat. 1102.)
1984 -- Pub. L. 98-369 struck out the comma after ''406'' and struck
out reference to subsec. (f) of section 405 of this title.
1972 -- Pub. L. 92-603 struck out reference to provisions of section
408 of this title.
Amendment by Pub. L. 98-369 effective July 18, 1984, but not to be
construed as changing or affecting any right, liability, status, or
interpretation which existed (under the provisions of law involved)
before that date, see section 2354(e)(1) of Pub. L. 98-369, set out as
a note under section 1320a-1 of this title.
Amendment by Pub. L. 92-603 not applicable to any acts, statements,
or representations made or committed prior to Oct. 30, 1972, see
section 242(d) of Pub. L. 92-603, set out as an Effective Date note
under section 1320a-7b of this title.
42 USC 1395jj. Designation of organization or publication by name
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
Designation in this subchapter, by name, of any nongovernmental
organization or publication shall not be affected by change of name of
such organization or publication, and shall apply to any successor
organization or publication which the Secretary finds serves the purpose
for which such designation is made.
(Aug. 14, 1935, ch. 531, title XVIII, 1873, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 332.)
42 USC 1395kk. Administration of insurance programs
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Functions of Secretary; performance directly or by contract
Except as otherwise provided in this subchapter and in the Railroad
Retirement Act of 1974 (45 U.S.C. 231 et seq.), the insurance programs
established by this subchapter shall be administered by the Secretary.
The Secretary may perform any of his functions under this subchapter
directly, or by contract providing for payment in advance or by way of
reimbursement, and in such installments, as the Secretary may deem
necessary.
(b) Contracts to secure special data, actuarial information, etc.
The Secretary may contract with any person, agency, or institution to
secure on a reimbursable basis such special data, actuarial information,
and other information as may be necessary in the carrying out of his
functions under this subchapter.
(c) Oaths and affirmations
In the course of any hearing, investigation, or other proceeding that
he is authorized to conduct under this subchapter, the Secretary may
administer oaths and affirmations.
(Aug. 14, 1935, ch. 531, title XVIII, 1874, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 332, and amended July 30,
1965, Pub. L. 89-97, title I, 111(a), 79 Stat. 340; Oct. 30, 1972,
Pub. L. 92-603, title II, 289, 86 Stat. 1457; Oct. 16, 1974, Pub. L.
93-445, title III, 310, 88 Stat. 1359.)
The Railroad Retirement Act of 1974, referred to in subsec. (a), is
title I of Pub. L. 93-445, Oct. 16, 1974, 88 Stat. 1305, and is
classified generally to subchapter IV ( 231 et seq.) of chapter 9 of
Title 45, Railroads. Such title I completely amended and revised the
Railroad Retirement Act of 1937 (approved June 24, 1937, ch. 382, 50
Stat. 307), and as thus amended and revised, the 1937 Act was
redesignated the Railroad Retirement Act of 1974. Previously, the 1937
Act had completely amended and revised the Railroad Retirement Act of
1935 (approved Aug. 29, 1935, ch. 812, 49 Stat. 967). Section 201 of the
1937 Act provided that the 1935 Act, as in force prior to amendment by
the 1937 Act, may be cited as the Railroad Retirement Act of 1935; and
that the 1935 Act, as amended by the 1937 Act may be cited as the
Railroad Retirement Act of 1937. The Railroad Retirement Acts of 1935
and 1937 were classified to subchapter II ( 215 et seq.) and subchapter
III ( 228a et seq.), respectively, of chapter 9 of Title 45.
1974 -- Subsec. (a). Pub. L. 93-445 substituted ''Railroad
Retirement Act of 1974'' for ''Railroad Retirement Act of 1937''.
1972 -- Subsec. (c). Pub. L. 92-603 added subsec. (c).
1965 -- Subsec. (a). Pub. L. 89-97 inserted reference to Railroad
Retirement Act of 1937 in first sentence.
Amendment by Pub. L. 93-445 effective Jan. 1, 1975, see section 603
of Pub. L. 93-445, set out as a note under section 402 of this title.
Amendment by Pub. L. 89-97 applicable to calendar year 1966 or to
any subsequent calendar year but only if by October 1 immediately
preceding such calendar year the Railroad Retirement Tax Act provides
for a maximum amount of monthly compensation taxable under such Act
during all months of such calendar year equal to one-twelfth of maximum
wages which Federal Insurance Contributions Act provides may be counted
for such calendar year, see section 111(e) of Pub. L. 89-97.
42 USC 1395ll. Studies and recommendations
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Health care of the aged and disabled
The Secretary shall carry on studies and develop recommendations to
be submitted from time to time to the Congress relating to health care
of the aged and the disabled, including studies and recommendations
concerning (1) the adequacy of existing personnel and facilities for
health care for purposes of the programs under parts A and B of this
subchapter; (2) methods for encouraging the further development of
efficient and economical forms of health care which are a constructive
alternative to inpatient hospital care; and (3) the effects of the
deductibles and coinsurance provisions upon beneficiaries, persons who
provide health services, and the financing of the program.
(b) Operation and administration of insurance programs
The Secretary shall make a continuing study of the operation and
administration of the insurance programs under parts A and B of this
subchapter (including a validation of the accreditation process of the
Joint Commission on Accreditation of Hospitals, the operation and
administration of health maintenance organizations authorized by section
226 of the Social Security Amendments of 1972 (42 U.S.C. 1395mm), the
experiments and demonstration projects authorized by section 402 of the
Social Security Amendments of 1967 (42 U.S.C. 1395b-1) and the
experiments and demonstration projects authorized by section 222(a) of
the Social Security Amendments of 1972 (42 U.S.C. 1395b-1 note)), and
shall transmit to the Congress annually a report concerning the
operation of such programs.
(Aug. 14, 1935, ch. 531, title XVIII, 1875, as added July 30, 1965,
Pub. L. 89-97, title I, 102(a), 79 Stat. 332, and amended Jan. 2,
1968, Pub. L. 90-248, title IV, 402(c), 81 Stat. 931; Oct. 30, 1972,
Pub. L. 92-603, title II, 201(c)(7), 222(c), 226(d), 244(d), 86 Stat.
1373, 1393, 1404, 1423; July 18, 1984, Pub. L. 98-369, div. B, title
III, 2354(b)(17), 98 Stat. 1101; Oct. 21, 1986, Pub. L. 99-509, title
IX, 9316(a), 100 Stat. 2006; Dec. 22, 1987, Pub. L. 100-203, title
IV, 4085(i)(20), 101 Stat. 1330-133; Nov. 10, 1988, Pub. L. 100-647,
title VIII, 8413, 102 Stat. 3801; Dec. 13, 1989, Pub. L. 101-234,
title III, 301(b)(5), (d)(2), 103 Stat. 1985, 1986; Dec. 19, 1989,
Pub. L. 101-239, title VI, 6103(b)(3)(A), 103 Stat. 2199.)
Parts A and B of this subchapter, referred to in text, are classified
to sections 1395c et seq. and 1395j et seq., respectively, of this
title.
Section 226 of the Social Security Amendments of 1972, referred to in
subsec. (b), is section 226 of Pub. L. 92-603, which enacted section
1395mm of this title and provisions set out as notes under that section
and amended this section and sections 1395f, 1395l, and 1396b of this
title.
Section 402 of the Social Security Amendments of 1967, referred to in
subsec. (b), is section 402 of Pub. L. 90-248, which enacted section
1395b-1 of this title and amended this section.
Section 222(a) of the Social Security Amendments of 1972, referred to
in subsec. (b), is section 222(a) of Pub. L. 92-603, which enacted
provisions set out as note under section 1395b-1 of this title.
1989 -- Subsec. (c). Pub. L. 101-239 struck out subsec. (c) which
related to patient outcome assessment research program.
Subsec. (c)(7). Pub. L. 101-234, 301(b)(5), (d)(2), amended par.
(7) identically, substituting ''date of the enactment of this section''
for ''date of the enactment of this Act''.
1988 -- Subsec. (c)(3). Pub. L. 100-647 amended par. (3) generally.
Prior to amendment, par. (3) read as follows: ''For purposes of
carrying out the research program, there are authorized to be
appropriated --
''(A) from the Federal Hospital Insurance Trust Fund $4,000,000 for
fiscal year 1987 and $5,000,000 for each of fiscal years 1988 and 1989,
and
''(B) from the Federal Supplementary Medical Insurance Trust Fund
$2,000,000 for fiscal year 1987 and $2,500,000 for each of fiscal years
1988 and 1989.''
1987 -- Subsec. (c)(3)(B). Pub. L. 100-203 substituted ''fiscal year
1987'' for ''fiscal years 1987''.
1986 -- Subsec. (c). Pub. L. 99-509 added subsec. (c).
1984 -- Subsec. (b). Pub. L. 98-369 struck out ''the'' after ''Joint
Commission on''.
1972 -- Subsec. (a). Pub. L. 92-603, 201(c)(7), inserted ''and the
disabled'' after ''aged''.
Subsec. (b). Pub. L. 92-603, 222(c), 226(d)(1), 244(d), substituted
''(including a validation of the accreditation process of the Joint
Commission on the Accreditation of Hospitals, the operation and
administration of health maintenance organizations authorized by section
226 of the Social Security Amendments of 1972, the experiments and
demonstration projects authorized by section 402 of the Social Security
Amendments of 1967 and the experiments and demonstration projects
authorized by section 222(a) of the Social Security Amendments of
1972)'' for ''(including the experimentation authorized by section 402
of the Social Security Amendments of 1967)''. Pub. L. 92-603,
226(d)(2), which directed the substitution of ''1972'' for ''1971'',
could not be executed because ''1971'' did not appear.
1968 -- Subsec. (b). Pub. L. 90-248 inserted ''(including the
experimentation authorized by section 402 of the Social Security
Amendments of 1967'' after ''under parts A and B of this subchapter''.
Section 6103(b)(3)(A) of Pub. L. 101-239 provided that the amendment
made by that section is effective for fiscal years beginning after
fiscal year 1990.
Amendment by Pub. L. 98-369 effective July 18, 1984, but not to be
construed as changing or affecting any right, liability, status, or
interpretation which existed (under the provisions of law involved)
before that date, see section 2354(e)(1) of Pub. L. 98-369, set out as
a note under section 1320a-1 of this title.
Amendment by section 226(d) 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.
Pub. L. 100-360, title II, 208, July 1, 1988, 102 Stat. 732, as
amended by Pub. L. 100-485, title VI, 608(d)(8), Oct. 13, 1988, 102
Stat. 2415, which required Secretary of Health and Human Services to
conduct a survey of adult day care services in United States and to
report to Congress, by not later than 1 year after July 1, 1988, on the
information collected in the survey, was repealed by Pub. L. 101-234,
title II, 201(a), Dec. 13, 1989, 103 Stat. 1981.
Section 9313(d) of Pub. L. 99-509, as amended by Pub. L. 100-203,
title IV, 4085(i)(21)(A), Dec. 22, 1987, 101 Stat. 1330-133, provided
that:
''(1) In general. -- The Secretary of Health and Human Services shall
arrange for a study to design a strategy for reviewing and assuring the
quality of care for which payment may be made under title XVIII of the
Social Security Act (this subchapter).
''(2) Items included in study. -- Among other items, the study shall
--
''(A) identify the appropriate considerations which should be used in
defining 'quality of care';
''(B) evaluate the relative roles of structure, process, and outcome
standards in assuring quality of care;
''(C) develop prototype criteria and standards for defining and
measuring quality of care;
''(D) evaluate the adequacy and focus of the current methods for
measuring, reviewing, and assuring quality of care;
''(E) evaluate the current research on methodologies for measuring
quality of care, and suggest areas of research needed for further
progress;
''(F) evaluate the adequacy and range of methods available to correct
or prevent identified problems with quality of care;
''(G) review mechanisms available for promoting, coordinating, and
supervising at the national level quality review and assurance
activities; and
''(H) develop general criteria which may be used in establishing
priorities in the allocation of funds and personnel in reviewing and
assuring quality of care.
''(3) Report. -- The Secretary shall submit to Congress, not later
than January 1, 1990, a report on the study. Such report shall address
the items described in paragraph (2) and shall include recommendations
with respect to strengthening quality assurance and review activities
for services furnished under the medicare program.
''(4) Arrangements for study. -- (A) The Secretary shall request the
National Academy of Sciences, acting through appropriate units, to
submit an application to conduct the study described in this subsection.
If the Academy submits an acceptable application, the Secretary shall
enter into an appropriate arrangement with the Academy for the conduct
of the study. If the Academy does not submit an acceptable application
to conduct the study, the Secretary may request one or more appropriate
nonprofit private entities to submit an application to conduct the study
and may enter into an appropriate arrangement for the conduct of the
study by the entity which submits the best acceptable application.
''(B) In developing plans for the conduct of the study, the Secretary
shall assure that consumer and provider groups, peer review
organizations, the Joint Commission on Accreditation of Hospitals,
professional societies, and private purchasers of care with experience
and expertise in the monitoring of the quality of care are consulted.
''(5) Coordination. -- The Secretary shall designate an office with
responsibilities for coordinating studies, under this subsection and
other authority, relating to the quality of services furnished to
medicare and medicaid beneficiaries, in particular studies relating to
the evaluation of the prospective payment system on the quality of
health care provided to medicare beneficiaries. These responsibilities
shall include assessing the feasibility and costs of alternative studies
in relation to their importance, overseeing and coordinating access to
needed data, and maintaining a clearinghouse for both public and private
sector studies.''
(Section 4085(i)(21) of Pub. L. 100-203 provided that the amendment
to section 9313(d)(3) of Pub. L. 99-509, set out above, by section
4085(i)(21)(A) of Pub. L. 100-203 is effective as if included in
enactment of Pub. L. 99-509.)
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.
Pub. L. 96-499, title IX, 931(f), Dec. 5, 1980, 94 Stat. 2634,
which related to a study of medicare coverage of certain additional
detoxification-related services, was repealed by Pub. L. 97-35, title
XXI, 2121(h), Aug. 13, 1981, 95 Stat. 796.
Pub. L. 96-499, title IX, 937(b), Dec. 5, 1980, 94 Stat. 2640,
provided that the Secretary of Health and Human Services submit to the
Congress by Jan. 1, 1982, legislative recommendations with respect to
reimbursement under title XVIII of the Social Security Act (this
subchapter) for services furnished by optometrists in connection with
cataracts and such other services which they are legally authorized to
perform.
Therapy Services, and Foot Conditions; Grants,
Payments, and Expenditures
Pub. L. 96-499, title IX, 958, Dec. 5, 1980, 94 Stat. 2648,
directed the Secretary of Health and Human Services to carry out certain
demonstration projects and conduct certain studies as follows: (a) a
demonstration project to determine extent to which nutritional therapy
in early renal failure could retard the disease with resultant
substantive deferment of dialysis, and aspects of making such therapy
available under this subchapter, report to Congress to be submitted
within twenty-four months of Dec. 5, 1980; (b) demonstration projects
with respect to waiving the applicable cost sharing amounts which
beneficiaries under this subchapter had to pay for obtaining a second
opinion on having surgery, report to be submitted within one year after
Dec. 5, 1980; (c) a study of conditions under which services of
registered dietitians could be covered as a home health benefit under
this subchapter, report to be submitted within twenty-four months of
Dec. 5, 1980; (d) demonstration projects to determine aspects of
making services of clinical social workers more generally available
under this subchapter, report to be submitted within twenty-four months
of Dec. 5, 1980; (e) a study of methods for providing coverage under
part B of this subchapter for orthopedic shoes for individuals with
disabling or deforming conditions requiring special fitting
considerations, or requiring special shoes in conjunction with the use
of an orthosis or foot support, report to be submitted no later than
July 1, 1981; (f) a study of conditions under which services with
respect to respiratory therapy could be covered as a home health benefit
under this subchapter, report to be submitted within twenty-four months
of Dec. 5, 1980; and (g) a study analyzing cost effects of alternative
approaches to improving coverage under this subchapter for treatment of
various types of foot conditions, report to be submitted within
twenty-four months of Dec. 5, 1980. Payments and expenditures for such
studies and projects were to be made in appropriate part from the
Federal Hospital Insurance Trust Fund established by section 1395i of
this title, and the Federal Supplemental Medical Insurance Trust Fund
established by section 1395t of this title.
Pub. L. 96-265, title V, 506, June 9, 1980, 94 Stat. 475, provided
that:
''(a) The Secretary of Health and Human Services is authorized to
provide for the participation, by the Social Security Administration, in
a demonstration project relating to the terminally ill which is
currently being conducted within the Department of Health and Human
Services. The purpose of such participation shall be to study the
impact on the terminally ill of provisions of the disability programs
administered by the Social Security Administration and to determine how
best to provide services needed by persons who are terminally ill
through programs over which the Social Security Administration has
administrative responsibility.
''(b) For the purpose of carrying out this section there are
authorized to be appropriated such sums (not in excess of $2,000,000 for
any fiscal year) as may be necessary.''
Later Than June 13, 1978
Pub. L. 95-210, 4, Dec. 13, 1977, 91 Stat. 1490, provided that the
Secretary submit to the Congress, no later than six months after Dec.
13, 1977, a report on the advantages and disadvantages of extending
coverage under this subchapter to urban or rural comprehensive mental
health centers and to centers for treatment of alcoholism and drug
abuse.
Congress
Pub. L. 95-142, 12, Oct. 25, 1977, 91 Stat. 1197, provided that
the Comptroller General conduct a comprehensive study and review of the
administrative structure established for the processing of claims under
this subchapter for the purpose of determining whether and to what
extent more efficient claims administration under this subchapter could
be achieved and that the Comptroller General submit to the Congress no
later than July 1, 1979, a complete report with respect to such study
and review.
Congress
Pub. L. 95-142, 18, Oct. 25, 1977, 91 Stat. 1202, provided that
not later than one year after Oct. 25, 1977, the Secretary of Health,
Education, and Welfare submit to the appropriate committees of the
Congress a report analyzing, evaluating, and making recommendations with
respect to all aspects of the delivery of home health and other in-home
services authorized to be provided under subchapters XVIII, XIX, and XX
of this chapter.
42 USC 1395mm. Payments to health maintenance organizations and
competitive medical plans
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Rates and adjustments
(1)(A) The Secretary shall annually determine, and shall announce (in
a manner intended to provide notice to interested parties) not later
than September 7 before the calendar year concerned --
(i) a per capita rate of payment for each class of individuals who
are enrolled under this section with an eligible organization which has
entered into a risk-sharing contract and who are entitled to benefits
under part A of this subchapter and enrolled under part B of this
subchapter, and
(ii) a per capita rate of payment for each class of individuals who
are so enrolled with such an organization and who are enrolled under
part B of this subchapter only.
For purposes of this section, the term ''risk-sharing contract''
means a contract entered into under subsection (g) of this section and
the term ''reasonable cost reimbursement contract'' means a contract
entered into under subsection (h) of this section.
(B) The Secretary shall define appropriate classes of members, based
on age, disability status, and such other factors as the Secretary
determines to be appropriate, so as to ensure actuarial equivalence.
The Secretary may add to, modify, or substitute for such classes, if
such changes will improve the determination of actuarial equivalence.
(C) The annual per capita rate of payment for each such class shall
be equal to 95 percent of the adjusted average per capita cost (as
defined in paragraph (4)) for that class.
(D) In the case of an eligible organization with a risk-sharing
contract, the Secretary shall make monthly payments in advance and in
accordance with the rate determined under subparagraph (C) and except as
provided in subsection (g)(2) of this section, to the organization for
each individual enrolled with the organization under this section.
(E)(i) The amount of payment under this paragraph may be
retroactively adjusted to take into account any difference between the
actual number of individuals enrolled in the plan under this section and
the number of such individuals estimated to be so enrolled in
determining the amount of the advance payment.
(ii)(I) Subject to subclause (II), the Secretary may make retroactive
adjustments under clause (i) to take into account individuals enrolled
during the period beginning on the date on which the individual enrolls
with an eligible organization (which has a risk-sharing contract under
this section) under a health benefit plan operated, sponsored, or
contributed to, by the individual's employer or former employer (or the
employer or former employer of the individual's spouse) and ending on
the date on which the individual is enrolled in the plan under this
section, except that for purposes of making such retroactive adjustments
under this clause, such period may not exceed 90 days.
(II) No adjustment may be made under subclause (I) with respect to
any individual who does not certify that the organization provided the
individual with the explanation described in subsection (c)(3)(E) of
this section at the time the individual enrolled with the organization.
(F)(i) At least 45 days before making the announcement under
subparagraph (A) for a year (beginning with the announcement for 1991),
the Secretary shall provide for notice to eligible organizations of
proposed changes to be made in the methodology or benefit coverage
assumptions from the methodology and assumptions used in the previous
announcement and shall provide such organizations an opportunity to
comment on such proposed changes.
(ii) In each announcement made under subparagraph (A) for a year
(beginning with the announcement for 1991), the Secretary shall include
an explanation of the assumptions (including any benefit coverage
assumptions) and changes in methodology used in the announcement in
sufficient detail so that eligible organizations can compute per capita
rates of payment for classes of individuals located in each county (or
equivalent area) which is in whole or in part within the service area of
such an organization.
(2) With respect to any eligible organization which has entered into
a reasonable cost reimbursement contract, payments shall be made to such
plan in accordance with subsection (h)(2) of this section rather than
paragraph (1).
(3) Subject to subsection (c)(7) of this section, payments under a
contract to an eligible organization under paragraph (1) or (2) shall be
instead of the amounts which (in the absence of the contract) would be
otherwise payable, pursuant to sections 1395f(b) and 1395l(a) of this
title, for services furnished by or through the organization to
individuals enrolled with the organization under this section.
(4) For purposes of this section, the term ''adjusted average per
capita cost'' means the average per capita amount that the Secretary
estimates in advance (on the basis of actual experience, or
retrospective actuarial equivalent based upon an adequate sample and
other information and data, in a geographic area served by an eligible
organization or in a similar area, with appropriate adjustments to
assure actuarial equivalence) would be payable in any contract year for
services covered under parts A and B of this subchapter, or part B only,
and types of expenses otherwise reimbursable under parts A and B of this
subchapter, or part B only (including administrative costs incurred by
organizations described in sections 1395h and 1395u of this title), if
the services were to be furnished by other than an eligible organization
or, in the case of services covered only under section 1395x(s)(2)(H) of
this title, if the services were to be furnished by a physician or as an
incident to a physician's service.
(5) The payment to an eligible organization under this section for
individuals enrolled under this section with the organization and
entitled to benefits under part A of this subchapter and enrolled under
part B of this subchapter shall be made from the Federal Hospital
Insurance Trust Fund and the Federal Supplementary Medical Insurance
Trust Fund. The portion of that payment to the organization for a month
to be paid by each trust fund shall be determined as follows:
(A) In regard to expenditures by eligible organizations having
risk-sharing contracts, the allocation shall be determined each year by
the Secretary based on the relative weight that benefits from each fund
contribute to the adjusted average per capita cost.
(B) In regard to expenditures by eligible organizations operating
under a reasonable cost reimbursement contract, the initial allocation
shall be based on the plan's most recent budget, such allocation to be
adjusted, as needed, after cost settlement to reflect the distribution
of actual expenditures.
The remainder of that payment shall be paid by the former trust fund.
(6) Subject to subsections (c)(2)(B)(ii) and (c)(7) of this section,
if an individual is enrolled under this section with an eligible
organization having a risk-sharing contract, only the eligible
organization shall be entitled to receive payments from the Secretary
under this subchapter for services furnished to the individual.
(b) Definitions; requirements
For purposes of this section, the term ''eligible organization''
means a public or private entity (which may be a health maintenance
organization or a competitive medical plan), organized under the laws of
any State, which --
(1) is a qualified health maintenance organization (as defined in
section 300e-9(d) of this title), or
(2) meets the following requirements:
(A) The entity provides to enrolled members at least the following
health care services:
(i) Physicians' services performed by physicians (as defined in
section 1395x(r)(1) of this title).
(ii) Inpatient hospital services.
(iii) Laboratory, X-ray, emergency, and preventive services.
(iv) Out-of-area coverage.
(B) The entity is compensated (except for deductibles, coinsurance,
and copayments) for the provision of health care services to enrolled
members by a payment which is paid on a periodic basis without regard to
the date the health care services are provided and which is fixed
without regard to the frequency, extent, or kind of health care service
actually provided to a member.
(C) The entity provides physicians' services primarily (i) directly
through physicians who are either employees or partners of such
organization, or (ii) through contracts with individual physicians or
one or more groups of physicians (organized on a group practice or
individual practice basis).
(D) The entity assumes full financial risk on a prospective basis for
the provision of the health care services listed in subparagraph (A),
except that such entity may --
(i) obtain insurance or make other arrangements for the cost of
providing to any enrolled member health care services listed in
subparagraph (A) the aggregate value of which exceeds $5,000 in any
year,
(ii) obtain insurance or make other arrangements for the cost of
health care service listed in subparagraph (A) provided to its enrolled
members other than through the entity because medical necessity required
their provision before they could be secured through the entity,
(iii) obtain insurance or make other arrangements for not more than
90 percent of the amount by which its costs for any of its fiscal years
exceed 115 percent of its income for such fiscal year, and
(iv) make arrangements with physicians or other health professionals,
health care institutions, or any combination of such individuals or
institutions to assume all or part of the financial risk on a
prospective basis for the provision of basic health services by the
physicians or other health professionals or through the institutions.
(E) The entity has made adequate provision against the risk of
insolvency, which provision is satisfactory to the Secretary.
Paragraph (2)(A)(ii) shall not apply to an entity which had
contracted with a single State agency administering a State plan
approved under subchapter XIX of this chapter for the provision of
services (other than inpatient hospital services) to individuals
eligible for such services under such State plan on a prepaid risk basis
prior to 1970.
(c) Enrollment in plan; duties of organization to enrollees
(1) The Secretary may not enter into a contract under this section
with an eligible organization unless it meets the requirements of this
subsection and subsection (e) of this section with respect to members
enrolled under this section.
(2)(A) The organization must provide to members enrolled under this
section, through providers and other persons that meet the applicable
requirements of this subchapter and part A of subchapter XI of this
chapter --
(i) only those services covered under parts A and B of this
subchapter, for those members entitled to benefits under part A of this
subchapter and enrolled under part B of this subchapter, or
(ii) only those services covered under part B of this subchapter, for
those members enrolled only under such part,
which are available to individuals residing in the geographic area
served by the organization, except that (I) the organization may provide
such members with such additional health care services as the members
may elect, at their option, to have covered, and (II) in the case of an
organization with a risk-sharing contract, the organization may provide
such members with such additional health care services as the Secretary
may approve. The Secretary shall approve any such additional health
care services which the organization proposes to offer to such members,
unless the Secretary determines that including such additional services
will substantially discourage enrollment by covered individuals with the
organization.
(B) If there is a national coverage determination made in the period
beginning on the date of an announcement under subsection (a)(1)(A) of
this section and ending on the date of the next announcement under such
subsection that the Secretary projects will result in a signifcant /1/
change in the costs to the organization of providing the benefits that
are the subject of such national coverage determination and that was not
incorporated in the determination of the per capita rate of payment
included in the announcement made at the beginning of such period --
(i) such determination shall not apply to risk-sharing contracts
under this section until the first contract year that begins after the
end of such period; and
(ii) if such coverage determination provides for coverage of
additional benefits or under additional circumstances, subsection (a)(3)
of this section shall not apply to payment for such additional benefits
or benefits provided under such additional circumstances until the first
contract year that begins after the end of such period,
unless otherwise required by law.
(3)(A)(i) Each eligible organization must have an open enrollment
period, for the enrollment of individuals under this section, of at
least 30 days duration every year and including the period or periods
specified under clause (ii), and must provide that at any time during
which enrollments are accepted, the organization will accept up to the
limits of its capacity (as determined by the Secretary) and without
restrictions, except as may be authorized in regulations, individuals
who are eligible to enroll under subsection (d) of this section in the
order in which they apply for enrollment, unless to do so would result
in failure to meet the requirements of subsection (f) of this section or
would result in the enrollment of enrollees substantially
nonrepresentative, as determined in accordance with regulations of the
Secretary, of the population in the geographic area served by the
organization.
(ii)(I) If a risk-sharing contract under this section is not renewed
or is otherwise terminated, eligible organizations with risk-sharing
contracts under this section and serving a part of the same service area
as under the terminated contract are required to have an open enrollment
period for individuals who were enrolled under the terminated contract
as of the date of notice of such termination. If a risk-sharing
contract under this section is renewed in a manner that discontinues
coverage for individuals residing in part of the service area, eligible
organizations with risk-sharing contracts under this section and
enrolling individuals residing in that part of the service area are
required to have an open enrollment period for individuals residing in
the part of the service area who were enrolled under the contract as of
the date of notice of such discontinued coverage.
(II) The open enrollment periods required under subclause (I) shall
be for 30 days and shall begin 30 days after the date that the Secretary
provides notice of such requirement.
(III) Enrollment under this clause shall be effective 30 days after
the end of the open enrollment period, or, if the Secretary determines
that such date is not feasible, such other date as the Secretary
specifies.
(B) An individual may enroll under this section with an eligible
organization in such manner as may be prescribed in regulations and may
terminate his enrollment with the eligible organization as of the
beginning of the first calendar month following the date on which the
request is made for such termination (or, in the case of financial
insolvency of the organization, as may be prescribed by regulations) or,
in the case of such an organization with a reasonable cost reimbursement
contract, as may be prescribed by regulations. In the case of an
individual's termination of enrollment, the organization shall provide
the individual with a copy of the written request for termination of
enrollment and a written explanation of the period (ending on the
effective date of the termination) during which the individual continues
to be enrolled with the organization and may not receive benefits under
this subchapter other than through the organization.
(C) The Secretary may prescribe the procedures and conditions under
which an eligible organization that has entered into a contract with the
Secretary under this subsection may inform individuals eligible to
enroll under this section with the organization about the organization,
or may enroll such individuals with the organization. No brochures,
application forms, or other promotional or informational material may be
distributed by an organization to (or for the use of) individuals
eligible to enroll with the organization under this section unless (i)
at least 45 days before its distribution, the organization has submitted
the material to the Secretary for review and (ii) the Secretary has not
disapproved the distribution of the material. The Secretary shall
review all such material submitted and shall disapprove such material if
the Secretary determines, in the Secretary's discretion, that the
material is materially inaccurate or misleading or otherwise makes a
material misrepresentation.
(D) The organization must provide assurances to the Secretary that it
will not expel or refuse to re-enroll any such individual because of the
individual's health status or requirements for health care services, and
that it will notify each such individual of such fact at the time of the
individual's enrollment.
(E) Each eligible organization shall provide each enrollee, at the
time of enrollment and not less frequently than annually thereafter, an
explanation of the enrollee's rights under this section, including an
explanation of --
(i) the enrollee's rights to benefits from the organization,
(ii) the restrictions on payments under this subchapter for services
furnished other than by or through the organization,
(iii) out-of-area coverage provided by the organization,
(iv) the organization's coverage of emergency services and urgently
needed care, and
(v) appeal rights of enrollees.
(F) Each eligible organization that provides items and services
pursuant to a contract under this section shall provide assurances to
the Secretary that in the event the organization ceases to provide such
items and services, the organization shall provide or arrange for
supplemental coverage of benefits under this subchapter related to a
pre-existing condition with respect to any exclusion period, to all
individuals enrolled with the entity who receive benefits under this
subchapter, for the lesser of six months or the duration of such period.
(G)(i) Each eligible organization having a risk-sharing contract
under this section shall notify individuals eligible to enroll with the
organization under this section and individuals enrolled with the
organization under this section that --
(I) the organization is authorized by law to terminate or refuse to
renew the contract, and
(II) termination or nonrenewal of the contract may result in
termination of the enrollments of individuals enrolled with the
organization under this section.
(ii) The notice required by clause (i) shall be included in --
(I) any marketing materials described in subparagraph (C) that are
distributed by an eligible organization to individuals eligible to
enroll under this section with the organization, and
(II) any explanation provided to enrollees by the organization
pursuant to subparagraph (E).
(4) The organization must --
(A) make the services described in paragraph (2) (and such other
health care services as such individuals have contracted for) (i)
available and accessible to each such individual, within the area served
by the organization, with reasonable promptness and in a manner which
assures continuity, and (ii) when medically necessary, available and
accessible twenty-four hours a day and seven days a week, and
(B) provide for reimbursement with respect to services which are
described in subparagraph (A) and which are provided to such an
individual other than through the organization, if (i) the services were
medically necessary and immediately required because of an unforeseen
illness, injury, or condition and (ii) it was not reasonable given the
circumstances to obtain the services through the organization.
(5)(A) The organization must provide meaningful procedures for
hearing and resolving grievances between the organization (including any
entity or individual through which the organization provides health care
services) and members enrolled with the organization under this section.
(B) A member enrolled with an eligible organization under this
section who is dissatisfied by reason of his failure to receive any
health service to which he believes he is entitled and at no greater
charge than he believes he is required to pay is entitled, if the amount
in controversy is $100 or more, to a hearing before the Secretary to the
same extent as is provided in section 405(b) of this title, and in any
such hearing the Secretary shall make the eligible organization a party.
If the amount in controversy is $1,000 or more, the individual or
eligible organization shall, upon notifying the other party, be entitled
to judicial review of the Secretary's final decision as provided in
section 405(g) of this title, and both the individual and the eligible
organization shall be entitled to be parties to that judicial review.
(6) The organization must have arrangements, established in
accordance with regulations of the Secretary, for an ongoing quality
assurance program for health care services it provides to such
individuals, which program (A) stresses health outcomes and (B) provides
review by physicians and other health care professionals of the process
followed in the provision of such health care services.
(7) A risk-sharing contract under this section shall provide that in
the case of an individual who is receiving inpatient hospital services
from a subsection (d) hospital (as defined in section 1395ww(d)(1)(B) of
this title) as of the effective date of the individual's --
(A) enrollment with an eligible organization under this section --
(i) payment for such services until the date of the individual's
discharge shall be made under this subchapter as if the individual were
not enrolled with the organization,
(ii) the organization shall not be financially responsible for
payment for such services until the date after the date of the
individual's discharge, and
(iii) the organization shall nonetheless be paid the full amount
otherwise payable to the organization under this section; or
(B) termination of enrollment with an eligible organization under
this section --
(i) the organization shall be financially responsible for payment for
such services after such date and until the date of the individual's
discharge,
(ii) payment for such services during the stay shall not be made
under section 1395ww(d) of this title, and
(iii) the organization shall not receive any payment with respect to
the individual under this section during the period the individual is
not enrolled.
(8) A contract under this section shall provide that the eligible
organization shall meet the requirement of section 1395cc(f) of this
title (relating to maintaining written policies and procedures
respecting advance directives).
(d) Right to enroll with contracting organization in geographic area
Subject to the provisions of subsection (c)(3) of this section, every
individual entitled to benefits under part A of this subchapter and
enrolled under part B of this subchapter or enrolled under part B of
this subchapter only (other than an individual medically determined to
have end-stage renal disease) shall be eligible to enroll under this
section with any eligible organization with which the Secretary has
entered into a contract under this section and which serves the
geographic area in which the individual resides.
(e) Limitation on charges; election of coverage; ''adjusted
community rate'' defined; workmen's compensation and insurance benefits
(1) In no case may --
(A) the portion of an eligible organization's premium rate and the
actuarial value of its deductibles, coinsurance, and copayments charged
(with respect to services covered under parts A and B of this
subchapter) to individuals who are enrolled under this section with the
organization and who are entitled to benefits under part A of this
subchapter and enrolled under part B of this subchapter, or
(B) the portion of its premium rate and the actuarial value of its
deductibles, coinsurance, and copayments charged (with respect to
services covered under part B of this subchapter) to individuals who are
enrolled under this section with the organization and enrolled under
part B of this subchapter only
exceed the actuarial value of the coinsurance and deductibles that
would be applicable on the average to individuals enrolled under this
section with the organization (or, if the Secretary finds that adequate
data are not available to determine that actuarial value, the actuarial
value of the coinsurance and deductibles applicable on the average to
individuals in the area, in the State, or in the United States, eligible
to enroll under this section with the organization, or other appropriate
data) and entitled to benefits under part A of this subchapter and
enrolled under part B of this subchapter, or enrolled under part B only,
respectively, if they were not members of an eligible organization.
(2) If the eligible organization provides to its members enrolled
under this section services in addition to services covered under parts
A and B of this subchapter, election of coverage for such additional
services (unless such services have been approved by the Secretary under
subsection (c)(2) of this section) shall be optional for such members
and such organization shall furnish such members with information on the
portion of its premium rate or other charges applicable to such
additional services. In no case may the sum of --
(A) the portion of such organization's premium rate charged, with
respect to such additional services, to members enrolled under this
section, and
(B) the actuarial value of its deductibles, coinsurance, and
copayments charged, with respect to such services to such members
exceed the adjusted community rate for such services.
(3) For purposes of this section, the term ''adjusted community
rate'' for a service or services means, at the election of an eligible
organization, either --
(A) the rate of payment for that service or services which the
Secretary annually determines would apply to a member enrolled under
this section with an eligible organization if the rate of payment were
determined under a ''community rating system'' (as defined in section
300e-1(8) of this title, other than subparagraph (C)), or
(B) such portion of the weighted aggregate premium, which the
Secretary annually estimates would apply to a member enrolled under this
section with the eligible organization, as the Secretary annually
estimates is attributable to that service or services,
but adjusted for differences between the utilization characteristics
of the members enrolled with the eligible organization under this
section and the utilization characteristics of the other members of the
organization (or, if the Secretary finds that adequate data are not
available to adjust for those differences, the differences between the
utilization characteristics of members in other eligible organizations,
or individuals in the area, in the State, or in the United States,
eligible to enroll under this section with an eligible organization and
the utilization characteristics of the rest of the population in the
area, in the State, or in the United States, respectively).
(4) Notwithstanding any other provision of law, the eligible
organization may (in the case of the provision of services to a member
enrolled under this section for an illness or injury for which the
member is entitled to benefits under a workmen's compensation law or
plan of the United States or a State, under an automobile or liability
insurance policy or plan, including a self-insured plan, or under no
fault insurance) charge or authorize the provider of such services to
charge, in accordance with the charges allowed under such law or policy
--
(A) the insurance carrier, employer, or other entity which under such
law, plan, or policy is to pay for the provision of such services, or
(B) such member to the extent that the member has been paid under
such law, plan, or policy for such services.
(f) Membership requirements
(1) Each eligible organization with which the Secretary enters into a
contract under this section shall have, for the duration of such
contract, an enrolled membership at least one-half of which consists of
individuals who are not entitled to benefits under this subchapter or
under a State plan approved under subchapter XIX of this chapter.
(2) The Secretary may modify or waive the requirement imposed by
paragraph (1) only --
(A) to the extent that more than 50 percent of the population of the
area served by the organization consists of individuals who are entitled
to benefits under this subchapter or under a State plan approved under
subchapter XIX of this chapter, or
(B) in the case of an eligible organization that is owned and
operated by a governmental entity, only with respect to a period of
three years beginning on the date the organization first enters into a
contract under this section, and only if the organization has taken and
is making reasonable efforts to enroll individuals who are not entitled
to benefits under this subchapter or under a State plan approved under
subchapter XIX of this chapter.
(3) If the Secretary determines that an eligible organization has
failed to comply with the requirements of this subsection, the Secretary
may provide for the suspension of enrollment of individuals under this
section or of payment to the organization under this section for
individuals newly enrolled with the organization, after the date the
Secretary notifies the organization of such noncompliance.
(g) Risk-sharing contract
(1) The Secretary may enter a risk-sharing contract with any eligible
organization, as defined in subsection (b) of this section, which has at
least 5,000 members, except that the Secretary may enter into such a
contract with an eligible organization that has fewer members if the
organization primarily serves members residing outside of urbanized
areas.
(2) Each risk-sharing contract shall provide that --
(A) if the adjusted community rate, as defined in subsection (e)(3)
of this section, for services under parts A and B of this subchapter (as
reduced for the actuarial value of the coinsurance and deductibles under
those parts) for members enrolled under this section with the
organization and entitled to benefits under part A of this subchapter
and enrolled in part B of this subchapter, or
(B) if the adjusted community rate for services under part B of this
subchapter (as reduced for the actuarial value of the coinsurance and
deductibles under that part) for members enrolled under this section
with the organization and entitled to benefits under part B of this
subchapter only
is less than the average of the per capita rates of payment to be
made under subsection (a)(1) of this section at the beginning of an
annual contract period for members enrolled under this section with the
organization and entitled to benefits under part A of this subchapter
and enrolled in part B of this subchapter, or enrolled in part B of this
subchapter only, respectively, the eligible organization shall provide
to members enrolled under a risk-sharing contract under this section
with the organization and entitled to benefits under part A of this
subchapter and enrolled in part B of this subchapter, or enrolled in
part B of this subchapter only, respectively, the additional benefits
described in paragraph (3) which are selected by the eligible
organization and which the Secretary finds are at least equal in value
to the difference between that average per capita payment and the
adjusted community rate (as so reduced); except that this paragraph
shall not apply with respect to any organization which elects to receive
a lesser payment to the extent that there is no longer a difference
between the average per capita payment and adjusted community rate (as
so reduced) and except that an organization (with the approval of the
Secretary) may provide that a part of the value of such additional
benefits be withheld and reserved by the Secretary as provided in
paragraph (5). If the Secretary finds that there is insufficient
enrollment experience to determine an average of the per capita rates of
payment to be made under subsection (a)(1) of this section at the
beginning of a contract period, the Secretary may determine such an
average based on the enrollment experience of other contracts entered
into under this section.
(3) The additional benefits referred to in paragraph (2) are --
(A) the reduction of the premium rate or other charges made with
respect to services furnished by the organization to members enrolled
under this section, or
(B) the provision of additional health benefits,
or both.
(4) Repealed. Pub. L. 100-203, title IV, 4012(b), Dec. 22, 1987,
101 Stat. 1330-61.
(5) An organization having a risk-sharing contract under this section
may (with the approval of the Secretary) provide that a part of the
value of additional benefits otherwise required to be provided by reason
of paragraph (2) be withheld and reserved in the Federal Hospital
Insurance Trust Fund and in the Federal Supplementary Medical Insurance
Trust Fund (in such proportions as the Secretary determines to be
appropriate) by the Secretary for subsequent annual contract periods, to
the extent required to stabilize and prevent undue fluctuations in the
additional benefits offered in those subsequent periods by the
organization in accordance with paragraph (3). Any of such value of
additional benefits which is not provided to members of the organization
in accordance with paragraph (3) prior to the end of such period, shall
revert for the use of such trust funds.
(6)(A) A risk-sharing contract under this section shall require the
eligible organization to provide prompt payment (consistent with the
provisions of sections 1395h(c)(2) and 1395u(c)(2) of this title) of
claims submitted for services and supplies furnished to individuals
pursuant to such contract, if the services or supplies are not furnished
under a contract between the organization and the provider or supplier.
(B) In the case of an eligible organization which the Secretary
determines, after notice and opportunity for a hearing, has failed to
make payments of amounts in compliance with subparagraph (A), the
Secretary may provide for direct payment of the amounts owed to
providers and suppliers for such covered services furnished to
individuals enrolled under this section under the contract. If the
Secretary provides for such direct payments, the Secretary shall provide
for an appropriate reduction in the amount of payments otherwise made to
the organization under this section to reflect the amount of the
Secretary's payments (and costs incurred by the Secretary in making such
payments).
(h) Reasonable cost reimbursement contract; requirements
(1) If --
(A) the Secretary is not satisfied that an eligible organization has
the capacity to bear the risk of potential losses under a risk-sharing
contract under this section, or
(B) the eligible organization so elects or has an insufficient number
of members to be eligible to enter into a risk-sharing contract under
subsection (g)(1) of this section,
the Secretary may, if he is otherwise satisfied that the eligible
organization is able to perform its contractual obligations effectively
and efficiently, enter into a contract with such organization pursuant
to which such organization is reimbursed on the basis of its reasonable
cost (as defined in section 1395x(v) of this title) in the manner
prescribed in paragraph (3).
(2) A reasonable cost reimbursement contract under this subsection
may, at the option of such organization, provide that the Secretary --
(A) will reimburse hospitals and skilled nursing facilities either
for the reasonable cost (as determined under section 1395x(v) of this
title) or for payment amounts determined in accordance with section
1395ww of this title, as applicable, of services furnished to
individuals enrolled with such organization pursuant to subsection (d)
of this section, and
(B) will deduct the amount of such reimbursement from payment which
would otherwise be made to such organization.
If such an eligible organization pays a hospital or skilled nursing
facility directly, the amount paid shall not exceed the reasonable cost
of the services (as determined under section 1395x(v) of this title) or
the amount determined under section 1395ww of this title, as applicable,
unless such organization demonstrates to the satisfaction of the
Secretary that such excess payments are justified on the basis of
advantages gained by the organization.
(3) Payments made to an organization with a reasonable cost
reimbursement contract shall be subject to appropriate retroactive
corrective adjustment at the end of each contract year so as to assure
that such organization is paid for the reasonable cost actually incurred
(excluding any part of incurred cost found to be unnecessary in the
efficient delivery of health services) or the amounts otherwise
determined under section 1395ww of this title for the types of expenses
otherwise reimbursable under this subchapter for providing services
covered under this subchapter to individuals described in subsection
(a)(1) of this section.
(4) Any reasonable cost reimbursement contract with an eligible
organization under this subsection shall provide that the Secretary
shall require, at such time following the expiration of each accounting
period of the eligible organization (and in such form and in such
detail) as he may prescribe --
(A) that the organization report to him in an independently certified
financial statement its per capita incurred cost based on the types of
components of expenses otherwise reimbursable under this subchapter for
providing services described in subsection (a)(1) of this section,
including therein, in accordance with accounting procedures prescribed
by the Secretary, its methods of allocating costs between individuals
enrolled under this section and other individuals enrolled with such
organization;
(B) that failure to report such information as may be required may be
deemed to constitute evidence of likely overpayment on the basis of
which appropriate collection action may be taken;
(C) that in any case in which an eligible organization is related to
another organization by common ownership or control, a consolidated
financial statement shall be filed and that the allowable costs for such
organization may not include costs for the types of expense otherwise
reimbursable under this subchapter, in excess of those which would be
determined to be reasonable in accordance with regulations (providing
for limiting reimbursement to costs rather than charges to the eligible
organization by related organizations and owners) issued by the
Secretary; and
(D) that in any case in which compensation is paid by an eligible
organization substantially in excess of what is normally paid for
similar services by similar practitioners (regardless of method of
compensation), such compensation may as appropriate be considered to
constitute a distribution of profits.
(i) Duration, termination, effective date, and terms of contract;
powers and duties of Secretary
(1) Each contract under this section shall be for a term of at least
one year, as determined by the Secretary, and may be made automatically
renewable from term to term in the absence of notice by either party of
intention to terminate at the end of the current term; except that the
Secretary may terminate any such contract at any time (after such
reasonable notice and opportunity for hearing to the eligible
organization involved as he may provide in regulations), if he finds
that the organization --
(A) has failed substantially to carry out the contract,
(B) is carrying out the contract in a manner inconsistent with the
efficient and effective administration of this section, or
(C) no longer substantially meets the applicable conditions of
subsections (b), (c), (e), and (f) of this section.
(2) The effective date of any contract executed pursuant to this
section shall be specified in the contract.
(3) Each contract under this section --
(A) shall provide that the Secretary, or any person or organization
designated by him --
(i) shall have the right to inspect or otherwise evaluate (I) the
quality, appropriateness, and timeliness of services performed under the
contract and (II) the facilities of the organization when there is
reasonable evidence of some need for such inspection, and
(ii) shall have the right to audit and inspect any books and records
of the eligible organization that pertain (I) to the ability of the
organization to bear the risk of potential financial losses, or (II) to
services performed or determinations of amounts payable under the
contract;
(B) shall require the organization with a risk-sharing contract to
provide (and pay for) written notice in advance of the contract's
termination, as well as a description of alternatives for obtaining
benefits under this subchapter, to each individual enrolled under this
section with the organization; and
(C)(i) shall require the organization to comply with subsections (a)
and (c) of section 300e-17 of this title (relating to disclosure of
certain financial information) and with the requirement of section
300e(c)(8) /2/ of this title (relating to liability arrangements to
protect members);
(ii) shall require the organization to provide and supply information
(described in section 1395cc(b)(2)(C)(ii) of this title) in the manner
such information is required to be provided or supplied under that
section;
(iii) shall require the organization to notify the Secretary of loans
and other special financial arrangements which are made between the
organization and subcontractors, affiliates, and related parties; and
(D) shall contain such other terms and conditions not inconsistent
with this section (including requiring the organization to provide the
Secretary with such information) as the Secretary may find necessary and
appropriate.
(4) The Secretary may not enter into a risk-sharing contract with an
eligible organization if a previous risk-sharing contract with that
organization under this section was terminated at the request of the
organization within the preceding five-year period, except in
circumstances which warrant special consideration, as determined by the
Secretary.
(5) The authority vested in the Secretary by this section may be
performed without regard to such provisions of law or regulations
relating to the making, performance, amendment, or modification of
contracts of the United States as the Secretary may determine to be
inconsistent with the furtherance of the purpose of this subchapter.
(6)(A) If the Secretary determines that an eligible organization with
a contract under this section --
(i) fails substantially to provide medically necessary items and
services that are required (under law or under the contract) to be
provided to an individual covered under the contract, if the failure has
adversely affected (or has substantial likelihood of adversely
affecting) the individual;
(ii) imposes premiums on individuals enrolled under this section in
excess of the premiums permitted;
(iii) acts to expel or to refuse to re-enroll an individual in
violation of the provisions of this section;
(iv) engages in any practice that would reasonably be expected to
have the effect of denying or discouraging enrollment (except as
permitted by this section) by eligible individuals with the organization
whose medical condition or history indicates a need for substantial
future medical services;
(v) misrepresents or falsifies information that is furnished --
(I) to the Secretary under this section, or
(II) to an individual or to any other entity under this section;
(vi) fails to comply with the requirements of subsection (g)(6)(A) of
this section or paragraph (8); or
(vii) in the case of a risk-sharing contract, employs or contracts
with any individual or entity that is excluded from participation under
this subchapter under section 1320a-7 or 1320a-7a of this title for the
provision of health care, utilization review, medical social work, or
administrative services or employs or contracts with any entity for the
provision (directly or indirectly) through such an excluded individual
or entity of such services;
the Secretary may provide, in addition to any other remedies
authorized by law, for any of the remedies described in subparagraph
(B).
(B) The remedies described in this subparagraph are --
(i) civil money penalties of not more than $25,000 for each
determination under subparagraph (A) or, with respect to a determination
under clause (iv) or (v)(I) of such subparagraph, of not more than
$100,000 for each such determination, plus, with respect to a
determination under subparagraph (A)(ii), double the excess amount
charged in violation of such subparagraph (and the excess amount charged
shall be deducted from the penalty and returned to the individual
concerned), and plus, with respect to a determination under subparagraph
(A)(iv), $15,000 for each individual not enrolled as a result of the
practice involved,
(ii) suspension of enrollment of individuals under this section after
the date the Secretary notifies the organization of a determination
under subparagraph (A) and until the Secretary is satisfied that the
basis for such determination has been corrected and is not likely to
recur, or
(iii) suspension of payment to the organization under this section
for individuals enrolled after the date the Secretary notifies the
organization of a determination under subparagraph (A) and until the
Secretary is satisfied that the basis for such determination has been
corrected and is not likely to recur.
The provisions of section 1320a-7a of this title (other than
subsections (a) and (b)) shall apply to a civil money penalty under
clause (i) in the same manner as they apply to a civil money penalty or
proceeding under section 1320a-7a(a) of this title.
(7)(A) Each risk-sharing contract with an eligible organization under
this section shall provide that the organization will maintain an
agreement with a utilization and quality control peer review
organization (which has a contract with the Secretary under part B of
subchapter XI of this chapter for the area in which the eligible
organization is located) or with an entity selected by the Secretary
under section 1320c-3(a)(4)(C) of this title under which the review
organization will perform functions under section 1320c-3(a)(4)(B) of
this title and section 1320c-3(a)(14) of this title (other than those
performed under contracts described in section 1395cc(a)(1)(F) of this
title) with respect to services, furnished by the eligible organization,
for which payment may be made under this subchapter.
(B) For purposes of payment under this subchapter, the cost of such
agreement to the eligible organization shall be considered a cost
incurred by a provider of services in providing covered services under
this subchapter and shall be paid directly by the Secretary to the
review organization on behalf of such eligible organization in
accordance with a schedule established by the Secretary.
(C) Such payments --
(i) shall be transferred in appropriate proportions from the Federal
Hospital Insurance Trust Fund and from the Supplementary Medical
Insurance Trust Fund, without regard to amounts appropriated in advance
in appropriation Acts, in the same manner as transfers are made for
payment for services provided directly to beneficiaries, and
(ii) shall not be less in the aggregate for such organizations for a
fiscal year than the amounts the Secretary determines to be sufficient
to cover the costs of such organizations' conducting activities
described in subparagraph (A) with respect to such eligible
organizations under part B of subchapter XI of this chapter.
(8)(A) Each contract with an eligible organization under this section
shall provide that the organization may not operate any physician
incentive plan (as defined in subparagraph (B)) unless the following
requirements are met:
(i) No specific payment is made directly or indirectly under the plan
to a physician or physician group as an inducement to reduce or limit
medically necessary services provided with respect to a specific
individual enrolled with the organization.
(ii) If the plan places a physician or physician group at substantial
financial risk (as determined by the Secretary) for services not
provided by the physician or physician group, the organization --
(I) provides stop-loss protection for the physician or group that is
adequate and appropriate, based on standards developed by the Secretary
that take into account the number of physicians placed at such
substantial financial risk in the group or under the plan and the number
of individuals enrolled with the organization who receive services from
the physician or the physician group, and
(II) conducts periodic surveys of both individuals enrolled and
individuals previously enrolled with the organization to determine the
degree of access of such individuals to services provided by the
organization and satisfaction with the quality of such services.
(iii) The organization provides the Secretary with descriptive
information regarding the plan, sufficient to permit the Secretary to
determine whether the plan is in compliance with the requirements of
this subparagraph.
(B) In this paragraph, the term ''physician incentive plan'' means
any compensation arrangement between an eligible organization and a
physician or physician group that may directly or indirectly have the
effect of reducing or limiting services provided with respect to
individuals enrolled with the organization.
(j) Limit on charges for emergency services and out-of-area coverage
(1)(A) In the case of physicians' services or renal dialysis services
described in paragraph (2) which are furnished by a participating
physician or provider of services or renal dialysis facility to an
individual enrolled with an eligible organization under this section and
enrolled under part B of this subchapter, the applicable participation
agreement is deemed to provide that the physician or provider of
services or renal dialysis facility will accept as payment in full from
the eligible organization the amount that would be payable to the
physician or provider of services or renal dialysis facility under part
B of this subchapter and from the individual under such part, if the
individual were not enrolled with an eligible organization under this
section.
(B) In the case of physicians' services described in paragraph (2)
which are furnished by a nonparticipating physician, the limitations on
actual charges for such services otherwise applicable under part B of
this subchapter (to services furnished by individuals not enrolled with
an eligible organization under this section) shall apply in the same
manner as such limitations apply to services furnished to individuals
not enrolled with such an organization.
(2) The physicians' services or renal dialysis services described in
this paragraph are physicians' services or renal dialysis services which
are furnished to an enrollee of an eligible organization under this
setion /3/ by a physician, provider of services, or renal dialysis
facility who is not under a contract with the organization.
(Aug. 14, 1935, ch. 531, title XVIII, 1876, as added and amended
Oct. 30, 1972, Pub. L. 92-603, title II, 226(a), 278(b)(3), 86 Stat.
1396, 1453; Dec. 31, 1973, Pub. L. 93-233, 18(m), (n), 87 Stat. 970,
971; Oct. 8, 1976, Pub. L. 94-460, title II, 201(a)-(d), 90 Stat.
1956, 1957; June 13, 1978, Pub. L. 95-292, 5, 92 Stat. 315; Sept. 3,
1982, Pub. L. 97-248, title I, 114(a), 96 Stat. 341; Jan. 12, 1983,
Pub. L. 97-448, title III, 309(b)(12), 96 Stat. 2409; Apr. 20, 1983,
Pub. L. 98-21, title VI, 602(g), 606(a)(3)(H), 97 Stat. 164, 171;
July 18, 1984, Pub. L. 98-369, div. B, title III, 2350(a)(1), (b)(1),
(2), (c), 2354(b)(37), (38), 98 Stat. 1097, 1098, 1102; Apr. 7, 1986,
Pub. L. 99-272, title IX, 9211(a)-(d), 100 Stat. 178, 179; Oct. 21,
1986, Pub. L. 99-509, title IX, 9312(b)(1), (c)(1), (2), (d)(1),
(e)(1), (f), 9353(e)(2), 100 Stat. 1999-2001, 2048; Oct. 22, 1986, Pub.
L. 99-514, title XVIII, 1895(b)(11)(A), 100 Stat. 2934; Dec. 22, 1987,
Pub. L. 100-203, title IV, 4011(a)(1), (b)(1), 4012(b), 4013(a), 4014,
4018(a), 4039(h)(8), 101 Stat. 1330-60, 1330-61, 1330-65, as amended
July 1, 1988, Pub. L. 100-360, title IV, 411(c)(3), (e)(3), 102 Stat.
773, 776; July 1, 1988, Pub. L. 100-360, title II, 202(f),
211(c)(3), 224, title IV, 411(c)(1), (4), (6), formerly (5), 102 Stat.
717, 738, 748, 772, 773, as amended Oct. 13, 1988, Pub. L. 100-485,
title VI, 608(d)(19)(B), (C), 102 Stat. 2419; Nov. 10, 1988, Pub. L.
100-647, title VIII, 8412(a)(1), 102 Stat. 3801; Dec. 13, 1989, Pub.
L. 101-234, title II, 201(a), 202(a), 103 Stat. 1981; Dec. 19, 1989,
Pub. L. 101-239, title VI, 6206(a)(1), (b)(1), 6212(b)(1), (c)(2),
6411(d)(3)(A), 103 Stat. 2244, 2250, 2271; Nov. 5, 1990, Pub. L.
101-508, title IV, 4204(a)(1), (2), (c)(1), (2), (d)(1), (e)(1),
4206(b)(1), 104 Stat. 1388-108 to 1388-111, 1388-116.)
Parts A and B of this subchapter, referred to in text, are classified
to sections 1395c et seq. and 1395j et seq., respectively, of this
title.
Parts A and B of subchapter XI of this chapter, referred to in
subsecs. (c)(2) and (i)(7)(A), (B)(ii), are classified to sections 1301
et seq. and 1320c et seq., respectively, of this title.
Section 300e(c)(8) of this title, referred to in subsec.
(i)(3)(C)(i), was redesignated section 300e(c)(7) of this title by Pub.
L. 100-517, 5(b), Oct. 24, 1988, 102 Stat. 2579.
1990 -- Subsec. (a)(1)(E). Pub. L. 101-508, 4204(e)(1), designated
existing provisions as cl. (i) and added cl. (ii).
Subsec. (a)(6). Pub. L. 101-508, 4204(c)(2), substituted
''subsections (c)(2)(B)(ii) and (c)(7)'' for ''subsection (c)(7)''.
Subsec. (c)(2). Pub. L. 101-508, 4204(c)(1), designated existing
provisions as subpar. (A), redesignated former subpars. (A) and (B)
and former cls. (i) and (ii) as cls. (i) and (ii) and subcls. (I) and
(II), respectively, and added subpar. (B).
Subsec. (c)(8). Pub. L. 101-508, 4206(b)(1), added par. (8).
Subsec. (i)(6)(A)(vi). Pub. L. 101-508, 4204(a)(2), inserted ''or
paragraph (8)'' after ''(g)(6)(A) of this section''.
Subsec. (i)(8). Pub. L. 101-508, 4204(a)(1), added par. (8).
Subsec. (j)(1)(A). Pub. L. 101-508, 4204(d)(1)(A), substituted
''physicians' services or renal dialysis services'' for ''physicians'
services'', ''physician or provider of services or renal dialysis
facility'' for ''physician'' in three places, and ''applicable
participation agreement'' for ''participation agreement under section
1395u(h)(1) of this title''.
Subsec. (j)(2). Pub. L. 101-508, 4204(d)(1)(B), substituted
''physicians' services or renal dialysis services'' for ''physicians'
services'' in two places and ''which are furnished to an enrollee of an
eligible organization under this setion by a physician, provider of
services, or renal dialysis facility who is not under a contract with
the organization.'' for ''which -- '' and subpars. (A) and (B) which
read as follows:
''(A) are emergency services or out-of-area coverage (described in
clauses (iii) and (iv) of subsection (b)(2)(A) of this section), and
''(B) are furnished to an enrollee of an eligible organization under
this section by a person who is not under a contract with the
organization.''
1989 -- Subsec. (a)(1)(F). Pub. L. 101-239, 6206(a)(1), added
subpar. (F).
Subsec. (a)(5). Pub. L. 101-234, 202(a), repealed Pub. L. 100-360,
211(c)(3)(A), and provided that the provisions of law amended or
repealed by such section are restored or revised as if such section had
not been enacted, see 1988 Amendment note below.
Subsec. (c)(3)(A)(i). Pub. L. 101-239, 6206(b)(1)(A), substituted
''period or periods'' for ''30-day period''.
Subsec. (c)(3)(A)(ii). Pub. L. 101-239, 6206(b)(1)(B), added cl.
(ii) and struck out former cl. (ii) which read as follows: ''For each
area served by more than one eligible organization under this section,
the Secretary (after consultation with such organizations) shall
establish a single 30-day period each year during which all eligible
organizations serving the area must provide for open enrollment under
this section. The Secretary shall determine annual per capita rates
under subsection (a)(1)(A) of this section in a manner that assures that
individuals enrolling during such a 30-day period will not have premium
charges increased or any additional benefits decreased for 12 months
beginning on the date the individual's enrollment becomes effective. An
eligible organization may provide for such other open enrollment period
or periods as it deems appropriate consistent with this section.''
Subsecs. (e)(1), (g)(3)(A). Pub. L. 101-234, 201(a), repealed Pub.
L. 100-360, 202(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 notes below.
Subsec. (g)(5). Pub. L. 101-239, 6212(c)(2), struck out ''and during
a period of not longer than four years'' after first reference to
''Secretary''.
Subsec. (i)(6)(A)(vii). Pub. L. 101-239, 6411(d)(3)(A), added cl.
(vii).
Subsec. (j). Pub. L. 101-239, 6212(b)(1), added subsec. (j).
1988 -- Subsec. (a)(5). Pub. L. 100-360, 211(c)(3)(B), amended
second sentence generally. Prior to amendment, second sentence read as
follows: ''The portion of that payment to the organization for a month
to be paid by the latter trust fund shall be equal to 200 percent of the
sum of --
''(A) the product of (i) the number of such individuals for the month
who have attained age 65, and (ii) the monthly actuarial rate for
supplementary medical insurance for the month as determined under
section 1395r(a)(1) of this title, and
''(B) the product of (i) the number of such individuals for the month
who have not attained age 65, and (ii) the monthly actuarial rate for
supplementary medical insurance for the month as determined under
section 1395r(a)(4) of this title.''
Pub. L. 100-360, 211(c)(3)(A), substituted '', the Federal
Supplementary Medical Insurance Trust Fund, and the Federal Catastrophic
Drug Insurance Trust Fund'' for ''and the Federal Supplementary Medical
Insurance Trust Fund'' in first sentence.
Subsec. (c)(3)(F). Pub. L. 100-360, 411(c)(1), realigned margin with
left margin of subpar. (G).
Subsec. (e)(1). Pub. L. 100-360, 202(f)(1), inserted at end ''The
preceding sentence shall be applied separately with respect to covered
outpatient drugs.''
Subsec. (f)(3). Pub. L. 100-647 redesignated par. (4) as (3) and
struck out former par. (3) which read as follows:
''(A) An eligible organization described in subparagraph (B) may
elect, for purposes of enrollment and residency requirements under this
section and for determining the compliance of a subdivision, subsidiary,
or affiliate described in subparagraph (B)(iii) with the requirement of
paragraph (1) for the period before October 1, 1992, to have members
described in subparagraph (B)(iii) who receive services through the
subdivision, subsidiary, or affiliate considered to be members of the
parent organization.
''(B) An eligible organization described in this subparagraph is an
eligible organization which --
''(i) is described in section 1396b(m)(2)(B)(iii) of this title;
''(ii) has members who have a collectively bargained contractual
right to obtain health benefits from the organization;
''(iii) elects to provide benefits under a risk-sharing contract to
individuals residing in a service area, who have a collectively
bargained contractual right to obtain benefits from the organization,
through a subdivision, subsidiary, or affiliate which itself is an
eligible organization serving the area and which is owned or controlled
by the parent eligible organization; and
''(iv) has assumed any risk of insolvency and quality assurance with
respect to individuals receiving benefits through such a subdivision,
subsidiary, or affiliate.''
Subsec. (f)(3)(A). Pub. L. 100-360, 411(c)(6), formerly 411(c)(5),
as redesignated by Pub. L. 100-485, 608(d)(19)(C), inserted
''enrollment and residency requirements under this section and for''
after ''for purposes of'' and substituted ''described in subparagraph
(B)(iii) who receives services through the subdivision'' for ''of the
subdivision''.
Subsec. (f)(4). Pub. L. 100-647 redesignated par. (4) as (3).
Subsec. (g)(3)(A). Pub. L. 100-360, 202(f)(2), substituted ''rates''
for ''rate''.
Subsec. (g)(5). Pub. L. 100-360, 411(c)(3), amended Pub. L.
100-203, 4013, see 1987 Amendment note below.
Subsec. (i)(6)(A). Pub. L. 100-360, 411(c)(4)(A), inserted '', in
addition to any other remedies authorized by law,'' after ''the
Secretary may provide'' in concluding provisions.
Subsec. (i)(6)(B). Pub. L. 100-360, 411(c)(4)(C), formerly
411(c)(4)(B), as redesignated by Pub. L. 100-485, 608(d)(19)(B)(ii),
substituted ''or proceeding under section 1320a-7a(a) of this title''
for ''under that section'' in last sentence.
Subsec. (i)(6)(B)(i). Pub. L. 100-360, 411(c)(4)(B), as added by
Pub. L. 100-485, 608(d)(19)(B)(i), (iii), inserted ''of such
subparagraph'' after ''(v)(I)''.
Pub. L. 100-360, 224, inserted at end ''plus, with respect to a
determination under subparagraph (A)(ii), double the excess amount
charged in violation of such subparagraph (and the excess amount charged
shall be deducted from the penalty and returned to the individual
concerned), and plus, with respect to a determination under subparagraph
(A)(iv), $15,000 for each individual not enrolled as a result of the
practice involved,''.
Subsec. (i)(7)(A). Pub. L. 100-360, 411(e)(3), added Pub. L.
100-203, 4039(h)(8)(A), (B), see 1987 Amendment note below.
Subsec. (i)(7)(B). Pub. L. 100-360, 411(e)(3), added Pub. L.
100-203, 4039(h)(8)(C), see 1987 Amendment note below.
1987 -- Subsec. (c)(3)(F). Pub. L. 100-203, 4011(a)(1), added
subpar. (F).
Subsec. (c)(3)(G). Pub. L. 100-203, 4011(b)(1), added subpar. (G).
Subsec. (f)(3), (4). Pub. L. 100-203, 4018(a), added par. (3) and
redesignated former par. (3) as (4).
Subsec. (g)(4). Pub. L. 100-203, 4012(b), struck out par. (4) which
read as follows: ''A risk-sharing contract under this subsection may,
at the option of an eligible organization, provide that the Secretary --
''(A) will reimburse hospitals and skilled nursing facilities either
for payment amounts determined in accordance with section 1395ww of this
title, or, if applicable, for the reasonable cost (as determined under
section 1395x(v) of this title) or other appropriate basis for payment
established under this subchapter, of inpatient services furnished to
individuals enrolled with such organization pursuant to subsection (d)
of this section, and
''(B) will deduct the amount of such reimbursement for payment which
would otherwise be made to such organization.''
Subsec. (g)(5). Pub. L. 100-203, 4013, which directed amendment of
par. (5) by substituting ''six years'' for ''four years'', was amended
generally by Pub. L. 100-360, 411(c)(3), so that it does not amend
this section.
Subsec. (i)(6). Pub. L. 100-203, 4014, amended par. (6) generally.
Prior to amendment, par. (6) read as follows:
''(6)(A) Any eligible organization with a risk-sharing contract under
this section that fails substantially to provide medically necessary
items and services that are required (under law or such contract) to be
provided to individuals covered under such contract, if the failure has
adversely affected (or has a substantial likelihood of adversely
affecting) these individuals, is subject to a civil money penalty of not
more than $10,000 for each such failure.
''(B) The provisions of section 1320a-7a of this title (other than
subsection (a)) shall apply to a civil money penalty under subparagraph
(A) in the same manner as they apply to a civil money penalty under that
section.''
Subsec. (i)(7)(A). Pub. L. 100-203, 4039(h)(8)(A), (B), as added by
Pub. L. 100-360, 411(e)(3), substituted ''Each'' for ''Except as
provided under section 1320c-3(a)(4)(C) of this title, each'', inserted
''or with an entity selected by the Secretary under section
1320c-3(a)(4)(C) of this title'' after ''located)'', and substituted
''which the review organization'' for ''which the peer review
organization''.
Subsec. (i)(7)(B). Pub. L. 100-203, 4039(h)(8)(C), as added by Pub.
L. 100-360, 411(e)(3), substituted ''the review organization'' for
''the peer review organization''.
1986 -- Subsec. (a)(1)(A). Pub. L. 99-514 substituted ''announce (in
a manner intended to provide notice to interested parties)'' for
''publish'' in introductory provisions.
Pub. L. 99-272, 9211(d), inserted '', and shall publish not later
than September 7 before the calendar year concerned'' after ''The
Secretary shall annually determine'' in introductory provisions.
Subsec. (a)(3). Pub. L. 99-272, 9211(a)(2), substituted ''Subject to
subsection (c)(7) of this section, payments'' for ''Payments''.
Subsec. (a)(6). Pub. L. 99-272, 9211(a)(3), substituted ''Subject to
subsection (c)(7) of this section, if'' for ''If''.
Subsec. (c)(3)(B). Pub. L. 99-272, 9211(b), substituted ''the date
on which'' for ''a full calendar month after'', and inserted provision
at end that in the case of an individual's termination of enrollment,
the organization shall provide the individual with a copy of the written
request for termination of enrollment and a written explanation of the
period (ending on the effective date of the termination) during which
the individual continues to be enrolled with the organization and may
not receive benefits under this subchapter other than through the
organization.
Subsec. (c)(3)(C). Pub. L. 99-272, 9211(c), inserted provisions at
end that no brochures, application forms, or other promotional or
informational material may be distributed by an organization to (or for
the use of) individuals eligible to enroll with the organization under
this section unless at least 45 days before its distribution, the
organization has submitted the material to the Secretary for review and
the Secretary has not disapproved the distribution of the material, and
that Secretary shall review all such material submitted and shall
disapprove such material if the Secretary determines, in the Secretary's
discretion, that the material is materially inaccurate or misleading or
otherwise makes a material misrepresentation.
Subsec. (c)(7). Pub. L. 99-272, 9211(a)(1), added par. (7).
Subsec. (c)(3)(E). Pub. L. 99-509, 9312(b)(1), added subpar. (E).
Subsec. (f)(2). Pub. L. 99-509, 9312(c)(1), struck out ''if the
Secretary determines that'' after ''imposed by paragraph (1) only'',
added new subpars. (A) and (B), and struck out former subpars. (A) and
(B) which read as follows:
''(A) special circumstances warrant such modification or waiver, and
''(B) the eligible organization has taken and is making reasonable
efforts to enroll individuals who are not entitled to benefits under
this subchapter or under a State plan approved under subchapter XIX of
this chapter.''
Subsec. (f)(3). Pub. L. 99-509, 9312(c)(2)(A), added par. (3).
Subsec. (g)(6). Pub. L. 99-509, 9312(d)(1), added par. (6).
Subsec. (i)(1)(C). Pub. L. 99-509, 9312(c)(3)(B), substituted ''(e),
and (f)'' for ''and (e)''.
Subsec. (i)(3)(C). Pub. L. 99-509, 9312(e)(1), designated existing
provisions as cl. (i) and added cls. (ii) and (iii).
Subsec. (i)(6). Pub. L. 99-509, 9312(f), added par. (6).
Subsec. (i)(7). Pub. L. 99-509, 9353(e)(2), added par. (7).
1984 -- Subsec. (b)(2)(D). Pub. L. 98-369, 2354(b)(37), substituted
''subparagraph (A)'' for ''paragraph (1)''.
Subsec. (c)(3)(A). Pub. L. 98-369, 2350(a)(1), designated existing
provisions as cl. (i), inserted ''and including the 30-day period
specified under clause (ii)'' after ''30 days duration every year'', and
added cl. (ii).
Subsec. (c)(4)(A)(i). Pub. L. 98-369, 2354(b)(38), substituted
''with reasonable promptness'' for ''promptly as appropriate''.
Subsec. (g)(2). Pub. L. 98-369, 2350(b)(1), inserted ''and except
that an organization (with the approval of the Secretary) may provide
that a part of the value of such additional benefits be withheld and
reserved by the Secretary as provided in paragraph (5)'' at end of first
sentence.
Subsec. (g)(4)(A). Pub. L. 98-369, 2350(c), inserted ''and skilled
nursing facilities'' after ''hospitals'', inserted ''or the appropriate
basis for payment established under this subchapter'' after ''section
1395x(v) of this title)'', and struck out ''hospital'' before ''services
furnished to individuals''.
Subsec. (g)(5). Pub. L. 98-369, 2350(b)(2), added par. (5).
1983 -- Subsec. (a)(5)(A)(ii), (B)(ii). Pub. L. 98-21,
606(a)(3)(H), substituted ''1395r(a)(1)'' for ''1395r(c)(1)''.
Subsec. (g)(1). Pub. L. 97-448 substituted ''subsection (b)'' for
''subsection (b)(1)''.
Subsec. (g)(4). Pub. L. 98-21, 602(g), added par. (4).
1982 -- Pub. L. 97-248 completely revised section, expanding its
coverage to permit payments to both health maintenance organizations and
competitive medical plans.
1978 -- Subsec. (b)(2)(B). Pub. L. 95-292 substituted
''Administrator of the Health Care Financing Administration'' for
''Commissioner of Social Security''.
1976 -- Subsec. (b). Pub. L. 94-460, 201(a), struck out provisions
defining a health maintenance organization as a public or private
organization which provides physicians' services and a sufficient number
of primary care and specialty care physicians, assures its members
access to qualified practitioners in specialties available in area
served by such organization, demonstrates financial responsibility and
means to provide comprehensive health care services, has at least half
of its enrolled members under age 65, assures prompt and qualified
health service, and has an open enrollment period at least every year,
and revised the definition and requirements of an health maintenance
organization to conform to those set forth in the Public Health Service
Act, except that the services which such an organization must provide
are those covered in parts A and B of this subchapter rather than the
basic health services defined in the Public Health Service Act, and
inserted provisions requiring Secretary to administer determinations of
whether an organization is a health maintenance organization through and
in the office of the Assistant Secretary for Health, to integrate the
administration of such functions and duties with the administration of
provisions requiring the continued regulation of health maintenance
organizations under the Public Health Service Act, and to administer
other provisions of this section through the Commissioner of Social
Security.
Subsec. (h). Pub. L. 94-460, 201(b), substituted provisions that
each health maintenance organization with which the Secretary enters
into a contract under this section have an enrolled membership at least
half of which consists of individuals who have not attained age 65, with
the Secretary empowered to waive that requirement for a period of not
more than three years from the date a health maintenance organization
first enters into an agreement with the Secretary pursuant to subsection
(i) of this section for provisions that such requirement not apply with
respect to any health maintenance organization for such period not to
exceed three years from the date such organization enters into an
agreement with the Secretary pursuant to subsection (i) of this section,
as the Secretary might permit.
Subsec. (i)(6)(B). Pub. L. 94-460, 201(c), substituted ''(other than
costs with respect to out-of-area services and, in the case of an
organization which has entered into a risk-sharing contract with the
Secretary pursuant to paragraph (2)(A), the cost of providing any member
with basic health services the aggregate value of which exceeds $5,000
in any year)'' for ''(Other than those with respect to out-of-area
services)''.
Subsec. (k). Pub. L. 94-460, 201(d), added subsec. (k).
1973 -- Subsec. (a)(3)(A)(ii). Pub. L. 93-233, 18(m), struck out
'', with the apportionment of savings being proportional to the losses
absorbed and not yet offset'' at end.
Subsec. (g)(2). Pub. L. 93-233, 18(n), substituted ''portion of its
premium rate or other charges'' for ''portion'' and ''shall not exceed''
for ''may not exceed'', and struck out cl. (i) designation preceding
''the actuarial value'' and provisions reading ''less (ii) the actuarial
value of other charges made in lieu of such deductible and
coinsurance'', respectively.
1972 -- Subsec. (i). Pub. L. 92-603, 278(b)(3), substituted
''skilled nursing facility'' for ''extended care facility'' and
''skilled nursing facilities'' for ''extended care facilities''.
Section 4204(a)(4) of Pub. L. 101-508 provided that: ''The
amendments made by paragraphs (1) and (2) (amending this section) shall
apply with respect to contract years beginning on or after January 1,
1992, and the amendments made by paragraph (3) (amending section
1320a-7a of this title) shall take effect on the date of the enactment
of this Act (Nov. 5, 1990).''
Section 4204(c)(3) of Pub. L. 101-508 provided that: ''The
amendments made by this subsection (amending this section) shall apply
with respect to national coverage determinations that are not
incorporated in the determination of the per capita rate of payment for
individuals enrolled for 1991 with an eligible organization which has
entered into a risk-sharing contract under section 1876 of the Social
Security Act (this section).''
Section 4204(d)(2) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply with
respect to items and services furnished on or after January 1, 1991.''
Section 4204(e)(2) of Pub. L. 101-508 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply
with respect to individuals enrolling with an eligible organization
(which has a risk-sharing contract under section 1876 of the Social
Security Act (this section)) under a health benefit plan operated,
sponsored, or contributed to, by the individual's employer or former
employer (or the employer or former employer of the individual's spouse)
on or after January 1, 1991.''
Amendment by section 4206(b)(1) of Pub. L. 101-508 applicable to
contracts under this section and payments under section 1395l(a)(1)(A)
of this title as of the first day of the first month beginning more than
1 year after Nov. 5, 1990, see section 4206(e)(2) of Pub. L. 101-508,
set out as a note under section 1395l of this title.
Section 6206(b)(2) of Pub. L. 101-239 provided that: ''The
amendments made by paragraph (1) (amending this section) shall take
effect 60 days after the date of the enactment of this Act (Dec. 19,
1989).''
Section 6212(b)(2) of Pub. L. 101-239 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply to
services furnished on or after April 1, 1990.''
Section 6212(c)(3) of Pub. L. 101-239 provided that: ''The
amendments made by this subsection (amending this section and repealing
provisions set out as notes below) shall take effect on the date of the
enactment of this Act (Dec. 19, 1989).''
Section 6411(d)(4)(B) of Pub. L. 101-239 provided that: ''The
amendments made by paragraph (3) (amending this section and section
1396a of this title) shall apply to employment and contracts as of 90
days after the date of the enactment of this Act (Dec. 19, 1989).''
Amendment by section 201(a) of Pub. L. 101-234 effective Jan. 1,
1990, see section 201(c) of Pub. L. 101-234, set out as a note under
section 1320a-7a of this title.
Amendment by section 202(a) of Pub. L. 101-234 effective Jan. 1,
1990, and applicable to premiums for months beginning after Dec. 31,
1989, see section 202(b) of Pub. L. 101-234, set out as a note under
section 401 of this title.
Section 8412(b) of Pub. L. 100-647 provided that: ''The amendments
made by subsection (a) (amending this section) shall not apply to
contracts in effect on the date of the enactment of this Act (Nov. 10,
1988) or extensions (not exceeding 90 days) thereof.''
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 202(f) of Pub. L. 100-360 applicable to
enrollments effected on or after Jan. 1, 1990, see section 202(m)(3) of
Pub. L. 100-360, set out as a note under section 1395u of this title.
Amendment by section 211(c)(3) of Pub. L. 100-360 applicable, except
as specified in such amendment, to monthly premiums for months beginning
with January 1989, see section 211(d) of Pub. L. 100-360, set out as a
note under section 1395r of this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(c)(1), (3), (4), (6), (e)(3) 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.
Section 4011(a)(2) of Pub. L. 100-203 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply with
respect to contracts entered into or renewed on or after the date of
enactment of this Act (Dec. 22, 1987).''
Section 4011(b)(2) of Pub. L. 100-203 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply to
contracts entered into or renewed on or after the date of the enactment
of this Act (Dec. 22, 1987).''
Section 4012(d) of Pub. L. 100-203 provided that: ''The amendments
made by subsections (a) and (b) (amending this section and section
1395cc this title) shall apply to admissions occurring on or after April
1, 1988, or, if later, the earliest date the Secretary can provide the
information required under subsection (c) (set out as a note below) in
machine readable form.''
Section 4013(b) of Pub. L. 100-203, which provided the effective
date for amendment made by section 4013(a) of Pub. L. 100-203, was
omitted in the general amendment of section 4013 of Pub. L. 100-203 by
Pub. L. 100-360, title IV, 411(c)(3), July 1, 1988, 102 Stat. 773.
Section 1895(b)(11)(B) of Pub. L. 99-514 provided that: ''The
amendment made by subparagraph (A) (amending this section) shall apply
to determinations of per capita payment rates for 1987 and subsequent
years.''
Section 9312(b)(2) of Pub. L. 99-509 provided that: ''The amendment
made by paragraph (1) (amending this section) shall take effect on
January 1, 1987, and shall apply to enrollments effected on or after
such date.''
Section 9312(c)(3) of Pub. L. 99-509, as amended by Pub. L.
100-203, title IV, 4018(d), Dec. 22, 1987, 101 Stat. 1330-66; Pub.
L. 101-239, title VI, 6212(a), Dec. 19, 1989, 103 Stat. 2249,
provided that:
''(A) New restriction. -- The amendment made by paragraph (1)
(amending this section) shall apply to modifications and waivers granted
after the date of the enactment of this Act (Oct. 21, 1986).
''(B) Sanctions for noncompliance. -- The amendments made by
paragraph (2) (amending this section) shall take effect on the date of
the enactment of this Act.
''(C) Treatment of current waivers. -- In the case of an eligible
organization (or successor organization) that --
''(i) as of the date of the enactment of this Act, has been granted,
under paragraph (2) of section 1876(f) of the Social Security Act
(subsec. (f)(2) of this section), a modification or waiver of the
requirement imposed by paragraph (1) of that section, but
''(ii) does not meet the requirement for such modification or waiver
under the amendment made by paragraph (1) of this subsection,
the organization shall make, and continue to make, reasonable efforts
to meet scheduled enrollment goals, consistent with a schedule of
compliance approved by the Secretary of Health and Human Services. If
the Secretary determines that the organization has complied, or made
significant progress towards compliance, with such schedule of
compliance, the Secretary may extend such waiver. If the Secretary
determines that the organization has not complied with such schedule,
the Secretary may provide for a sanction described in section 1876(f)(3)
of the Social Security Act (subsec. (f)(3) of this section) (as amended
by this section) effective with respect to individuals enrolling with
the organization after the date the Secretary notifies the organization
of such noncompliance.
''(D) Treatment of certain waivers. -- In the case of an eligible
organization (or successor organization) that is described in clauses
(i) and (ii) of subparagraph (C) and that received a grant or grants
totaling at least $3,000,000 in fiscal year 1987 under section
329(d)(1)(A) or 330(d)(1) of the Public Health Service Act (42 U.S.C.
254b(d)(1)(A), 254c(d)(1)) --
''(i) before January 1, 1994, section 1876(f) of the Social Security
Act (subsec. (f) of this section) shall not apply to the organization;
''(ii) beginning on January 1, 1990, the Secretary of Health and
Human Services shall conduct an annual review of the organization to
determine the organization's compliance with the quality assurance
requirements of section 1876(c)(6) of such Act (subsec. (c)(6) of this
section); and
''(iii) after January 1, 1990, if the organization receives an
unfavorable review under clause (ii), the Secretary, after notice to the
organization of the unfavorable review and an opportunity to correct any
deficiencies identified during the review, may provide for the sanction
described in section 1876(f)(3) of such Act (subsec. (f)(3) of this
section) effective with respect to individuals enrolling with the
organization after the date the Secretary notifies the organization that
the organization is not in compliance with the requirements of section
1876(c)(6) of such Act.''
Section 9312(d)(2) of Pub. L. 99-509 provided that: ''The amendment
made by paragraph (1) (amending this section) shall apply to
risk-sharing contracts under section 1876 of the Social Security Act
(this section) with respect to services furnished on or after January 1,
1987.''
Section 9312(e)(2) of Pub. L. 99-509 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
contracts as of January 1, 1987.''
Section 9353(e)(3)(B) of Pub. L. 99-509, as amended by Pub. L.
100-203, title IV, 4039(h)(9)(C), as added by Pub. L. 100-360, title
IV, 411(e)(3), July 1, 1988, 102 Stat. 776, provided that: ''The
amendment made by paragraph (2) (amending this section) shall apply to
risk-sharing contracts with eligible organizations, under section 1876
of the Social Security Act (this section), as of April 1, 1987. The
provisions of section 1876(i)(7) of the Social Security Act (subsec.
(i)(7) of this section) (added by such amendment) shall apply to health
maintenance organizations with contracts in effect under section 1876 of
such Act (as in effect before the date of the enactment of Public Law
97-248 (Sept. 3, 1982)) in the same manner as it applies to eligible
organizations with risk-sharing contracts in effect under section 1876
of such Act (as in effect on the date of the enactment of this Act (Dec.
22, 1987)).''
Section 9211(e) of Pub. L. 99-272 provided that:
''(1) Financial responsibility. -- The amendments made by subsection
(a) (amending this section) shall apply to enrollments and
disenrollments that become effective on or after the date of the
enactment of this Act (Apr. 7, 1986).
''(2) Disenrollments. -- The amendments made by subsection (b)
(amending this section) shall apply to requests for termination of
enrollment submitted on or after May 1, 1986.
''(3) Material review. -- (A) The amendment made by subsection (c)
(amending this section) shall not apply to material which has been
distributed before July 1, 1986.
''(B) Such amendment also shall not apply so as to require the
submission of material which is distributed before July 1, 1986.
''(C) Such amendment shall also not apply to material which the
Secretary determines has been prepared before the date of the enactment
of this Act (Apr. 7, 1986) and for which a commitment for distribution
has been made, if the application of such amendment would constitute a
hardship for the organization involved.
''(4) Publication. -- The amendment made by subsection (d) (amending
this section) shall apply to determinations of per capita rates of
payment for 1987 and subsequent years.
''(5) Necessary modification of contracts. -- The Secretary of Health
and Human Services shall provide for such changes in the risk-sharing
contracts which have been entered into under section 1876 of the Social
Security Act (this section) as may be necessary to conform to the
requirements imposed by the amendments made by this section (amending
this section) on a timely basis.''
Section 2350(d) of Pub. L. 98-369 provided that: ''The amendments
made by this section (amending this section and enacting provisions set
out as notes under this section) shall become effective on the date of
the enactment of this Act (July 18, 1984).''
Amendment by section 2354(b)(37), (38) 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 602(g) of 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 section 606(a)(3)(H) of 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.
Amendment by section 309(b)(12) of 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.
Section 114(c) of Pub. L. 97-248, as amended by Pub. L. 98-369,
div. B, title III, 2354(c)(3)(A), (B), July 18, 1984, 98 Stat. 1102;
Pub. L. 98-617, 3(a)(5), Nov. 8, 1984, 98 Stat. 3295; Pub. L.
99-509, title IX, 9312(a), Oct. 21, 1986, 100 Stat. 1999, provided
that:
''(1) Subject to paragraph (2), the amendment made by subsection (a)
(amending this section) shall apply with respect to services furnished
on or after the initial effective date (as defined in paragraph (4)),
except that such amendment shall not apply --
''(A) with respect to services furnished by an eligible organization
to any individual who is enrolled with that organization under an
existing cost contract (as defined in paragraph (3)(A)) and entitled to
benefits under part A, or enrolled in part B, of title XVIII of the
Social Security Act (this subchapter) at the time the organization first
enters into a new risk-sharing contract (as defined in paragraph (3)(D))
unless --
''(i) the individual requests at any time that the amendment apply,
or
''(ii) the Secretary determines at any time that the amendment should
apply to all members of the organization because of administrative costs
or other administrative burdens involved and so informs in advance each
affected member of the eligible organization;
''(B) with respect to services furnished by an eligible organization
during the five-year period beginning on the initial effective date, if
--
''(i) the organization has an existing risk-sharing contract (as
defined in paragraph (3)(B)) on the initial effective date, or
''(ii) on the date of the enactment of this Act (Sept. 3, 1982) the
organization was furnishing services pursuant to an existing
demonstration project (as defined in paragraph (3)(C)), such
demonstration project is concluded before the initial effective date,
and before such initial effective date the organization enters into an
existing risk-sharing contract,
unless the organization requests that the amendment apply earlier;
or
''(C) with respect to services furnished by an eligible organization
during the period of an existing demonstration project if on the initial
effective date the organization was furnishing services pursuant to the
project and if the project concludes after such date.
''(2)(A) In the case of an eligible organization which has in effect
an existing cost contract (as defined in paragraph (3)(A)) on the
initial effective date, the organization may receive payment under a new
risk-sharing contract with respect to a current, nonrisk medicare
enrollee (as defined in subparagraph (C)) only to the extent that the
organization enrolls, for each such enrollee, two new medicare enrollees
(as defined in subparagraph (D)). The selection of those current
nonrisk medicare enrollees with respect to whom payment may be so
received under a new risk-sharing contract shall be made in a nonbiased
manner.
''(B) Subparagraph (A) shall not be construed to prevent an eligible
organization from providing for enrollment, on a basis described in
subsection (a)(6) of section 1876 of the Social Security Act (subsec.
(a)(6) of this section) (as amended by this Act (Pub. L. 97-248), other
than under a reasonable cost reimbursement contract), of current,
nonrisk medicare enrollees and from providing such enrollees with some
or all of the additional benefits described in section 1876(g)(2) of the
Social Security Act (subsec. (g)(2) of this section) (as amended by this
Act (Pub. L. 97-248)), but (except as provided in subparagraph (A)) --
''(i) payment to the organization with respect to such enrollees
shall only be made in accordance with the terms of a reasonable cost
reimbursement contract, and
''(ii) no payment may be made under section 1876 of such Act (this
section) with respect to such enrollees for any such additional
benefits.
Individuals enrolled with the organization under this subparagraph
shall be considered to be individuals enrolled with the organization for
the purpose of meeting the requirement of section 1876(g)(2) of the
Social Security Act (subsec. (g)(2) of this section) (as amended by this
Act (Pub. L. 97-248)).
''(C) For purposes of this paragraph, the term 'current, nonrisk
medicare enrollee' means, with respect to an organization, an individual
who on the initial effective date --
''(i) is enrolled with that organization under an existing cost
contract, and
''(ii) is entitled to benefits under part A and enrolled under part
B, or enrolled in part B, of title XVIII of the Social Security Act
(this subchapter).
''(D) For purposes of this paragraph, the term 'new medicare
enrollee' means, with respect to an organization, an individual who --
''(i) is enrolled with the organization after the date the
organization first enters into a new risk-sharing contract,
''(ii) at the time of such enrollment is entitled to benefits under
part A, or enrolled in part B, of title XVIII of the Social Security Act
(this subchapter), and
''(iii) was not enrolled with the organization at the time the
individual became entitled to benefits under part A, or to enroll in
part B, of such title (this subchapter).
''(E) The preceding provisions of this paragraph shall not to (sic)
apply to payments made for current, nonrisk medicare enrollees for
months beginning with April 1987.
''(3) For purposes of this subsection:
''(A) The term 'existing cost contract' means a contract which is
entered into under section 1876 of the Social Security Act (this
section), as in effect before the initial effective date, or
reimbursement on a reasonable cost basis under section 1833(a)(1)(A) of
such Act (section 1395l(a)(1)(A) of this title), and which is not an
existing risk-sharing contract or an existing demonstration project.
''(B) The term 'existing risk-sharing contract' means a contract
entered into under section 1876(i)(2)(A) of the Social Security Act
(subsec. (i)(2)(A) of this section), as in effect before the initial
effective date.
''(C) The term 'existing demonstration project' means a demonstration
project under section 402(a) of the Social Security Amendments of 1967
(section 1395b-1(a) of this title) or under section 222(a) of the Social
Security Amendments of 1972 (section 222(a) of Pub. L. 92-603, set out
as a note under section 1395b-1 of this title), relating to the
provision of services for which payment may be made under title XVIII of
the Social Security Act (this subchapter).
''(D) The term 'new risk-sharing contract' means a contract entered
into under section 1876(g) of the Social Security Act (subsec. (g) of
this section), as amended by this Act (Pub. L. 97-248).
''(E) The term 'reasonable cost reimbursement contract' means a
contract entered into under section 1876(h) of such Act (subsec. (h) of
this section), as amended by this Act, or reimbursement on a reasonable
cost basis under section 1833(a)(1)(A) of such Act (section
1395l(a)(1)(A) of this title).
''(4) As used in this section, the term 'initial effective date'
means --
''(A) the first day of the thirteenth month which begins after the
date of the enactment of this Act (Sept. 3, 1982), or
''(B) the first day of the first month (Feb. 1, 1985) after the month
in which the Secretary of Health and Human Services notifies the
Committee on Finance of the Senate and the Committees on Ways and Means
and on Energy and Commerce of the House of Representatives that he is
reasonably certain that the methodology to make appropriate adjustments
(referred to in section 1876(a)(4) of the Social Security Act (subsec.
(a)(4) of this section), as amended by this Act (Pub. L. 97-248)) has
been developed and can be implemented to assure actuarial equivalence in
the estimation of adjusted average per capita costs under that section,
whichever is later.''
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.
Section 201(e) of Pub. L. 94-460 provided that: ''The amendments
made by this section (amending this section) shall be effective with
respect to contracts entered into between the Secretary and health
maintenance organizations under section 1876 of the Social Security Act
(this section) on and after the first day of the first calendar month
which begins more than 30 days after the date of enactment of this Act
(Oct. 8, 1976).''
Section 18(z-3)(3) of Pub. L. 93-233 provided that: ''The
amendments made by subsections (m) and (n) (amending this section) shall
be effective with respect to services provided after June 30, 1973.''
Section 226(f) of Pub. L. 92-603 provided that: ''The amendments
made by this section (enacting this section, amending sections 1395f,
1395l, 1395ll, and 1396b of this title, and enacting provisions set out
as notes under this section) shall be effective with respect to services
provided on or after July 1, 1973.''
Section 4204(b) of Pub. L. 101-508 provided that:
''(1) Not later than January 1, 1992, the Secretary of Health and
Human Services (in this section referred to as the 'Secretary') shall
submit a proposal to Congress that provides for a modified payment
method for organizations with a risk contract under section 1876(g) of
the Social Security Act (subsec. (g) of this section) that is more
accurate than the current payment methodology in predicting the actual
service utilization and annual medical expenditures of the beneficiary
population enrolled in a specific organization.
''(2) The proposal shall include --
''(A)(i) recommendations on modifying the current adjusted average
per capita cost formula, by adding predictors of medical utilization
such as health status adjustors or prior utilization measures; or
''(ii) recommendations for a new payment methodology as an
alternative to the adjusted average per capita cost;
''(B) data to support any recommended changes in payment methodology
for organizations with risk contracts under section 1876(g) of the
Social Security Act; and
''(C) analysis demonstrating that any proposed or revised payment
methodology under this section is effective in explaining at least 15
percent of the variation in health care utilization and costs (as
determined in consultation with the American Academy of Actuaries) among
individuals enrolled in such organizations.
''(3) Not later than March 1, 1992, the Secretary shall cause to have
published in the Federal Register a proposed rule providing for the
implementation of the payment methodology specified in the proposal
submitted pursuant to paragraph (1).
''(4) Not later than May 1, 1992, the Comptroller General shall
review the proposal and recommendations made pursuant to paragraphs (1)
and (2), and shall report to Congress on appropriate modifications in
such payment methodology.
''(5) Taking into account the recommendations made pursuant to
paragraph (4), on or after August 1, 1992, the Secretary shall issue a
final rule implementing a payment methodology that meets the
requirements of paragraph (1), effective for contract years beginning on
or after January 1, 1993.''
Section 4204(f) of Pub. L. 101-508 provided that:
''(1) The Secretary shall conduct a study of the extent to which
health maintenance organizations with contracts under section 1876 of
the Social Security Act (this section) make available to enrollees
entitled to benefits under title XVIII of such Act (this subchapter)
chiropractic services that are covered under such title.
''(2) The study shall examine the arrangements under which such
services are made available and the types of practitioners furnishing
such services to such enrollees.
''(3) The study shall be based on contracts entered into or renewed
on or after January 1, 1991, and before January 1, 1993.
''(4) The Secretary shall issue a final report to the Committees on
Ways and Means and Energy and Commerce of the House of Representatives
and the Committee on Finance of the Senate on the results of the study
not later than January 1, 1993. The report shall include
recommendations with respect to any legislative and regulatory changes
that the Secretary determines are necessary to ensure access to such
services.''
Conscientious objections of health care provider under State law
unaffected by enactment of subsec. (c)(8) of this section, see section
4206(c) of Pub. L. 101-508, set out as a note under section 1395cc of
this title.
Section 6206(a)(2) of Pub. L. 101-239 provided that: ''Before July
1, 1990, the Secretary of Health and Human Services shall provide for
notice to eligible organizations of the methodology used in making the
announcement under section 1876(a)(1)(A) of the Social Security Act
(subsec. (a)(1)(A) of this section) for 1990.''
Section 203(b) of Pub. L. 101-234 provided that: ''Notwithstanding
any other provision of this Act (see Tables for classification), the
amendments made by this Act (other than the repeal of sections
1833(c)(5) and 1834(c)(6) of the Social Security Act (sections
1395l(c)(5) and 1395m(c)(6) of this title)) shall not apply to
risk-sharing contracts, for contract year 1990 --
''(1) with eligible organizations under section 1876 of the Social
Security Act (this section), or
''(2) with health maintenance organizations under section
1876(i)(2)(A) of such Act (subsec. (i)(2)(A) of this section) (as in
effect before February 1, 1985), under section 402(a) of the Social
Security Amendments of 1967 (section 1395b-1(a) of this title), or under
section 222(a) of the Social Security Amendments of 1972 (Pub. L.
92-603, set out as a note under section 1395b-1 of this title).''
Section 222 of Pub. L. 100-360, as amended by Pub. L. 100-485,
title VI, 608(d)(13), Oct. 13, 1988, 102 Stat. 2415, provided that:
''The Secretary of Health and Human Services shall --
''(1) modify contracts under section 1876 of the Social Security Act
(this section), for portions of contract years occurring after December
31, 1988, to take into account the amendments made by this Act (see
Short Title of 1988 Amendment note under section 1305 of this title);
and
''(2) require such organizations and organizations paid under section
1833(a)(1)(A) of such Act (section 1395l(a)(1)(A) of this title) to make
appropriate adjustments (including adjustments in premiums and benefits)
in the terms of their agreements with medicare beneficiaries to take
into account such amendments.
The Secretary shall also provide for appropriate modifications of
contracts with health maintenance organizations under section
1876(i)(2)(A) of the Social Security Act (subsec. (i)(2)(A) of this
section) (as in effect before February 1, 1985), under section 402(a) of
the Social Security Amendments of 1967 (section 1395b-1(a) of this
title), or under section 222(a) of the Social Security Amendments of
1972 (42 U.S.C. 1395b-1 note), for portions of contract years occurring
after December 31, 1988, so as to apply to such organizations and
contracts the requirements imposed by the amendments made by this Act
upon an organization with a risk-sharing contract under section 1876 of
the Social Security Act.''
Section 4012(c) of Pub. L. 100-203, as amended by Pub. L. 100-360,
title IV, 411(c)(2)(B), July 1, 1988, 102 Stat. 773, provided that:
''The Secretary of Health and Human Services shall provide (in machine
readable form) to eligible organizations under section 1876 of the
Social Security Act (this section) medicare DRG rates for payments
required by the amendment made by subsection (a) (amending section
1395cc of this title) and data on cost pass-through items for all
inpatient services provided to medicare beneficiaries enrolled with such
organizations.''
Section 4015 of Pub. L. 100-203, as amended by Pub. L. 100-360,
title IV, 411(c)(5), as added by Pub. L. 100-485, title VI,
608(d)(19)(C), Oct. 13, 1988, 102 Stat. 2419, provided that:
''(a) Medicare Insured Group Demonstration Projects. --
''(1) The Secretary of Health and Human Services (in this subsection
referred to as the 'Secretary') may provide for capitation demonstration
projects (in this subsection referred to as 'projects') with an entity
which is an eligible organization with a contract with the Secretary
under section 1876 of the Social Security Act (this section) or which
meets the restrictions and requirements of this subsection. The
Secretary may not approve a project unless it meets the requirements of
this subsection.
''(2) The Secretary may not conduct more than 3 projects and may not
expend, from funds under title XVIII of the Social Security Act (this
subchapter), more than $600,000,000 in any fiscal year for all such
projects.
''(3) The per capita rate of payment under a project --
''(A) may be based on the adjusted average per capita cost (as
defined in section 1876(a)(4) of the Social Security Act (subsec.
(a)(4) of this section)) determined only with respect to the group of
individuals involved (rather than with respect to medicare beneficiaries
generally), but
''(B) the rate of payment may not exceed the lesser of --
''(i) 95 percent of the adjusted average per capita cost described in
subparagraph (A), or
''(ii)(I) in the 4th year or 5th year of a project, 115 percent of
the adjusted average per capita cost (as defined in section 1876(a)(4)
of such Act (subsec. (a)(4) of this section)) for classes of individuals
described in section 1876(a)(1)(B) of that Act (subsec. (a)(1)(B) of
this section), or
''(II) in any subsequent year of a project, 95 percent of the
adjusted average per capita cost (as defined in section 1876(a)(4)
(subsec. (a)(4) of this section)) for such classes.
''(4) If the payment amounts made to a project are greater than the
costs of the project (as determined by the Secretary or, if applicable,
on the basis of adjusted community rates described in section 1876(e)(3)
of the Social Security Act (subsec. (e)(3) of this section)), the
project --
''(A) may retain the surplus, but not to exceed 5 percent of the
average adjusted per capita cost determined in accordance with paragraph
(3)(A), and
''(B) with respect to any additional surplus not retained by the
project, shall apply such surplus to additional benefits for individuals
served by the project or return such surplus to the Secretary.
''(5) Enrollment under the project shall be voluntary. Individuals
enrolled with the project may terminate such enrollment as of the
beginning of the first calendar month following the date on which the
request is made for such termination. Upon such termination, such
individuals shall retain the same rights to other health benefits that
such individuals would have had if they had never enrolled with the
project without any exclusion or waiting period for pre-existing
conditions.
''(6) The requirements of --
''(A) subsection (c)(3)(C) (relating to dissemination of
information),
''(B) subsection (c)(3)(E) (annual statement of rights),
''(C) subsection (c)(5) (grievance procedures),
''(D) subsection (c)(6) (on-going quality),
''(E) subsection (g)(6) (relating to prompt payment of claims),
''(F) subsection (i)(3)(A) and (B) (relating to access to information
and termination notices),
''(G) subsection (i)(6) (relating to providing necessary services),
and
''(H) subsection (i)(7) (relating to agreements with peer review
organizations),
of section 1876 of the Social Security Act (this section) shall apply
to a project in the same manner as they apply to eligible organizations
with risk-sharing contracts under such section.
''(7) The benefits provided under a project must be at least
actuarially equivalent to the combination of the benefits available
under title XVIII of the Social Security Act (this subchapter) and the
benefits available through any alternative plans in which the individual
can enroll through the employer. The project shall guarantee the
actuarial value of benefits available under the employer plan for the
duration of the project.
''(8) A project shall comply with all applicable State laws.
''(9) The Secretary may not authorize a project unless the entity
offering the project demonstrates to the satisfaction of the Secretary
that it has the necessary financial reserves to pay for any liability
for benefits under the project (including those liabilities for health
benefits under medicare and any supplemental benefits).
''(10) The Comptroller General shall monitor projects under this
subsection and shall report periodically (not less often than once every
year) to the Committee on Finance of the Senate and the Committee on
Energy and Commerce and Committee on Ways and Means of the House of
Representatives on the status of such projects and the effect on such
projects of the requirements of this section and shall submit a final
report to each such committee on the results of such projects.
''(b) Payment Methodology Reform Demonstrations Projects. --
''(1) The Secretary of Health and Human Services (in this subsection
referred to as the 'Secretary') is specifically authorized to conduct
demonstration projects under this subsection for the purpose of testing
alternative payment methodologies pertaining to capitation payments
under title XVIII of the Social Security Act (this subchapter),
including --
''(A) computing adjustments to the average per capita cost under
section 1876 of such Act (this section) on the basis of health status or
prior utilization of services, and
''(B) accounting for geographic variations in cost in the adjusted
average per capita costs applicable to an eligible organization under
such section which differs from payments currently provided on a
county-by-county basis.
''(2) No project may be conducted under this subsection --
''(A) with an entity which is not an eligible organization (as
defined in section 1876(b) of the Social Security Act (subsec. (b) of
this section)), and
''(B) unless the project meets all the requirements of subsections
(c) and (i)(3) of section 1876 of such Act (subsecs. (c) and (i)(3) of
this section).
''(3) There are authorized to be appropriated to carry out projects
under this subsection $5,000,000 in each of fiscal years 1989 and 1990.
''(c) Application of Provisions. -- The provisions of subsection
(a)(2) and the first sentence of subsection (b) of section 402 of the
Social Security Amendments of 1967 (section 1395b-1(a)(2), (b) of this
title) shall apply to the demonstration projects under this section in
the same manner as they apply to experiments under subsection (a)(1) of
that section.''
Section 4017 of Pub. L. 100-203 provided that:
''(a) Study. -- The Comptroller General shall conduct a study on
medicare capitation rates that shall include an analysis and assessment
of --
''(1) the current method for computing per capita rates of payment
under section 1876 of the Social Security Act (this section) (including
the method for determining the United States per capita cost);
''(2) the method for establishing relative costs for geographic areas
and the data used to establish age, sex, and other weighting factors;
''(3) ways to refine the calculation of adjusted average per capita
costs under section 1876 of such Act (this section) (including making
adjustments for health status or prior utilization of services and
improvements in the definition of geographic areas);
''(4) the extent to which individuals enrolled with organizations
with a risk-sharing contract with the Secretary under section 1876 of
such Act (this section) differ in utilization and cost from
fee-for-service beneficiaries and ways for modifying enrollment patterns
through program changes or for reflecting the differences in rates
through group experience rating or other means;
''(5) approaches for limiting the liability of the contracting
organization under section 1876 of such Act (this section) in
catastrophic cases;
''(6) ways of establishing capitation rates on a basis other than
fee-for-service experience in areas with high prepaid market
penetration; and
''(7) methods for providing the rate levels necessary to maintain
access to quality prepaid services in rural or medically underserved
areas (while maintaining cost savings).
''(b) Reports. --
''(1) Not later than January 1 of 1989 and 1990, the Comptroller
General shall submit to the Committee on Finance of the Senate and the
Committee on Energy and Commerce and Committee on Ways and Means of the
House of Representatives interim reports on the progress of the study
conducted under subsection (a).
''(2) Not later than January 1, 1991, the Comptroller General shall
submit to each such committee a final report on the results of such
study.''
Section 4079 of Pub. L. 100-203, as amended by Pub. L. 100-360,
title IV, 411(h)(8), July 1, 1988, 102 Stat. 787, provided that:
''(a) In General. -- The Secretary of Health and Human Services (in
this section referred to as the 'Secretary') shall enter into an
agreement with not less than four eligible organizations submitting
applications under this section to conduct demonstration projects to
provide payment on a prepaid, capitated basis for community nursing and
ambulatory care furnished to any individual entitled to benefits under
part A and enrolled under part B of title XVIII of the Social Security
Act (part A and part B of this subchapter) (other than an individual
medically determined to have end-stage renal disease) who resides in the
geographic area served by the organization and enrolls with such
organization (in accordance with subsection (c)(2)).
''(b) Definitions of Community Nursing and Ambulatory Care and
Eligible Organization. -- As used in this section:
''(1) The term 'community nursing and ambulatory care' means the
following services:
''(A) Part-time or intermittent nursing care furnished by or under
the supervision of registered professional nurses.
''(B) Physical, occupational, or speech therapy.
''(C) Social and related services supportive of a plan of ambulatory
care.
''(D) Part-time or intermittent services of a home health aide.
''(E) Medical supplies (other than drugs and biologicals) and durable
medical equipment while under a plan of care.
''(F) Medical and other health services described in paragraphs
(2)(H)(ii) and (5) through (9) of section 1861(s) of the Social Security
Act (section 1395x(s)(2)(H)(ii), (5)-(9) of this title).
''(G) Rural health clinic services described in section
1861(aa)(1)(C) of such Act (section 1395x(aa)(1)(C) of this title).
''(H) Certain other related services listed in section 1915(c)(4)(B)
of such Act (section 1396n(c)(4)(B) of this title) to the extent the
Secretary finds such services are appropriate to prevent the need for
institutionalization of a patient.
''(2) The term 'eligible organization' means a public or private
entity, organized under the laws of any State, which meets the following
requirements:
''(A) The entity (or a division or part of such entity) is primarily
engaged in the direct provision of community nursing and ambulatory
care.
''(B) The entity provides directly, or through arrangements with
other qualified personnel, the services described in paragraph (1).
''(C) The entity provides that all nursing care (including services
of home health aids) is furnished by or under the supervision of a
registered nurse.
''(D) The entity provides that all services are furnished by
qualified staff and are coordinated by a registered professional nurse.
''(E) The entity has policies governing the furnishing of community
nursing and ambulatory care that are developed by registered
professional nurses in cooperation with (as appropriate) other
professionals.
''(F) The entity maintains clinical records on all patients.
''(G) The entity has protocols and procedures to assure, when
appropriate, timely referral to or consultation with other health care
providers or professionals.
''(H) The entity complies with applicable State and local laws
governing the provision of community nursing and ambulatory care to
patients.
''(I) The requirements of subparagraphs (B), (D), and (E) of section
1876(b)(2) of the Social Security Act (42 U.S.C. 1395mm(b)(2)(B), (D),
(E)).
''(c) Agreements With Eligible Organizations To Conduct Demonstration
Projects. --
''(1) The Secretary may not enter into an agreement with an eligible
organization to conduct a demonstration project under this section
unless the organization meets the requirements of this subsection and
subsection (e) with respect to members enrolled with the organization
under this section.
''(2) The organization shall have an open enrollment period for the
enrollment of individuals under this section. The duration of such
period of enrollment and any other requirement pertaining to enrollment
or termination of enrollment shall be specified in the agreement with
the organization.
''(3) The organization must provide to members enrolled with the
organization under this section, through providers and other persons
that meet the applicable requirements of titles XVIII and XIX of the
Social Security Act (this subchapter and subchapter XIX of this
chapter), community nursing and ambulatory care (as defined in
subsection (b)(1)) which is generally available to individuals residing
in the geographic area served by the organization, except that the
organization may provide such members with such additional health care
services as the members may elect, at their option, to have covered.
''(4) The organization must make community nursing and ambulatory
care (and such other health care services as such individuals have
contracted for) available and accessible to each individual enrolled
with the organization under this section, within the area served by the
organization, with reasonable promptness and in a manner which assures
continuity.
''(5) Section 1876(c)(5) of the Social Security Act (subsec. (c)(5)
of this section) shall apply to organizations under this section in the
same manner as it applies to organizations under section 1876 of such
Act.
''(6) The organization must have arrangements, established in
accordance with regulations of the Secretary, for an ongoing quality
assurance program for health care services it provides to such
individuals under the demonstration project conducted under this
section, which program (A) stresses health outcomes and (B) provides
review by health care professionals of the process followed in the
provision of such health care services.
''(7) Under a demonstration project under this section --
''(A) the Secretary could require the organization to provide
financial or other assurances (including financial risk-sharing) that
minimize the inappropriate substitution of other services under title
XVIII of such Act (this subchapter) for community nursing services; and
''(B) if the Secretary determines that the organization has failed to
perform in accordance with the requirements of the project (including
meeting financial responsibility requirements under the project, any
pattern of disproportionate or inappropriate institutionalization) the
Secretary shall, after notice, terminate the project.
''(d) Determination of Per Capita Payment Rates. --
''(1) The Secretary shall determine for each 12-month period in which
a demonstration project is conducted under this section, and shall
announce (in a manner intended to provide notice to interested parties)
not later than three months before the beginning of such period, with
respect to each eligible organization conducting a demonstration project
under this section, a per capita rate of payment for each class of
individuals who are enrolled with such organization who are entitled to
benefits under part A and enrolled under part B of title XVIII of the
Social Security Act (part A and part B of this subchapter).
''(2)(A) Except as provided in paragraph (3), the per capita rate of
payment under paragraph (1) shall be determined in accordance with this
paragraph.
''(B) The Secretary shall define appropriate classes of members,
based on age, disability status, and such other factors as the Secretary
determines to be appropriate, so as to ensure actuarial equivalence.
The Secretary may add to, modify, or substitute for such classes, if
such changes will improve the determination of actuarial equivalence.
''(C) The per capita rate of payment under paragraph (1) for each
such class shall be equal to 95 percent of the adjusted average per
capita cost (as defined in subparagraph (D)) for that class.
''(D) For purposes of subparagraph (C), the term 'adjusted average
per capita cost' means the average per capita amount that the Secretary
estimates in advance (on the basis of actual experience, or
retrospective actuarial equivalent based upon an adequate sample and
other information and data, in a geographic area served by an eligible
organization or in a similar area, with appropriate adjustments to
assure actuarial equivalence) would be payable in any contract year for
those services covered under parts A and B of title XVIII of the Social
Security Act (parts A and B of this subchapter) and types of expenses
otherwise reimbursable under such parts A and B which are described in
subparagraphs (A) through (G) of subsection (b)(1) (including
administrative costs incurred by organizations described in sections
1816 and 1842 of such Act (sections 1395h and 1395u of this title)), if
the services were to be furnished by other than an eligible
organization.
''(3) The Secretary shall, in consultation with providers, health
policy experts, and consumer groups develop capitation-based
reimbursement rates for such classes of individuals entitled to benefits
under part A and enrolled under part B of the Social Security Act
(probably means parts A and B of title XVIII of that Act, this
subchapter) as the Secretary shall determine. Such rates shall be
applied in determining per capita rates of payment under paragraph (1)
with respect to at least one eligible organization conducting a
demonstration project under this section.
''(4)(A) In the case of an eligible organization conducting a
demonstration project under this section, the Secretary shall make
monthly payments in advance and in accordance with the rate determined
under paragraph (2) or (3), except as provided in subsection (e)(3)(B),
to the organization for each individual enrolled with the organization.
''(B) The amount of payment under paragraph (2) or (3) may be
retroactively adjusted to take into account any difference between the
actual number of individuals enrolled in the plan under this section and
the number of such individuals estimated to be so enrolled in
determining the amount of the advance payment.
''(5) The payment to an eligible organization under this section for
individuals enrolled under this section with the organization and
entitled to benefits under part A and enrolled under part B of the
Social Security Act shall be made from the Federal Hospital Insurance
Trust Fund and the Federal Supplementary Medical Insurance Trust Fund
established under such Act (this chapter) in such proportions from each
such trust fund as the Secretary deems to be fair and equitable taking
into consideration benefits attributable to such parts A and B,
respectively.
''(6) During any period in which an individual is enrolled with an
eligible organization conducting a demonstration project under this
section, only the eligible organization (and no other individual or
person) shall be entitled to receive payments from the Secretary under
this title (probably means title XVIII of the Social Security Act, this
subchapter) for community nursing and ambulatory care (as defined in
subsection (b)(1)) furnished to the individual.
''(e) Restriction on Premiums, Deductibles, Copayments, and
Coinsurance. --
''(1) In no case may the portion of an eligible organization's
premium rate and the actuarial value of its deductibles, coinsurance,
and copayments charged (with respect to community nursing and ambulatory
care) to individuals who are enrolled under this section with the
organization, exceed the actuarial value of the coinsurance and
deductibles that would be applicable on the average to individuals
enrolled under this section with the organization (or, if the Secretary
finds that adequate data are not available to determine that actuarial
value, the actuarial value of the coinsurance and deductibles applicable
on the average to individuals in the area, in the State, or in the
United States, eligible to enroll under this section with the
organization, or other appropriate data) and entitled to benefits under
part A and enrolled under part B of the Social Security Act (probably
means parts A and B of title XVIII of that Act, this subchapter), if
they were not members of an eligible organization.
''(2) If the eligible organization provides to its members enrolled
under this section services in addition to community nursing and
ambulatory care, election of coverage for such additional services shall
be optional for such members and such organization shall furnish such
members with information on the portion of its premium rate or other
charges applicable to such additional services. In no case may the sum
of --
''(A) the portion of such organization's premium rate charged, with
respect to such additional services, to members enrolled under this
section, and
''(B) the actuarial value of its deductibles, coinsurance, and
copayments charged, with respect to such services to such members
exceed the adjusted community rate for such services (as defined in
section 1876(e)(3) of the Social Security Act (subsec. (e)(3) of this
section)).
''(3)(A) Subject to subparagraphs (B) and (C), each agreement to
conduct a demonstration project under this section shall provide that if
--
''(i) the adjusted community rate, referred to in paragraph (2), for
community nursing and ambulatory care covered under parts A and B of
title XVIII of the Social Security Act (parts A and B of this
subchapter) (as reduced for the actuarial value of the coinsurance and
deductibles under those parts) for members enrolled under this section
with the organization,
is less than
''(ii) the average of the per capita rates of payment to be made
under subsection (d)(1) at the beginning of the 12-month period (as
determined on such basis as the Secretary determines appropriate)
described in such subsection for members enrolled under this section
with the organization,
the eligible organization shall provide to such members the
additional benefits described in section 1876(g)(3) of the Social
Security Act (subsec. (g)(3) of this section) which are selected by the
eligible organization and which the Secretary finds are at least equal
in value to the difference between that average per capita payment and
the adjusted community rate (as so reduced).
''(B) Subparagraph (A) shall not apply with respect to any
organization which elects to receive a lesser payment to the extent that
there is no longer a difference between the average per capita payment
and adjusted community rate (as so reduced).
''(C) An organization conducting a demonstration project under this
section may provide (with the approval of the Secretary) that a part of
the value of such additional benefits under subparagraph (A) be withheld
and reserved by the Secretary as provided in section 1876(g)(5) of the
Social Security Act (subsec. (g)(5) of this section).
''(4) The provisions of paragraphs (3), (5), and (6) of section
1876(g) of the Social Security Act (subsec. (g)(3), (5), and (6) of this
section) shall apply in the same manner to agreements under this section
as they apply to risk-sharing contracts under section 1876 of such Act,
and, for this purpose, any reference in such paragraphs to paragraph (2)
is deemed a reference to paragraph (3) of this subsection.
''(5) Section 1876(e)(4) of the Social Security Act (subsec. (e)(4)
of this section) shall apply to eligible organizations under this
section in the same manner as it applies to eligible organizations under
section 1876 of such Act.
''(f) Commencement and Duration of Projects. -- Each demonstration
project under this section shall begin not later than July 1, 1989, and
shall be conducted for a period of three years.
''(g) Report. -- Not later than January 1, 1992, the Secretary shall
submit to the Congress a report on the results of the demonstration
projects conducted under this section.''
Section 9312(g) of Pub. L. 99-509 provided that: ''The Secretary of
Health and Human Services shall provide, through contract with an
appropriate organization, for a study of the methods by which --
''(1) the adjusted average per capita cost ('AAPCC', as defined in
section 1876(a)(4) of the Social Security Act (subsec. (a)(4) of this
section)) can be refined to more accurately reflect the average cost of
providing care to different classes of patients, and
''(2) the adjusted community rate ('ACR', as defined in section
1876(e)(3) of such Act (subsec. (e)(3) of this section)) can be refined.
The Secretary shall submit to Congress, by not later than January 1,
1988, specific legislative recommendations concerning methods by which
the calculation of the AAPCC and the ACR can be refined.''
Section 9312(h) of Pub. L. 99-509 provided that: ''The Secretary of
Health and Human Services shall provide that individuals enrolled with
an eligible organization under section 1876 of the Social Security Act
(this section) may disenroll, on and after June 1, 1987, at any local
office of the Social Security Administration.''
Section 9312(i) of Pub. L. 99-509 provided that: ''Notwithstanding
any provision of section 1876(g)(5) of the Social Security Act (42
U.S.C. 1395mm(g)(5)) to the contrary, funds reserved by an eligible
organization under such section before the date of the enactment of this
Act (Oct. 21, 1986) may be applied, at the organization's option, to
offset the amount of any reduction in payment amounts to the
organization effected under Public Law 99-177 (Dec. 12, 1985, 99 Stat.
1037, see Tables for classification) during fiscal year 1986.''
Section 2350(a)(2) of Pub. L. 98-369 provided that: ''The Secretary
of Health and Human Services may phase in, over a period of not longer
than three years, the application of the amendments made by paragraph
(1) (amending this section) to all applicable areas in the United States
if the Secretary determines that it is not administratively feasible to
establish a single 30-day open enrollment period for all such applicable
areas before the end of the period.''
Report to Congress
Section 2350(b)(3), (4) of Pub. L. 98-369, as amended by Pub. L.
100-203, title IV, 4013, Dec. 22, 1987, 101 Stat. 1330-61; Pub. L.
100-360, title IV, 411(c)(3), July 1, 1988, 102 Stat. 773, which
prohibited the Secretary of Health and Human Services from approving the
establishment of a stabilization fund by an eligible organization under
subsec. (g)(5) of this section for any contract period beginning later
than September 30, 1990, and which required the Secretary to report to
Congress with respect to the use of stabilization funds by eligible
organizations under subsec. (g)(5) of this section and to assess the
need for such funds not later than 54 months after July 1984, was
repealed by Pub. L. 101-239, title VI, 6212(c)(1), Dec. 19, 1989, 103
Stat. 2250.
Section 114(d) of Pub. L. 97-248 provided that: ''The Secretary of
Health and Human Services shall conduct a study of the additional
benefits selected by eligible organizations pursuant to section
1876(g)(2) of the Social Security Act (subsec. (g)(2) of this section),
as amended by subsection (a) of this section (section 114(a) of Pub. L.
97-248). The Secretary shall report to the Congress within 24 months of
the initial effective date (as defined in subsection (c)(4) (section
114(c)(4) of Pub. L. 97-248, set out as an Effective Date of 1982
Amendment note above)) with respect to the findings and conclusions made
as a result of such study.''
Section 114(e) of Pub. L. 97-248 provided that: ''The Secretary of
Health and Human Services shall conduct a study evaluating the extent
of, and reasons for, the termination by medicare beneficiaries of their
memberships in organizations with contracts under section 1876 of the
Social Security Act (this section). Such study may be coordinated with
the study provided for under section 2178(d) of the Omnibus Budget
Reconciliation Act of 1981 (section 2178(d) of Pub. L. 97-35, set out
as a note under section 1396a of this title). In conducting such study,
the Secretary shall place special emphasis on the quantity and quality
of medical care provided in such organizations and the quality of such
care when provided on a fee-for-service basis. The Secretary shall
submit an interim report to the Congress, within two years after the
initial effective date (as defined in subsection (c)(4) (section
114(c)(4) of Pub. L. 97-248, set out as an Effective Date of 1982
Amendment note above)), and a final report within five years after such
date containing the respective interim and final findings and
conclusions made as a result of such study.''
Section 226(b) of Pub. L. 92-603 provided that:
''(1) Notwithstanding the provisions of section 1814 and section 1833
of the Social Security Act (sections 1395f and 1395l of this title), any
health maintenance organization which has entered into a contract with
the Secretary pursuant to section 1876 of such Act (this section) shall,
for the duration of such contract, (except as provided in paragraph (2))
be entitled to reimbursement only as provided in section 1876 of such
Act (this section) for individuals who are members of such
organizations.
''(2) With respect to individuals who are members of organizations
which have entered into a risk-sharing contract with the Secretary
pursuant to subsection (i)(2)(A) (of this section) prior to July 1,
1973, and who, although eligible to have payment made pursuant to
section 1876 of such Act (this section) for services rendered to them,
chose (in accordance with regulations) not to have such payment made
pursuant to such section, the Secretary shall, for a period not to
exceed three years commencing on July 1, 1973, pay to such organization
on the basis of an interim per capita rate, determined in accordance
with the provisions of section 1876(a)(2) of such Act (subsec. (a)(2) of
this section), with appropriate actuarial adjustments to reflect the
difference in utilization of out-of-plan services, which would have been
considered sufficiently reasonable and necessary under the rules of the
health maintenance organization to be provided by that organization,
between such individuals and individuals who are enrolled with such
organization pursuant to section 1876 of such Act (this section).
Payments under this paragraph shall be subject to retroactive adjustment
at the end of each contract year as provided in paragraph (3).
''(3) If the Secretary determines that the per capita cost of any
such organization in any contract year for providing services to
individuals described in paragraph (2), when combined with the cost of
the Federal Hospital Insurance Trust Fund and the Federal Supplementary
Medical Insurance Trust Fund in such year for providing out-of-plan
services to such individuals, is less than or greater than the adjusted
average per capita cost (as defined in section 1876(a)(3) of such Act)
(subsec. (a)(3) of this section) of providing such services, the
resulting savings shall be apportioned between such organization and
such Trust Funds, or the resulting losses shall be absorbed by such
organization, in the manner prescribed in section 1876(a)(3) of such Act
(subsec. (a)(3) of this section).''
/1/ So in original. Probably should be ''significant''.
/2/ See References in Text note below.
/3/ So in original. Probably should be ''section''.
42 USC 1395nn. Limitation on certain physician referrals
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Prohibition of certain referrals
(1) In general
Except as provided in subsection (b) of this section, if a physician
(or immediate family member of such physician) has a financial
relationship with an entity specified in paragraph (2), then --
(A) the physician may not make a referral to the entity for the
furnishing of clinical laboratory services for which payment otherwise
may be made under this subchapter, and
(B) the entity may not present or cause to be presented a claim under
this subchapter or bill to any individual, third party payor, or other
entity for clinical laboratory services furnished pursuant to a referral
prohibited under subparagraph (A).
(2) Financial relationship specified
For purposes of this section, a financial relationship of a physician
(or immediate family member) with an entity specified in this paragraph
is --
(A) except as provided in subsections (c) and (d) of this section, an
ownership or investment interest in the entity; or
(B) except as provided in subsection (e) of this section, a
compensation arrangement (as defined in subsection (h)(1)(A) of this
section) between the physician (or immediate family member) and the
entity.
An ownership or investment interest described in subparagraph (A) may
be through equity, debt, or other means.
(b) General exceptions to both ownership and compensation arrangement
prohibitions
Subsection (a)(1) of this section shall not apply in the following
cases:
(1) Physicians' services
In the case of physicians' services (as defined in section 1395x(q)
of this title) provided personally by (or under the personal supervision
of) another physician in the same group practice (as defined in
subsection (h)(4) of this section) as the referring physician.
(2) In-office ancillary services
In the case of services --
(A) that are furnished --
(i) personally by the referring physician, personally by a physician
who is a member of the same group practice as the referring physician,
or personally by individuals who are employed by such physician or group
practice and who are personally supervised by the physician or by
another physician in the group practice, and
(ii)(I) in a building in which the referring physician (or another
physician who is a member of the same group practice) furnishes
physicians' services unrelated to the furnishing of clinical laboratory
services, or
(II) in the case of a referring physician who is a member of a group
practice, in another building which is used by the group practice for
the centralized provision of the group's clinical laboratory services,
and
(B) that are billed by the physician performing or supervising the
services, by a group practice of which such physician is a member, or by
an entity that is wholly owned by such physician or such group practice,
if the ownership or investment interest in such services meets such
other requirements as the Secretary may impose by regulation as needed
to protect against program or patient abuse.
(3) Prepaid plans
In the case of services furnished --
(A) by an organization with a contract under section 1395mm of this
title to an individual enrolled with the organization,
(B) by an organization described in section 1395l(a)(1)(A) of this
title to an individual enrolled with the organization, or
(C) by an organization receiving payments on a prepaid basis, under a
demonstration project under section 1395b-1(a) of this title or under
section 222(a) of the Social Security Amendments of 1972, to an
individual enrolled with the organization.
(4) Hospital financial relationship unrelated to provision of
clinical laboratory services
In the case of a financial relationship with a hospital if the
financial relationship does not relate to the provision of clinical
laboratory services.
(5) Other permissible exceptions
In the case of any other financial relationship which the Secretary
determines, and specifies in regulations, does not pose a risk of
program or patient abuse.
(c) General exception related only to ownership or investment
prohibition for ownership in publicly-traded securities
Ownership of investment securities (including shares or bonds,
debentures, notes, or other debt instruments) which were purchased on
terms generally available to the public and which are in a corporation
that --
(1) is listed for trading on the New York Stock Exchange or on the
American Stock Exchange, or is a national market system security traded
under an automated interdealer quotation system operated by the National
Association of Securities Dealers, and
(2) had, at the end of the corporation's most recent fiscal year,
total assets exceeding $100,000,000,
shall not be considered to be an ownership or investment interest
described in subsection (a)(2)(A) of this section.
(d) Additional exceptions related only to ownership or investment
prohibition
The following, if not otherwise excepted under subsection (b) of this
section, shall not be considered to be an ownership or investment
interest described in subsection (a)(2)(A) of this section:
(1) Hospitals in Puerto Rico
In the case of clinical laboratory services provided by a hospital
located in Puerto Rico.
(2) Rural provider
In the case of clinical laboratory services if the laboratory
furnishing the services is in a rural area (as defined in section
1395ww(d)(2)(D) of this title).
(3) Hospital ownership
In the case of clinical laboratory services provided by a hospital
(other than a hospital described in paragraph (1)) if --
(A) the referring physician is authorized to perform services at the
hospital, and
(B) the ownership or investment interest is in the hospital itself
(and not merely in a subdivision thereof).
(e) Exceptions relating to other compensation arrangements
The following shall not be considered to be a compensation
arrangement described in subsection (a)(2)(B) of this section:
(1) Rental of office space
Payments made for the rental or lease of office space if --
(A) there is a written agreement, signed by the parties, for the
rental or lease of the space, which agreement --
(i) specifies the space covered by the agreement and dedicated for
the use of the lessee, /1/
(ii) provides for a term of rental or lease of at least one year;
(iii) provides for payment on a periodic basis of an amount that is
consistent with fair market value;
(iv) provides for an amount of aggregate payments that does not vary
(directly or indirectly) based on the volume or value of any referrals
of business between the parties; and
(v) would be considered to be commercially reasonable even if no
referrals were made between the parties;
(B) in the case of rental or lease of office space in which a
physician who is an interested investor (or an interested investor who
is an immediate family member of the physician) has an ownership or
investment interest, the office space is in the same building as the
building in which the physician (or group practice of which the
physician is a member) has a practice; and
(C) the arrangement meets such other requirements as the Secretary
may impose by regulation as needed to protect against program or patient
abuse.
(2) Employment and service arrangements with hospitals
An arrangement between a hospital and a physician (or immediate
family member) for the employment of the physician (or family member) or
for the provision of administrative services, if --
(A) the arrangement is for identifiable services;
(B) the amount of the remuneration under the arrangement --
(i) is consistent with the fair market value of the services, and
(ii) is not determined in a manner that takes into account (directly
or indirectly) the volume or value of any referrals by the referring
physician;
(C) the remuneration is provided pursuant to an agreement which would
be commercially reasonable even if no referrals were made to the
hospital; and
(D) the arrangement meets such other requirements as the Secretary
may impose by regulation as needed to protect against program or patient
abuse.
(3) Other service arrangements
Remuneration from an entity (other than a hospital) under an
arrangement if --
(A) the arrangement is --
(i) for specific identifiable services as the medical director or as
a member of a medical advisory board at the entity pursuant to a
requirement of this subchapter,
(ii) for specific identifiable physicians' services to be furnished
to an individual receiving hospice care if payment for such services may
only be made under this subchapter as hospice care,
(iii) for specific physicians' services furnished to a nonprofit
blood center, or
(iv) for specific identifiable administrative services (other than
direct patient care services), but only under exceptional circumstances
specified by the Secretary in regulations;
(B) the requirements described in subparagraphs (B) and (C) of
paragraph (2) are met with respect to the entity in the same manner as
they apply to a hospital; and
(C) the arrangement meets such other requirements as the Secretary
may impose by regulation as needed to protect against program or patient
abuse.
(4) Physician recruitment
In the case of remuneration which is provided by a hospital to a
physician to induce the physician to relocate to the geographic area
served by the hospital in order to be a member of the medical staff of
the hospital, if --
(A) the physician is not required to refer patients to the hospital,
(B) the amount of the remuneration under the arrangement is not
determined in a manner that takes into account (directly or indirectly)
the volume or value of any referrals by the referring physician, and
(C) the arrangement meets such other requirements as the Secretary
may impose by regulation as needed to protect against program or patient
abuse.
(5) Isolated transactions
In the case of an isolated financial transaction, such as a one-time
sale of property, if --
(A) the requirements described in subparagraphs (B) and (C) of
paragraph (2) are met with respect to the entity in the same manner as
they apply to a hospital, and
(B) the transaction meets such other requirements as the Secretary
may impose by regulation as needed to protect against program or patient
abuse.
(6) Salaried physicians in a group practice
A compensation arrangement involving payment by a group practice of
the salary of a physician member of the group practice.
(f) Reporting requirements
Each entity providing covered items or services for which payment may
be made under this subchapter shall provide the Secretary with the
information concerning the entity's ownership arrangements, including --
(1) the covered items and services provided by the entity, and
(2) the names and unique physician identification numbers of all
physicians with an ownership or investment interest (as described in
subsection (a)(2)(A) of this section) in the entity, or whose immediate
relatives have such an ownership or investment.
Such information shall be provided in such form, manner, and at such
times as the Secretary shall specify. Such information shall first be
provided not later than October 1, 1991. The requirement of this
subsection shall not apply to covered items and services provided
outside the United States or to entities which the Secretary determines
provides /2/ services for which payment may be made under this
subchapter very infrequently. The Secretary may waive the requirements
of this subsection (and the requirements of chapter 35 of title 44 with
respect to information provided under this subsection) with respect to
reporting by entities in a State (except for entities providing clinical
laboratory services) so long as such reporting occurs in at least 10
States, and the Secretary may waive such requirements with respect to
the providers in a State required to report so long as such requirements
are not waived with respect to parenteral and enteral suppliers, end
stage renal disease facilities, suppliers of ambulance services,
hospitals, entities providing physical therapy services, and entities
providing diagnostic imaging services of any type.
(g) Sanctions
(1) Denial of payment
No payment may be made under this subchapter for a clinical
laboratory service which is provided in violation of subsection (a)(1)
of this section.
(2) Requiring refunds for certain claims
If a person collects any amounts that were billed in violation of
subsection (a)(1) of this section, the person shall be liable to the
individual for, and shall refund on a timely basis to the individual,
any amounts so collected.
(3) Civil money penalty and exclusion for improper claims
Any person that presents or causes to be presented a bill or a claim
for a service that such person knows or should know is for a service for
which payment may not be made under paragraph (1) or for which a refund
has not been made under paragraph (2) shall be subject to a civil money
penalty of not more than $15,000 for each such service. The provisions
of section 1320a-7a of this title (other than the first sentence of
subsection (a) and other than subsection (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.
(4) Civil money penalty and exclusion for circumvention schemes
Any physician or other entity that enters into an arrangement or
scheme (such as a cross-referral arrangement) which the physician or
entity knows or should know has a principal purpose of assuring
referrals by the physician to a particular entity which, if the
physician directly made referrals to such entity, would be in violation
of this section, shall be subject to a civil money penalty of not more
than $100,000 for each such arrangement or scheme. The provisions of
section 1320a-7a of this title (other than the first sentence of
subsection (a) and other than subsection (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.
(5) Failure to report information
Any person who is required, but fails, to meet a reporting
requirement of subsection (f) of this section is subject to a civil
money penalty of not more than $10,000 for each day for which reporting
is required to have been made. The provisions of section 1320a-7a of
this title (other than the first sentence of subsection (a) and other
than subsection (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.
(h) Definitions
For purposes of this section:
(1) Compensation arrangement; remuneration
(A) The term ''compensation arrangement'' means any arrangement
involving any remuneration between a physician (or immediate family
member) and an entity.
(B) The term ''remuneration'' includes any remuneration, directly or
indirectly, overtly or covertly, in cash or in kind.
(2) Employee
An individual is considered to be ''employed by'' or an ''employee''
of an entity if the individual would be considered to be an employee of
the entity under the usual common law rules applicable in determining
the employer-employee relationship (as applied for purposes of section
3121(d)(2) of the Internal Revenue Code of 1986).
(3) Fair market value
The term ''fair market value'' means the value in arms length
transactions, consistent with the general market value, and, with
respect to rentals or leases, the value of rental property for general
commercial purposes (not taking into account its intended use) and, in
the case of a lease of space, not adjusted to reflect the additional
value the prospective lessee or lessor would attribute to the proximity
or convenience to the lessor where the lessor is a potential source of
patient referrals to the lessee.
(4) Group practice
The term ''group practice'' means a group of two or more physicians
legally organized as a partnership, professional corporation,
foundation, not-for-profit corporation, faculty practice plan, or
similar association --
(A) in which each physician who is a member of the group provides
substantially the full range of services which the physician routinely
provides (including medical care, consultation, diagnosis, or treatment)
through the joint use of shared office space, facilities, equipment, and
personnel;
(B) for which substantially all of the services of the physicians who
are members of the group are provided through the group and are billed
in the name of the group and amounts so received are treated as receipts
of the group;
(C) in which the overhead expenses of and the income from the
practice are distributed in accordance with methods previously
determined by members of the group; and
(D) which meets such other standards as the Secretary may impose by
regulation.
In the case of a faculty practice plan associated with a hospital
with an approved medical residency training program in which physician
members may provide a variety of different specialty services and
provide professional services both within and outside the group (as well
as perform other tasks such as research), the previous sentence shall be
applied only with respect to the services provided within the faculty
practice plan.
(5) Interested investor; disinterested investor
The term ''interested investor'' means, with respect to an entity, an
investor who is a physician in a position to make or to influence
referrals or business to the entity (or who is an immediate family
member of such an investor), and the term ''disinterested investor''
means an investor other than an interested investor.
(6) Investor
The term ''investor'' means, with respect to an entity, a person with
a financial relationship specified in subsection (a)(2) of this section
with the entity.
(7) Referral; referring physician
(A) Physicians' services
Except as provided in subparagraph (C), in the case of an item or
service for which payment may be made under part B of this subchapter,
the request by a physician for the item or service, including the
request by a physician for a consultation with another physician (and
any test or procedure ordered by, or to be performed by (or under the
supervision of) that other physician), constitutes a ''referral'' by a
''referring physician''.
(B) Other items
Except as provided in subparagraph (C), the request or establishment
of a plan of care by a physician which includes the provision of the
clinical laboratory service constitutes a ''referral'' by a ''referring
physician''.
(C) Clarification respecting certain services integral to a
consultation by certain specialists
A request by a pathologist for clinical diagnostic laboratory tests
and pathological examination services, if such services are furnished by
(or under the supervision of) such pathologist pursuant to a
consultation requested by another physician does not constitute a
''referral'' by a ''referring physician''.
(Aug. 14, 1935, ch. 531, title XVIII, 1877, as added Dec. 19, 1989,
Pub. L. 101-239, title VI, 6204(a), 103 Stat. 2236, and amended Nov. 5,
1990, Pub. L. 101-508, title IV, 4027(4207)(e)(1)-(3), (k)(2), 104
Stat. 1388-121, 1388-122, 1388-124.)
Section 222(a) of the Social Security Amendments of 1972, referred to
in subsec. (b)(3)(C), is section 222(a) of Pub. L. 92-603, Oct. 30,
1972, 86 Stat. 1329, which is set out as a note under section 1395b-1
of this title.
Section 3121(d)(2) of the Internal Revenue Code of 1986, referred to
in subsec. (h)(2), is classified to section 3121(d)(2) of Title 26,
Internal Revenue Code.
Part B of this subchapter, referred to in subsec. (h)(7)(A), is
classified to section 1395j et seq. of this title.
A prior section 1395nn, act Aug. 14, 1935, ch. 531, title XVIII,
1877, as added and amended Oct. 30, 1972, Pub. L. 92-603, title II,
242(b), 278(b)(8), 86 Stat. 1419, 1454; Oct. 25, 1977, Pub. L.
95-142, 4(a), 91 Stat. 1179; Dec. 5, 1980, Pub. L. 96-499, title IX,
917, 94 Stat. 2625; July 18, 1984, Pub. L. 98-369, div. B, title
III, 2306(f)(2), 98 Stat. 1073; Oct. 21, 1986, Pub. L. 99-509,
title IX, 9321(a)(1), 100 Stat. 2016; Aug. 18, 1987, Pub. L. 100-93,
4(c), 101 Stat. 689, which enumerated offenses relating to the
Medicare program and penalties for such offenses, was repealed by Pub.
L. 100-93, 4(e), 15(a), Aug. 18, 1987, 101 Stat. 689, 698, effective
at end of fourteen-day period beginning Aug. 18, 1987, and inapplicable
to administrative proceedings commenced before end of such period.
1990 -- Subsec. (b)(4), (5). Pub. L. 101-508, 4027(4207)(e)(2),
added par. (4) and redesignated former par. (4) as (5).
Subsec. (f). Pub. L. 101-508, 4027(4207)(e)(3)(B), (C), substituted
''October 1, 1991'' for ''1 year after December 19, 1989'' in second
sentence and inserted at end ''The requirement of this subsection shall
not apply to covered items and services provided outside the United
States or to entities which the Secretary determines provides services
for which payment may be made under this subchapter very infrequently.
The Secretary may waive the requirements of this subsection (and the
requirements of chapter 35 of title 44 with respect to information
provided under this subsection) with respect to reporting by entities in
a State (except for entities providing clinical laboratory services) so
long as such reporting occurs in at least 10 States, and the Secretary
may waive such requirements with respect to the providers in a State
required to report so long as such requirements are not waived with
respect to parenteral and enteral suppliers, end stage renal disease
facilities, suppliers of ambulance services, hospitals, entities
providing physical therapy services, and entities providing diagnostic
imaging services of any type.''
Subsec. (f)(2). Pub. L. 101-508, 4027(4207)(e)(3)(A), amended par.
(2) generally. Prior to amendment, par. (2) read as follows: ''the
names and all of the medicare provider numbers of the physicians who are
interested investors or who are immediate relatives of interested
investors.''
Subsec. (g)(5). Pub. L. 101-508, 4027(4207)(k)(2), inserted at end
''The provisions of section 1320a-7a of this title (other than the first
sentence of subsection (a) and other than subsection (b)) shall apply to
a civil money penalty under the previous sentence in the same manner as
such provisions apply to a penalty or proceeding under section
1320a-7a(a) of this title.''
Subsec. (h)(6). Pub. L. 101-508, 4027(4207)(e)(1)(C), added par.
(6). Former par. (6) redesignated (7).
Pub. L. 101-508, 4027(4207)(e)(1)(A), (B), substituted ''in the case
of an item or service for which payment may be made under part B of this
subchapter, the request by a physician for the item or service,'' for
''in the case of a clinical laboratory service which under law is
required to be provided by (or under the supervision of) a physician,
the request by a physician for the service,'' in subpar. (A) and struck
out ''in the case of another clinical laboratory service,'' after
''subparagraph (C),'' in subpar. (B).
Subsec. (h)(7). Pub. L. 101-508, 4027(4207)(e)(1)(C), redesignated
par. (6) as (7).
Section 4027(4207)(e)(5) of Pub. L. 101-508 provided that: ''The
amendments made by this subsection (amending this section and provisions
set out below) shall be effective as if included in the enactment of
section 6204 of the Omnibus Budget Reconciliation Act of 1989 (Pub. L.
101-239).''
Section 6204(c) of Pub. L. 101-239 provided that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (enacting this section and amending section 1395l of this
title) shall become effective with respect to referrals made on or after
January 1, 1992.
''(2) The reporting requirement of section 1877(f) of the Social
Security Act (subsec. (f) of this section) shall take effect on October
1, 1990.''
Section 6204(d) of Pub. L. 101-239, as amended by Pub. L. 101-508,
title IV, 4027(4207)(e)(4)(B), Nov. 5, 1990, 104 Stat. 1388-122,
provided that: ''The Secretary of Health and Human Services shall
publish final regulations to carry out section 1877 of the Social
Security Act (this section) by not later than October 1, 1991.''
Section 6204(e) of Pub. L. 101-239 provided that: ''The Comptroller
General shall conduct a study of the ownership of hospitals and other
providers of medicare services by referring physicians. Such study
shall investigate --
''(1) the types of such ownership arrangements and types of services
offered under such arrangements,
''(2) the returns generally earned by physician investors in such
arrangements,
''(3) the effect of such arrangements on (A) the utilization of items
and services by medicare beneficiaries, (B) medicare expenditures, and
(C) other entities providing items and services in the communities
served,
''(4) the effect of such arrangements on independent providers of
similar services, and
''(5) the effect on the provision of in-office clinical laboratory
services of the limitation on payment for certain referrals contained in
section 1877 of the Social Security Act (this section).
By not later than February 1, 1991, the Comptroller General shall
report to Congress on the results of such study.''
Section 6204(f) of Pub. L. 101-239, as amended by Pub. L. 101-508,
title IV, 4027(4207)(e)(4)(A), Nov. 5, 1990, 104 Stat. 1388-122,
provided that: ''Not later than June 30, 1992, the Secretary of Health
and Human Services shall submit to Congress a statistical profile
comparing utilization of items and services by medicare beneficiaries
served by entities in which the referring physician has a direct or
indirect financial interest and by medicare beneficiaries served by
other entities, for the States and entities specified in section 1877(f)
of the Social Security Act (subsec. (f) of this section) (other than
entities providing clinical laboratory services).''
/1/ So in original. The comma probably should be a semicolon.
/2/ So in original. Probably should be ''provide''.
42 USC 1395oo. Provider Reimbursement Review Board
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Establishment
Any provider of services which has filed a required cost report
within the time specified in regulations may obtain a hearing with
respect to such cost report by a Provider Reimbursement Review Board
(hereinafter referred to as the ''Board'') which shall be established by
the Secretary in accordance with subsection (h) of this section and
(except as provided in subsection (g)(2) of this section) any hospital
which receives payments in amounts computed under subsection (b) or (d)
of section 1395ww of this title and which has submitted such reports
within such time as the Secretary may require in order to make payment
under such section may obtain a hearing with respect to such payment by
the Board, if --
(1) such provider --
(A)(i) is dissatisfied with a final determination of the organization
serving as its fiscal intermediary pursuant to section 1395h of this
title as to the amount of total program reimbursement due the provider
for the items and services furnished to individuals for which payment
may be made under this subchapter for the period covered by such report,
or
(ii) is dissatisfied with a final determination of the Secretary as
to the amount of the payment under subsection (b) or (d) of section
1395ww of this title,
(B) has not received such final determination from such intermediary
on a timely basis after filing such report, where such report complied
with the rules and regulations of the Secretary relating to such report,
or
(C) has not received such final determination on a timely basis after
filing a supplementary cost report, where such cost report did not so
comply and such supplementary cost report did so comply,
(2) the amount in controversy is $10,000 or more, and
(3) such provider files a request for a hearing within 180 days after
notice of the intermediary's final determination under paragraph
(1)(A)(i), or with respect to appeals under paragraph (1)(A)(ii), 180
days after notice of the Secretary's final determination, or with
respect to appeals pursuant to paragraph (1) (B) or (C), within 180 days
after notice of such determination would have been received if such
determination had been made on a timely basis.
(b) Appeals by groups
The provisions of subsection (a) of this section shall apply to any
group of providers of services if each provider of services in such
group would, upon the filing of an appeal (but without regard to the
$10,000 limitation), be entitled to such a hearing, but only if the
matters in controversy involve a common question of fact or
interpretation of law or regulations and the amount in controversy is,
in the aggregate, $50,000 or more.
(c) Right to counsel; rules of evidence
At such hearing, the provider of services shall have the right to be
represented by counsel, to introduce evidence, and to examine and
cross-examine witnesses. Evidence may be received at any such hearing
even though inadmissible under rules of evidence applicable to court
procedure.
(d) Decisions of Board
A decision by the Board shall be based upon the record made at such
hearing, which shall include the evidence considered by the intermediary
and such other evidence as may be obtained or received by the Board, and
shall be supported by substantial evidence when the record is viewed as
a whole. The Board shall have the power to affirm, modify, or reverse a
final determination of the fiscal intermediary with respect to a cost
report and to make any other revisions on matters covered by such cost
report (including revisions adverse to the provider of services) even
though such matters were not considered by the intermediary in making
such final determination.
(e) Rules and regulations
The Board shall have full power and authority to make rules and
establish procedures, not inconsistent with the provisions of this
subchapter or regulations of the Secretary, which are necessary or
appropriate to carry out the provisions of this section. In the course
of any hearing the Board may administer oaths and affirmations. The
provisions of subsections (d) and (e) of section 405 of this title with
respect to subpenas shall apply to the Board to the same extent as they
apply to the Secretary with respect to subchapter II of this chapter.
(f) Finality of decision; judicial review; determinations of Board
authority; jurisdiction; venue; interest on amount in controversy
(1) A decision of the Board shall be final unless the Secretary, on
his own motion, and within 60 days after the provider of services is
notified of the Board's decision, reverses, affirms, or modifies the
Board's decision. Providers shall have the right to obtain judicial
review of any final decision of the Board, or of any reversal,
affirmance, or modification by the Secretary, by a civil action
commenced within 60 days of the date on which notice of any final
decision by the Board or of any reversal, affirmance, or modification by
the Secretary is received. Providers shall also have the right to
obtain judicial review of any action of the fiscal intermediary which
involves a question of law or regulations relevant to the matters in
controversy whenever the Board determines (on its own motion or at the
request of a provider of services as described in the following
sentence) that it is without authority to decide the question, by a
civil action commenced within sixty days of the date on which
notification of such determination is received. If a provider of
services may obtain a hearing under subsection (a) of this section and
has filed a request for such a hearing, such provider may file a request
for a determination by the Board of its authority to decide the question
of law or regulations relevant to the matters in controversy
(accompanied by such documents and materials as the Board shall require
for purposes of rendering such determination). The Board shall render
such determination in writing within thirty days after the Board
receives the request and such accompanying documents and materials, and
the determination shall be considered a final decision and not subject
to review by the Secretary. If the Board fails to render such
determination within such period, the provider may bring a civil action
(within sixty days of the end of such period) with respect to the matter
in controversy contained in such request for a hearing. Such action
shall be brought in the district court of the United States for the
judicial district in which the provider is located (or, in an action
brought jointly by several providers, the judicial district in which the
greatest number of such providers are located) or in the District Court
for the District of Columbia and shall be tried pursuant to the
applicable provisions under chapter 7 of title 5 notwithstanding any
other provisions in section 405 of this title. Any appeal to the Board
or action for judicial review by providers which are under common
ownership or control or which have obtained a hearing under subsection
(b) of this section must be brought by such providers as a group with
respect to any matter involving an issue common to such providers.
(2) Where a provider seeks judicial review pursuant to paragraph (1),
the amount in controversy shall be subject to annual interest beginning
on the first day of the first month beginning after the 180-day period
as determined pursuant to subsection (a)(3) of this section and equal to
the rate of return on equity capital established by regulation pursuant
to section 1395x(v)(1)(B) of this title and in effect at the time the
civil action authorized under paragraph (1) is commenced, to be awarded
by the reviewing court in favor of the prevailing party.
(3) No interest awarded pursuant to paragraph (2) shall be deemed
income or cost for the purposes of determining reimbursement due
providers under this chapter.
(g) Certain findings not reviewable
(1) The finding of a fiscal intermediary that no payment may be made
under this subchapter for any expenses incurred for items or services
furnished to an individual because such items or services are listed in
section 1395y of this title shall not be reviewed by the Board, or by
any court pursuant to an action brought under subsection (f) of this
section.
(2) The determinations and other decisions described in section
1395ww(d)(7) of this title shall not be reviewed by the Board or by any
court pursuant to an action brought under subsection (f) of this section
or otherwise.
(h) Composition and compensation
The Board shall be composed of five members appointed by the
Secretary without regard to the provisions of title 5 governing
appointments in the competitive services. Two of such members shall be
representative of providers of services. All of the members of the
Board shall be persons knowledgeable in the field of payment of
providers of services, and at least one of them shall be a certified
public accountant. Members of the Board shall be entitled to receive
compensation at rates fixed by the Secretary, but not exceeding the rate
specified (at the time the service involved is rendered by such members)
for grade GS-18 in section 5332 of title 5. The term of office shall be
three years, except that the Secretary shall appoint the initial members
of the Board for shorter terms to the extent necessary to permit
staggered terms of office.
(i) Technical and clerical assistance
The Board is authorized to engage such technical assistance as may be
required to carry out its functions, and the Secretary shall, in
addition, make available to the Board such secretarial, clerical, and
other assistance as the Board may require to carry out its functions.
(j) ''Provider of services'' defined
In this section, the term ''provider of services'' includes a rural
health clinic and a Federally qualified health center.
(Aug. 14, 1935, ch. 531, title XVIII, 1878, as added Oct. 30, 1972,
Pub. L. 92-603, title II, 243(a), 86 Stat. 1420, and amended Oct. 26,
1974, Pub. L. 93-484, 3(a), 88 Stat. 1459; Dec. 5, 1980, Pub. L.
96-499, title IX, 955, 94 Stat. 2647; Apr. 20, 1983, Pub. L. 98-21,
title VI, 602(h), 97 Stat. 165; July 18, 1984, Pub. L. 98-369, div.
B, title III, 2351(a)(1), (b)(1), 2354(b)(39), (40), 98 Stat. 1098,
1099, 1102; Nov. 5, 1990, Pub. L. 101-508, title IV, 4161(a)(6),
(b)(4), 104 Stat. 1388-94, 1388-95.)
The provisions of title 5 governing appointments in the competitive
service, referred to in subsec. (h), are classified to section 3301 et
seq. of Title 5, Government Organization and Employees.
1990 -- Subsec. (j). Pub. L. 101-508, 4161(b)(4), inserted ''a
rural health clinic and'' after ''includes''.
Pub. L. 101-508, 4161(a)(6), added subsec. (j).
1984 -- Subsec. (c). Pub. L. 98-369, 2354(b)(39), substituted
''inadmissible'' for ''inadmissable''.
Subsec. (e). Pub. L. 98-369, 2354(b)(40), substituted ''and (e)''
for '', (e), and (f)''.
Subsec. (f)(1). Pub. L. 98-369, 2351(a)(1), substituted
''notification of such determination is received'' for ''such
determination is rendered'' in third sentence.
Pub. L. 98-369, 2351(b)(1), inserted ''or which have obtained a
hearing under subsection (b) of this section'' after ''common ownership
or control'' in last sentence.
1983 -- Subsec. (a). Pub. L. 98-21, 602(h)(1)(A), inserted
provision in introductory text that, except as provided in subsec.
(g)(2) of this section, any hospital which receives payments in amounts
computed under section 1395ww(b) or (d) of this title and which has
submitted such reports within such time as Secretary may require in
order to make payment under such section may obtain a hearing with
respect to such payment by Board.
Subsec. (a)(1)(A). Pub. L. 98-21, 602(h)(1)(B), (C), designated
existing provisions as cl. (i) and added cl. (ii).
Subsec. (a)(3). Pub. L. 98-21, 602(h)(1)(D), substituted
''(1)(A)(i), or with respect to appeals under paragraph (1)(A)(ii), 180
days after notice of the Secretary's final determination,'' for
''(1)(A)''.
Subsec. (f)(1). Pub. L. 98-21, 602(h)(2), inserted ''(or, in an
action brought jointly by several providers, the judicial district in
which the greatest number of such providers are located)'' after ''the
judicial district in which the provider is located'', and ''Any appeal
to the Board or action for judicial review by providers which are under
common ownership or control must be brought by such providers as a group
with respect to any matter involving an issue common to such
providers.''
Subsec. (g). Pub. L. 98-21, 602(h)(3), designated existing
provisions as par. (1) and added par. (2).
Subsec. (h). Pub. L. 98-21, 602(h)(4), substituted ''payment of
providers of services'' for ''cost reimbursement''.
1980 -- Subsec. (f)(1). Pub. L. 96-499 inserted provision empowering
providers of services to obtain judicial review of any action of a
fiscal intermediary involving a question of law or regulations relevant
to matters in controversy whenever Board determined that it was without
authority to decide such matters in controversy.
1974 -- Subsec. (f). Pub. L. 93-484 redesignated existing provisions
as par. (1), inserted provisions authorizing judicial review for
providers of final decisions of Board and judicial review of any
affirmance by Secretary, and added pars. (2) and (3).
Amendment by section 4161(a)(6) of Pub. L. 101-508 applicable to
cost reports for periods beginning on or after Oct. 1, 1991, see
section 4161(a)(8)(C) of Pub. L. 101-508, set out as a note under
section 1395k of this title.
Amendment by section 4161(b)(4) of Pub. L. 101-508 applicable to
cost reports for periods beginning on or after Oct. 1, 1991, see
section 4161(b)(5) of Pub. L. 101-508, set out as a note under section
1395x of this title.
Section 2351(a)(2) of Pub. L. 98-369 provided that: ''The amendment
made by paragraph (1) (amending this section) shall be effective with
respect to any civil action commenced on or after the date of the
enactment of this Act (July 18, 1984).''
Section 2351(b)(2) of Pub. L. 98-369 provided that: ''The amendment
made by paragraph (1) (amending this section) shall be effective with
respect to any appeal or action brought on or after the date of the
enactment of this Act (July 18, 1984).''
Amendment by section 2354(b)(39), (40) 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 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. See, also, section 2351(c) of Pub.
L. 98-369, set out as a note below.
Section 3(b) of Pub. L. 93-484 provided that: ''The amendment made
by subsection (a) (amending this section) shall be applicable to cost
reports of providers of services for accounting periods ending on or
after June 30, 1973.''
Section 243(c) of Pub. L. 92-603 provided that: ''The amendments
made by this section (enacting this section and amending section 1395h
of this title) shall apply with respect to cost reports of providers of
services, as defined in title XVIII of the Social Security Act (this
subchapter), for accounting periods ending on or after June 30, 1973.''
References in laws to the rates of pay for GS-16, 17, or 18, or to
maximum rates of pay under the General Schedule, to be considered
references to rates payable under specified sections of Title 5,
Government Organization and Employees, see section 529 (title I,
101(c)(1)) of Pub. L. 101-509, set out in a note under section 5376 of
Title 5.
Section 2351(c) of Pub. L. 98-369 provided that: ''Notwithstanding
section 604 of the Social Security Amendments of 1983 (Public Law 98-21)
(set out as an Effective Date of 1983 Amendments note under section
1395ww of this title) --
''(1) the amendments made by section 602(h)(2)(A) of that Act
(amending this section) shall be effective with respect to any appeal or
action brought on or after April 20, 1983; and
''(2) the amendments made by section 602(h)(2)(B) of that Act
(amending this section) shall be effective with respect to any appeal or
action brought on or after the date of the enactment of this Act (July
18, 1984).''
42 USC 1395pp. Limitation on liability where claims are disallowed
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Conditions prerequisite to payment for items and services
notwithstanding determination of disallowance
Where --
(1) a determination is made that, by reason of section 1395y(a)(1) or
(9) of this title or by reason of a coverage denial described in
subsection (g) of this section, payment may not be made under part A or
part B of this subchapter for any expenses incurred for items or
services furnished an individual by a provider of services or by another
person pursuant to an assignment under section 1395u(b)(3)(B)(ii) of
this title, and
(2) both such individual and such provider of services or such other
person, as the case may be, did not know, and could not reasonably have
been expected to know, that payment would not be made for such items or
services under such part A or part B of this subchapter,
then to the extent permitted by this subchapter, payment shall,
notwithstanding such determination, be made for such items or services
(and for such period of time as the Secretary finds will carry out the
objectives of this subchapter), as though section 1395y(a)(1) and
section 1395y(a)(9) of this title did not apply and as though the
coverage denial described in subsection (g) of this section had not
occurred. In each such case the Secretary shall notify both such
individual and such provider of services or such other person, as the
case may be, of the conditions under which payment for such items or
services was made and in the case of comparable situations arising
thereafter with respect to such individual or such provider or such
other person, each shall, by reason of such notice (or similar notices
provided before the enactment of this section), be deemed to have
knowledge that payment cannot be made for such items or services or
reasonably comparable items or services. Any provider or other person
furnishing items or services for which payment may not be made by reason
of section 1395y(a)(1) or (9) of this title or by reason of a coverage
denial described in subsection (g) of this section shall be deemed to
have knowledge that payment cannot be made for such items or services if
the claim relating to such items or services involves a case, provider
or other person furnishing services, procedure, or test, with respect to
which such provider or other person has been notified by the Secretary
(including notification by a utilization and quality control peer review
organization) that a pattern of inappropriate utilization has occurred
in the past, and such provider or other person has been allowed a
reasonable time to correct such inappropriate utilization.
(b) Knowledge of person or provider that payment could not be made;
indemnification of individual
In any case in which the provisions of paragraphs (1) and (2) of
subsection (a) of this section are met, except that such provider or
such other person, as the case may be, knew, or could be expected to
know, that payment for such services or items could not be made under
such part A or part B of this subchapter, then the Secretary shall, upon
proper application filed within such time as may be prescribed in
regulations, indemnify the individual (referred to in such paragraphs)
for any payments received from such individual by such provider or such
other person, as the case may be, for such items or services. Any
payments made by the Secretary as indemnification shall be deemed to
have been made to such provider or such other person, as the case may
be, and shall be treated as overpayments, recoverable from such provider
or such other person, as the case may be, under applicable provisions of
law. In each such case the Secretary shall notify such individual of
the conditions under which indemnification is made and in the case of
comparable situations arising thereafter with respect to such
individual, he shall, by reason of such notice (or similar notices
provided before the enactment of this section), be deemed to have
knowledge that payment cannot be made for such items or services. No
item or service for which an individual is indemnified under this
subsection shall be taken into account in applying any limitation on the
amount of items and services for which payment may be made to or on
behalf of the individual under this subchapter.
(c) Knowledge of both provider and individual to whom items or
services were furnished that payment could not be made
No payments shall be made under this subchapter in any cases in which
the provisions of paragraph (1) of subsection (a) of this section are
met, but both the individual to whom the items or services were
furnished and the provider of service or other person, as the case may
be, who furnished the items or services knew, or could reasonably have
been expected to know, that payment could not be made for items or
services under part A or part B of this subchapter by reason of section
1395y(a)(1) or (a)(9) of this title or by reason of a coverage denial
described in subsection (g) of this section.
(d) Exercise of rights
In any case arising under subsection (b) of this section (but without
regard to whether payments have been made by the individual to the
provider or other person) or subsection (c) of this section, the
provider or other person shall have the same rights that an individual
has under sections 1395ff(b) and 1395u(b)(3)(C) of this title (as may be
applicable) when the amount of benefit or payments is in controversy,
except that such rights may, under prescribed regulations, be exercised
by such provider or other person only after the Secretary determines
that the individual will not exercise such rights under such sections.
(e) Payment where beneficiary not at fault
Where payment for inpatient hospital services or extended care
services may not be made under part A of this subchapter on behalf of an
individual entitled to benefits under such part solely because of an
unintentional, inadvertent, or erroneous action with respect to the
transfer of such individual from a hospital or skilled nursing facility
that meets the requirements of section 1395x(e) or (j) of this title by
such a provider of services acting in good faith in accordance with the
advice of a utilization review committee, quality control and peer
review organization, or fiscal intermediary, or on the basis of a
clearly erroneous administrative decision by a provider of services, the
Secretary shall take such action with respect to the payment of such
benefits as he determines may be necessary to correct the effects of
such unintentional, inadvertent, or erroneous action.
(f) Presumption with respect to coverage denial; rebuttal;
requirements; ''fiscal intermediary'' defined
(1) A home health agency which meets the applicable requirements of
paragraphs (3) and (4) shall be presumed to meet the requirement of
subsection (a)(2) of this section.
(2) The presumption of paragraph (1) with respect to specific
services may be rebutted by actual or imputed knowledge of the facts
described in subsection (a)(2) of this section, including any of the
following:
(A) Notice by the fiscal intermediary of the fact that payment may
not be made under this subchapter with respect to the services.
(B) It is clear and obvious that the provider should have known at
the time the services were furnished that they were excluded from
coverage.
(3) The requirements of this paragraph are as follows:
(A) The agency complies with requirements of the Secretary under this
subchapter respecting timely submittal of bills for payment and medical
documentation.
(B) The agency program has reasonable procedures to notify promptly
each patient (and the patient's physician) where it is determined that a
patient is being or will be furnished items or services which are
excluded from coverage under this subchapter.
(4)(A) The requirement of this paragraph is that, on the basis of
bills submitted by a home health agency during the previous quarter, the
rate of denial of bills for the agency by reason of a coverage denial
described in subsection (g) of this section does not exceed 2.5 percent,
computed based on visits for home health services billed.
(B) For purposes of determining the rate of denial of bills for a
home health agency under subparagraph (A), a bill shall not be
considered to be denied until the expiration of the 60-day period that
begins on the date such bill is denied by the fiscal intermediary, or,
with respect to such a denial for which the agency requests
reconsideration, until the fiscal intermediary issues a decision denying
payment for such bill.
(5) In this subsection, the term ''fiscal intermediary'' means, with
respect to a home health agency, an agency or organization with an
agreement under section 1395h of this title with respect to the agency.
(6) The Secretary shall monitor the proportion of denied bills
submitted by home health agencies for which reconsideration is
requested, and shall notify Congress if the proportion of denials
reversed upon reconsideration increases significantly.
(g) Coverage denial defined
The coverage denial described in this subsection is, with respect to
the provision of home health services to an individual, a failure to
meet the requirements of section 1395f(a)(2)(C) of this title or section
1395n(a)(2)(A) of this title in that the individual --
(1) is or was not confined to his home, or
(2) does or did not need skilled nursing care on an intermittent
basis.
(Aug. 14, 1935, ch. 531, title XVIII, 1879, as added Oct. 30, 1972,
Pub. L. 92-603, title II, 213(a), 86 Stat. 1384, and amended Dec. 5,
1980, Pub. L. 96-499, title IX, 956(a), 94 Stat. 2648; Sept. 3, 1982,
Pub. L. 97-248, title I, 145, 148(e), 96 Stat. 393, 394; Oct. 21,
1986, Pub. L. 99-509, title IX, 9305(g)(1), 9341(a)(3), 100 Stat.
1991, 2038; Dec. 22, 1987, Pub. L. 100-203, title IV, 4096(b), 101
Stat. 1330-139; Dec. 19, 1989, Pub. L. 101-239, title VI, 6214(a),
(b), 103 Stat. 2252.)
Parts A and B of this subchapter, referred to in text, are classified
to sections 1395c et seq. and 1395j et seq., respectively, of this
title.
1989 -- Subsec. (f)(1). Pub. L. 101-239, 6214(a)(1), struck out
''with respect to any coverage denial described in subsection (g) of
this section'' before period at end.
Subsec. (f)(4). Pub. L. 101-239, 6214(a)(2), designated existing
provisions as subpar. (A) and added subpar. (B).
Subsec. (f)(6). Pub. L. 101-239, 6214(b), added par. (6).
1987 -- Subsec. (b). Pub. L. 100-203 struck out '', subject to the
deductible and coinsurance provisions of this subchapter,'' after
''(referred to in such paragraphs)'' and inserted at end ''No item or
service for which an individual is indemnified under this subsection
shall be taken into account in applying any limitation on the amount of
items and services for which payment may be made to or on behalf of the
individual under this subchapter.''
1986 -- Subsec. (a). Pub. L. 99-509, 9305(g)(1)(A)- (C), (3),
temporarily inserted in par. (1) ''or by reason of a coverage denial
described in subsection (g) of this section'', and in concluding
provisions inserted ''and as though the coverage denial described in
subsection (g) of this section had not occurred'' and ''or by reason of
a coverage denial described in subsection (g) of this section''. See
Effective and Termination Dates of 1986 Amendment note below.
Subsec. (c). Pub. L. 99-509, 9305(g)(1)(D), (3), temporarily
inserted ''or by reason of a coverage denial described in subsection (g)
of this section''. See Effective and Termination Dates of 1986
Amendment note below.
Subsec. (d). Pub. L. 99-509, 9341(a)(3), substituted ''sections
1395ff(b) and 1395u(b)(3)(C) of this title (as may be applicable)'' for
''section 1395ff(b) of this title (when the determination is under part
A) or section 1395u(b)(3)(C) of this title (when the determination is
under part B)''.
Subsecs. (f), (g). Pub. L. 99-509, 9305(g)(1)(E), (3), temporarily
added subsecs. (f) and (g). See Effective and Termination Dates of
1986 Amendment note below.
1982 -- Subsec. (a). Pub. L. 97-248, 145, inserted provisions
relating to imputing knowledge to provider or other person furnishing
items or services for which payment may not be made that payment may not
be made if the provider or other person has been notified that a pattern
of inappropriate utilization has occurred in the past and there has been
a reasonable time for correction of such utilization.
Subsec. (e). Pub. L. 97-248, 148(e), substituted ''quality control
and peer review organization'' for ''professional standards review
organization''.
1980 -- Subsec. (e). Pub. L. 96-499 added subsec. (e).
Section 6214(c) of Pub. L. 101-239 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply to
determinations for quarters beginning on or after the date of the
enactment of this Act (Dec. 19, 1989).''
Amendment by Pub. L. 100-203 applicable to services furnished on or
after Jan. 1, 1988, see section 4096(d) of Pub. L. 100-203, set out as
a note under section 1320c-3 of this title.
Section 9305(g)(3) of Pub. L. 99-509, as amended by Pub. L.
100-360, title IV, 426(c), July 1, 1988, 102 Stat. 814; Pub. L.
101-508, title IV, 4027(4207)(b)(3), Nov. 5, 1990, 104 Stat.
1388-118, provided that: ''The amendments made by paragraph (1)
(amending this section) shall apply to coverage denials occurring on or
after July 1, 1987, and before December 31, 1995.''
Amendment by section 9341(a)(3) of Pub. L. 99-509 applicable to
items and services furnished on or after Jan. 1, 1987, see section
9341(b) of Pub. L. 99-509, set out as a note under section 1395ff of
this title.
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.
Section 956(b) of Pub. L. 96-499 provided that: ''The amendment
made by subsection (a) (amending this section) shall take effect on
January 1, 1981.''
Section 213(b) of Pub. L. 92-603 provided that: ''The amendments
made by this section (enacting this section) shall be effective with
respect to claims under part A or part B of title XVIII of the Social
Security Act (part A or part B of this subchapter), filed with respect
to items or services furnished after the date of the enactment of this
Act (Oct. 30, 1972).''
Section 9305(g)(2) of Pub. L. 99-509 provided that: ''The Secretary
of Health and Human Services shall report to Congress annually in March
of 1987 and 1988 --
''(A) information on the frequency and distribution (by type of
provider) of denials of bills for payment under title XVIII of the
Social Security Act (this subchapter) for extended care services, home
health services, and hospice care, by reason of section 1862(a)(1) or
(9) of such Act (section 1395y(a)(1) or (9) of this title), and coverage
denials described in section 1879(g) of such Act (subsec. (g) of this
section), including --
''(i) the reasons for such denials,
''(ii) the extent to which payments were nonetheless made because of
section 1879 of such Act (this section), and
''(iii) the rate of reversals of such denials, and
''(B) such other information as may be appropriate to evaluate the
appropriateness of any percentage standards established for the granting
of favorable presumptions with respect to such denials.''
42 USC 1395qq. Indian health service facilities
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Eligibility for payments; conditions and requirements
A hospital or skilled nursing facility of the Indian Health Service,
whether operated by such Service or by an Indian tribe or tribal
organization (as those terms are defined in section 1603 of title 25),
shall be eligible for payments under this subchapter, notwithstanding
sections 1395f(c) and 1395n(d) of this title, if and for so long as it
meets all of the conditions and requirements for such payments which are
applicable generally to hospitals or skilled nursing facilities (as the
case may be) under this subchapter.
(b) Eligibility based on submission of plan to achieve compliance
with conditions and requirements; twelve-month period
Notwithstanding subsection (a) of this section, a hospital or skilled
nursing facility of the Indian Health Service which does not meet all of
the conditions and requirements of this subchapter which are applicable
generally to hospitals or skilled nursing facilities (as the case may
be), but which submits to the Secretary within six months after
September 30, 1976, an acceptable plan for achieving compliance with
such conditions and requirements, shall be deemed to meet such
conditions and requirements (and to be eligible for payments under this
subchapter), without regard to the extent of its actual compliance with
such conditions and requirements, during the first 12 months after the
month in which such plan is submitted.
(c) Payments into special fund for improvements to achieve compliance
with conditions and requirements; certification of compliance by
Secretary
Notwithstanding any other provision of this subchapter, payments to
which any hospital or skilled nursing facility of the Indian Health
Service is entitled by reason of this section shall be placed in a
special fund to be held by the Secretary and used by him (to such extent
or in such amounts as are provided in appropriation Acts) exclusively
for the purpose of making any improvements in the hospitals and skilled
nursing facilities of such Service which may be necessary to achieve
compliance with the applicable conditions and requirements of this
subchapter. The preceding sentence shall cease to apply when the
Secretary determines and certifies that substantially all of the
hospitals and skilled nursing facilities of such Service in the United
States are in compliance with such conditions and requirements.
(d) Report by Secretary; status of facilities in complying with
conditions and requirements
The annual report of the Secretary which is required by section 1671
of title 25 shall include (along with the matters specified in section
403 of such Act) a detailed statement of the status of the hospitals and
skilled nursing facilities of the Service in terms of their compliance
with the applicable conditions and requirements of this subchapter and
of the progress being made by such hospitals and facilities (under plans
submitted under subsection (b) of this section and otherwise) toward the
achievement of such compliance.
(Aug. 14, 1935, ch. 531, title XVIII, 1880, as added Sept. 30, 1976,
Pub. L. 94-437, title IV, 401(b), 90 Stat. 1408.)
Section 403 of such Act, referred to in subsec. (d), is section 403
of the Indian Health Care Improvement Act, Pub. L. 94-437, which is set
out as a note under section 1671 of Title 25, Indians.
Pub. L. 94-437, title IV, 405, as added by Pub. L. 100-713, title
IV, 402, Nov. 23, 1988, 102 Stat. 4818, provided that:
''(a) The Secretary shall establish a demonstration program under
which Indian tribes, tribal organizations, and Alaska Native health
organizations, which are contracting the entire operation of an entire
hospital or clinic of the Service under the authority of the Indian
Self-Determination Act (25 U.S.C. 450f et seq.), shall directly bill
for, and receive payment for, health care services provided by such
hospital or clinic for which payment is made under title XVIII of the
Social Security Act (this subchapter) (medicare), under a State plan for
medical assistance approved under title XIX of the Social Security Act
(subchapter XIX of this chapter) (medicaid), or from any other
third-party payor. The last sentence of section 1905(b) of the Social
Security Act (section 1396d(b) of this title) shall apply for purposes
of the demonstration program.
''(b)(1) Each hospital or clinic participating in the demonstration
program described in subsection (a) shall be reimbursed directly under
the medicare and medicaid programs for services furnished, without
regard to the provisions of section 1880(c) of the Social Security Act
(subsec. (c) of this section) and sections 402(c) and 713(b)(2)(A) of
this Act (42 U.S.C. 1396j note, 25 U.S.C. 1680c(b)(2)(A)), but all
funds so reimbursed shall first be used by the hospital or clinic for
the purpose of making any improvements in the hospital or clinic that
may be necessary to achieve or maintain compliance with the conditions
and requirements applicable generally to facilities of such type under
the medicare or medicaid program. Any funds so reimbursed which are in
excess of the amount necessary to achieve or maintain such conditions or
requirements shall be used --
''(A) solely for improving the health resources deficiency level of
the Indian tribe, and
''(B) in accordance with the regulations of the Service applicable to
funds provided by the Service under any contract entered into under the
Indian Self-Determination Act (25 U.S.C. 450f et seq.).
''(2) The amounts paid to the hospitals and clinics participating in
the demonstration program described in subsection (a) shall be subject
to all auditing requirements applicable to programs administered
directly by the Service and to facilities participating in the medicare
and medicaid programs.
''(3) The Secretary shall monitor the performance of hospitals and
clinics participating in the demonstration program described in
subsection (a), and shall require such hospitals and clinics to submit
reports on the program to the Secretary on a quarterly basis (or more
frequently if the Secretary deems it to be necessary).
''(4) Notwithstanding section 1880(c) of the Social Security Act or
section 402(c) of this Act, no payment may be made out of the special
fund described in section 1880(c) of the Social Security Act, or section
402(c) of this Act, for the benefit of any hospital or clinic
participating in the demonstration program described in subsection (a)
during the period of such participation.
''(c)(1) In order to be considered for participation in the
demonstration program described in subsection (a), a hospital or clinic
must submit an application to the Secretary which establishes to the
satisfaction of the Secretary that --
''(A) the Indian tribe, tribal organization, or Alaska Native health
organization contracts the entire operation of the Service facility;
''(B) the facility is eligible to participate in the medicare and
medicaid programs under sections 1880 and 1911 of the Social Security
Act (this section and section 1396j of this title);
''(C) the facility meets any requirements which apply to programs
operated directly by the Service; and
''(D) the facility is accredited by the Joint Commission on
Accreditation of Hospitals, or has submitted a plan, which has been
approved by the Secretary, for achieving such accreditation prior to
October 1, 1990.
''(2) From among the qualified applicants, the Secretary shall, prior
to October 1, 1989, select no more than 4 facilities to participate in
the demonstration program described in subsection (a). The
demonstration program described in subsection (a) shall begin by no
later than October 1, 1991, and end on September 30, 1995.
''(d)(1) Upon the enactment of the Indian Health Care Amendments of
1988 (Nov. 23, 1988), the Secretary, acting through the Service, shall
commence an examination of --
''(A) any administrative changes which may be necessary to allow
direct billing and reimbursement under the demonstration program
described in subsection (a), including any agreements with States which
may be necessary to provide for such direct billing under the medicaid
program; and
''(B) any changes which may be necessary to enable participants in
such demonstration program to provide to the Service medical records
information on patients served under such demonstration program which is
consistent with the medical records information system of the Service.
''(2) Prior to the commencement of the demonstration program
described in subsection (a), the Secretary shall implement all changes
required as a result of the examinations conducted under paragraph (1).
''(3) Prior to October 1, 1990, the Secretary shall determine any
accounting information which a participant in the demonstration program
described in subsection (a) would be required to report.
''(e) The Secretary shall submit a final report at the end of fiscal
year 1995, on the activities carried out under the demonstration program
described in subsection (a) which shall include an evaluation of whether
such activities have fulfilled the objectives of such program. In such
report the Secretary shall provide a recommendation, based upon the
results of such demonstration program, as to whether direct billing of,
and reimbursement by, the medicare and medicaid programs and other
third-party payors should be authorized for all Indian tribes and Alaska
Native health organizations which are contracting the entire operation
of a facility of the Service.
''(f) The Secretary shall provide for the retrocession of any
contract entered into between a participant in the demonstration program
described in subsection (a) and the Service under the authority of the
Indian Self-Determination Act (25 U.S.C. 450f et seq.). All cost
accounting and billing authority shall be retroceded to the Secretary
upon the Secretary's acceptance of a retroceded contract.''
Section 401(c) of Pub. L. 94-437 provided that: ''Any payments
received for services provided to beneficiaries hereunder (under this
section) shall not be considered in determining appropriations for
health care and services to Indians.''
Section 401(d) of Pub. L. 94-437 provided that: ''Nothing herein
authorizes the Secretary to provide services to an Indian beneficiary
with coverage under title XVIII of the Social Security Act, as amended
(this subchapter), in preference to an Indian beneficiary without such
coverage.''
42 USC 1395rr. End stage renal disease program
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Type, duration, and scope of benefits
The benefits provided by parts A and B of this subchapter shall
include benefits for individuals who have been determined to have end
stage renal disease as provided in section 426-1 of this title, and
benefits for kidney donors as provided in subsection (d) of this
section. Notwithstanding any other provision of this subchapter, the
type, duration, and scope of the benefit provided by parts A and B of
this subchapter with respect to individuals who have been determined to
have end stage renal disease and who are entitled to such benefits
without regard to section 426-1 of this title shall in no case be less
than the type, duration, and scope of the benefits so provided for
individuals entitled to such benefits solely by reason of that section.
(b) Payments with respect to services; dialysis; regulations;
physicians' services; target reimbursement rates; home dialysis
supplies and equipment; self-care home dialysis support services;
self-care dialysis units; hepatitis B vaccine
(1) Payments under this subchapter with respect to services, in
addition to services for which payment would otherwise be made under
this subchapter, furnished to individuals who have been determined to
have end stage renal disease shall include (A) payments on behalf of
such individuals to providers of services and renal dialysis facilities
which meet such requirements as the Secretary shall by regulation
prescribe for institutional dialysis services and supplies (including
self-dialysis services in a self-care dialysis unit maintained by the
provider or facility), transplantation services, self-care home dialysis
support services which are furnished by the provider or facility, and
routine professional services performed by a physician during a
maintenance dialysis episode if payments for his other professional
services furnished to an individual who has end stage renal disease are
made on the basis specified in paragraph (3)(A) of this subsection, (B)
payments to or on behalf of such individuals for home dialysis supplies
and equipment, and (C) payments to a supplier of home dialysis supplies
and equipment that is not a provider of services, a renal dialysis
facility, or a physician for self-administered erythropoietin as
described in section 1395x(s)(2)(Q) of this title if the Secretary finds
that the patient receiving such drug from such a supplier can safely and
effectively administer the drug (in accordance with the applicable
methods and standards established by the Secretary pursuant to such
section). The requirements prescribed by the Secretary under
subparagraph (A) shall include requirements for a minimum utilization
rate for transplantations.
(2)(A) With respect to payments for dialysis services furnished by
providers of services and renal dialysis facilities to individuals
determined to have end stage renal disease for which payments may be
made under part B of this subchapter, such payments (unless otherwise
provided in this section) shall be equal to 80 percent of the amounts
determined in accordance with subparagraph (B); and with respect to
payments for services for which payments may be made under part A of
this subchapter, the amounts of such payments (which amounts shall not
exceed, in respect to costs in procuring organs attributable to payments
made to an organ procurement agency or histocompatibility laboratory,
the costs incurred by that agency or laboratory) shall be determined in
accordance with section 1395x(v) of this title or section 1395ww of this
title (if applicable). Payments shall be made to a renal dialysis
facility only if it agrees to accept such payments as payment in full
for covered services, except for payment by the individual of 20 percent
of the estimated amounts for such services calculated on the basis
established by the Secretary under subparagraph (B) and the deductible
amount imposed by section 1395l(b) of this title.
(B) The Secretary shall prescribe in regulations any methods and
procedures to (i) determine the costs incurred by providers of services
and renal dialysis facilities in furnishing covered services to
individuals determined to have end stage renal disease, and (ii)
determine, on a cost-related basis or other economical and equitable
basis (including any basis authorized under section 1395x(v) of this
title) and consistent with any regulations promulgated under paragraph
(7), the amounts of payments to be made for part B services furnished by
such providers and facilities to such individuals.
(C) Such regulations, in the case of services furnished by
proprietary providers and facilities (other than hospital outpatient
departments) may include, if the Secretary finds it feasible and
appropriate, provision for recognition of a reasonable rate of return on
equity capital, providing such rate of return does not exceed the rate
of return stipulated in section 1395x(v)(1)(B) of this title.
(D) For purposes of section 1395oo of this title, a renal dialysis
facility shall be treated as a provider of services.
(3) With respect to payments for physicians' services furnished to
individuals determined to have end stage renal disease, the Secretary
shall pay 80 percent of the amounts calculated for such services --
(A) on a reasonable charge basis (but may, in such case, make payment
on the basis of the prevailing charges of other physicians for
comparable services or, for services furnished on or after January 1,
1992, on the basis described in section 1395w-4 of this title) except
that payment may not be made under this subparagraph for routine
services furnished during a maintenance dialysis episode, or
(B) on a comprehensive monthly fee or other basis (which effectively
encourages the efficient delivery of dialysis services and provides
incentives for the increased use of home dialysis) for an aggregate of
services provided over a period of time (as defined in regulations).
(4)(A) Pursuant to agreements with approved providers of services and
renal dialysis facilities, the Secretary may make payments to such
providers and facilities for the cost of home dialysis supplies and
equipment and self-care home dialysis support services furnished to
patients whose self-care home dialysis is under the direct supervision
of such provider or facility, on the basis of a target reimbursement
rate (as defined in paragraph (6)) or on the basis of a method
established under paragraph (7).
(B) The Secretary shall make payments to a supplier of home dialysis
supplies and equipment furnished to a patient whose self-care home
dialysis is not under the direct supervision of an approved provider of
services or renal dialysis facility only in accordance with a written
agreement under which --
(i) the patient certifies that the supplier is the sole provider of
such supplies and equipment to the patient,
(ii) the supplier agrees to receive payment for the cost of such
supplies and equipment only on an assignment-related basis, and
(iii) the supplier certifies that it has entered into a written
agreement with an approved provider of services or renal dialysis
facility under which such provider or facility agrees to furnish to such
patient all self-care home dialysis support services and all other
necessary dialysis services and supplies, including institutional
dialysis services and supplies and emergency services.
(5) An agreement under paragraph (4) shall require, in accordance
with regulations prescribed by the Secretary, that the provider or
facility will --
(A) assume full responsibility for directly obtaining or arranging
for the provision of --
(i) such medically necessary dialysis equipment as is prescribed by
the attending physician;
(ii) dialysis equipment maintenance and repair services;
(iii) the purchase and delivery of all necessary medical supplies;
and
(iv) where necessary, the services of trained home dialysis aides;
(B) perform all such administrative functions and maintain such
information and records as the Secretary may require to verify the
transactions and arrangements described in subparagraph (A);
(C) submit such cost reports, data, and information as the Secretary
may require with respect to the costs incurred for equipment, supplies,
and services furnished to the facility's home dialysis patient
population; and
(D) provide for full access for the Secretary to all such records,
data, and information as he may require to perform his functions under
this section.
(6) The Secretary shall establish, for each calendar year, commencing
with January 1, 1979, a target reimbursement rate for home dialysis
which shall be adjusted for regional variations in the cost of providing
home dialysis. In establishing such a rate, the Secretary shall include
--
(A) the Secretary's estimate of the cost of providing medically
necessary home dialysis supplies and equipment;
(B) an allowance, in an amount determined by the Secretary, to cover
the cost of providing personnel to aid in home dialysis; and
(C) an allowance, in an amount determined by the Secretary, to cover
administrative costs and to provide an incentive for the efficient
delivery of home dialysis;
but in no event (except as may be provided in regulations under
paragraph (7)) shall such target rate exceed 75 percent of the national
average payment, adjusted for regional variations, for maintenance
dialysis services furnished in approved providers and facilities during
the preceding fiscal year. Any such target rate so established shall be
utilized, without renegotiation of the rate, throughout the calendar
year for which it is established. During the last quarter of each
calendar year, the Secretary shall establish a home dialysis target
reimbursement rate for the next calendar year based on the most recent
data available to the Secretary at the time. In establishing any rate
under this paragraph, the Secretary may utilize a competitive-bid
procedure, a prenegotiated rate procedure, or any other procedure
(including methods established under paragraph (7)) which the Secretary
determines is appropriate and feasible in order to carry out this
paragraph in an effective and efficient manner.
(7) The Secretary shall provide by regulation for a method (or
methods) for determining prospectively the amounts of payments to be
made for dialysis services furnished by providers of services and renal
dialysis facilities to individuals in a facility and to such individuals
at home. Such method (or methods) shall provide for the prospective
determination of a rate (or rates) for each mode of care based on a
single composite weighted formula (which takes into account the mix of
patients who receive dialysis services at a facility or at home and the
relative costs of providing such services in such settings) for
hospital-based facilities and such a single composite weighted formula
for other renal dialysis facilities, or based on such other method or
combination of methods which differentiate between hospital-based
facilities and other renal dialysis facilities and which the Secretary
determines, after detailed analysis, will more effectively encourage the
more efficient delivery of dialysis services and will provide greater
incentives for increased use of home dialysis than through the single
composite weighted formulas. The amount of a payment made under any
method other than a method based on a single composite weighted formula
may not exceed the amount (or, in the case of continuous cycling
peritoneal dialysis, 130 percent of the amount) of the median payment
that would have been made under the formula for hospital-based
facilities. The Secretary shall provide for such exceptions to such
methods as may be warranted by unusual circumstances (including the
special circumstances of sole facilities located in isolated, rural
areas and of pediatric facilities). Each application for such an
exception shall be deemed to be approved unless the Secretary
disapproves it by not later than 60 working days after the date the
application is filed. The Secretary may provide that such method will
serve in lieu of any target reimbursement rate that would otherwise be
established under paragraph (6). The Secretary shall reduce the amount
of each composite rate payment under this paragraph for each treatment
by 50 cents (subject to such adjustments as may be required to reflect
modes of dialysis other than hemodialysis) and provide for payment of
such amount to the organizations (designated under subsection (c)(1)(A)
of this section) for such organizations' necessary and proper
administrative costs incurred in carrying out the responsibilities
described in subsection (c)(2) of this section. The Secretary shall
provide that amounts paid under the previous sentence shall be
distributed to the organizations described in subsection (c)(1)(A) of
this section to ensure equitable treatment of all such network
organizations. The Secretary in distributing any such payments to
network organizations shall take into account --
(A) the geographic size of the network area;
(B) the number of providers of end stage renal disease services in
the network area;
(C) the number of individuals who are entitled to end stage renal
disease services in the network area; and
(D) the proportion of the aggregate administrative funds collected in
the network area.
(8) For purposes of this subchapter, the term ''home dialysis
supplies and equipment'' means medically necessary supplies and
equipment (including supportive equipment) required by an individual
suffering from end stage renal disease in connection with renal dialysis
carried out in his home (as defined in regulations), including
obtaining, installing, and maintaining such equipment.
(9) For purposes of this subchapter, the term ''self-care home
dialysis support services'', to the extent permitted in regulation,
means --
(A) periodic monitoring of the patient's home adaptation, including
visits by qualified provider or facility personnel (as defined in
regulations), so long as this is done in accordance with a plan prepared
and periodically reviewed by a professional team (as defined in
regulations) including the individual's physician;
(B) installation and maintenance of dialysis equipment;
(C) testing and appropriate treatment of the water; and
(D) such additional supportive services as the Secretary finds
appropriate and desirable.
(10) For purposes of this subchapter, the term ''self-care dialysis
unit'' means a renal dialysis facility or a distinct part of such
facility or of a provider of services, which has been approved by the
Secretary to make self-dialysis services, as defined by the Secretary in
regulations, available to individuals who have been trained for
self-dialysis. A self-care dialysis unit must, at a minimum, furnish
the services, equipment and supplies needed for self-care dialysis, have
patient-staff ratios which are appropriate to self-dialysis (allowing
for such appropriate lesser degree of ongoing medical supervision and
assistance of ancillary personnel than is required for full care
maintenance dialysis), and meet such other requirements as the Secretary
may prescribe with respect to the quality and cost-effectiveness of
services.
(11)(A) Hepatitis B vaccine and its administration, when provided to
a patient determined to have end stage renal disease, shall not be
included as dialysis services for purposes of payment under any
prospective payment amount or comprehensive fee established under this
section. Payment for such vaccine and its administration shall be made
separately in accordance with section 1395l of this title.
(B) Erythropoietin, when provided to a patient determined to have end
stage renal disease, shall not be included as a dialysis service for
purposes of payment under any prospective payment amount or
comprehensive fee established under this section, and payment for such
item shall be made separately --
(i) in the case of erythropoietin provided by a physician, in
accordance with section 1395l of this title; and
(ii) in the case of erythropoietin provided by a provider of
services, renal dialysis facility, or other supplier of home dialysis
supplies and equipment --
(I) for erythropoietin provided during 1991, in an amount equal to
$11 per thousand units (rounded to the nearest 100 units), and
(II) for erythropoietin provided during a subsequent year, in an
amount determined to be appropriate by the Secretary, except that such
amount may not exceed the amount determined under this clause for the
previous year increased by the percentage increase (if any) in the
implicit price deflator for gross national product (as published by the
Department of Commerce) for the second quarter of the preceding year
over the implicit price deflator for the second quarter of the second
preceding year.
(C) The amount payable to a supplier of home dialysis supplies and
equipment that is not a provider of services, a renal dialysis facility,
or a physician for erythropoietin shall be determined in the same manner
as the amount payable to a renal dialysis facility for such item.
(c) Renal disease network areas; coordinating councils, executive
committees, and medical review boards; national end stage renal disease
medical information system; functions of network organizations
(1)(A)(i) For the purpose of assuring effective and efficient
administration of the benefits provided under this section, the
Secretary shall, in accordance with such criteria as he finds necessary
to assure the performance of the responsibilities and functions
specified in paragraph (2) --
(I) establish at least 17 end stage renal disease network areas, and
(II) for each such area, designate a network administrative
organization which, in accordance with regulations of the Secretary,
shall establish (aa) a network council of renal dialysis and transplant
facilities located in the area and (bb) a medical review board, which
has a membership including at least one patient representative and
physicians, nurses, and social workers engaged in treatment relating to
end stage renal disease.
The Secretary shall publish in the Federal Register a description of
the geographic area that he determines, after consultation with
appropriate professional and patient organizations, constitutes each
network area and the criteria on the basis of which such determination
is made.
(ii)(I) In order to determine whether the Secretary should enter
into, continue, or terminate an agreement with a network administrative
organization designated for an area established under clause (i), the
Secretary shall develop and publish in the Federal Register standards,
criteria, and procedures to evaluate an applicant organization's
capabilities to perform (and, in the case of an organization with which
such an agreement is in effect, actual performance of) the
responsibilities described in paragraph (2). The Secretary shall
evaluate each applicant based on quality and scope of services and may
not accord more than 20 percent of the weight of the evaluation to the
element of price.
(II) An agreement with a network administrative organization may be
terminated by the Secretary only if he finds, after applying such
standards and criteria, that the organization has failed to perform its
prescribed responsibilities effectively and efficiently. If such an
agreement is to be terminated, the Secretary shall select a successor to
the agreement on the basis of competitive bidding and in a manner that
provides an orderly transition.
(B) At least one patient representative shall serve as a member of
each network council and each medical review board.
(C) The Secretary shall, in regulations, prescribe requirements with
respect to membership in network organizations by individuals (and the
relatives of such individuals) (i) who have an ownership or control
interest in a facility or provider which furnishes services referred to
in section 1395x(s)(2)(F) of this title, or (ii) who have received
remuneration from any such facility or provider in excess of such
amounts as constitute reasonable compensation for services (including
time and effort relative to the provision of professional medical
services) or goods supplied to such facility or provider; and such
requirements shall provide for the definition, disclosure, and, to the
maximum extent consistent with effective administration, prevention of
potential or actual financial or professional conflicts of interest with
respect to decisions concerning the appropriateness, nature, or site of
patient care.
(2) The network organizations of each network shall be responsible,
in addition to such other duties and functions as may be prescribed by
the Secretary, for --
(A) encouraging, consistent with sound medical practice, the use of
those treatment settings most compatible with the successful
rehabilitation of the patient and the participation of patients,
providers of services, and renal disease facilities in vocational
rehabilitation programs;
(B) developing criteria and standards relating to the quality and
appropriateness of patient care and with respect to working with
patients, facilities, and providers in encouraging participation in
vocational rehabilitation programs; and network goals with respect to
the placement of patients in self-care settings and undergoing or
preparing for transplantation;
(C) evaluating the procedure by which facilities and providers in the
network assess the appropriateness of patients for proposed treatment
modalities;
(D) implementing a procedure for evaluating and resolving patient
grievances;
(E) conducting on-site reviews of facilities and providers as
necessary (as determined by a medical review board or the Secretary),
utilizing standards of care established by the network organization to
assure proper medical care;
(F) collecting, validating, and analyzing such data as are necessary
to prepare the reports required by subparagraph (H) and to assure the
maintenance of the registry established under paragraph (7);
(G) identifying facilities and providers that are not cooperating
toward meeting network goals and assisting such facilities and providers
in developing appropriate plans for correction and reporting to the
Secretary on facilities and providers that are not providing appropriate
medical care; and
(H) submitting an annual report to the Secretary on July 1 of each
year which shall include a full statement of the network's goals, data
on the network's performance in meeting its goals (including data on the
comparative performance of facilities and providers with respect to the
identification and placement of suitable candidates in self-care
settings and transplantation and encouraging participation in vocational
rehabilitation programs), identification of those facilities that have
consistently failed to cooperate with network goals, and recommendations
with respect to the need for additional or alternative services or
facilities in the network in order to meet the network goals, including
self-dialysis training, transplantation, and organ procurement
facilities.
(3) Where the Secretary determines, on the basis of the data
contained in the network's annual report and such other relevant data as
may be available to him, that a facility or provider has consistently
failed to cooperate with network plans and goals or to follow the
recommendations of the medical review board, he may terminate or
withhold certification of such facility or provider (for purposes of
payment for services furnished to individuals with end stage renal
disease) until he determines that such provider or facility is making
reasonable and appropriate efforts to cooperate with the network's plans
and goals. If the Secretary determines that the facility's or
provider's failure to cooperate with network plans and goals does not
jeopardize patient health or safety or justify termination of
certification, he may instead, after reasonable notice to the provider
or facility and to the public, impose such other sanctions as he
determines to be appropriate, which sanctions may include denial of
reimbursement with respect to some or all patients admitted to the
facility after the date of notice to the facility or provider, and
graduated reduction in reimbursement for all patients.
(4) The Secretary shall, in determining whether to certify additional
facilities or expansion of existing facilities within a network, take
into account the network's goals and performance as reflected in the
network's annual report.
(5) The Secretary, after consultation with appropriate professional
and planning organizations, shall provide such guidelines with respect
to the planning and delivery of renal disease services as are necessary
to assist network organizations in their development of their respective
networks' goals to promote the optimum use of self-dialysis and
transplantation by suitable candidates for such modalities.
(6) It is the intent of the Congress that the maximum practical
number of patients who are medically, socially, and psychologically
suitable candidates for home dialysis or transplantation should be so
treated and that the maximum practical number of patients who are
suitable candidates for vocational rehabilitation services be given
access to such services and encouraged to return to gainful employment.
The Secretary shall consult with appropriate professional and network
organizations and consider available evidence relating to developments
in research, treatment methods, and technology for home dialysis and
transplantation.
(7) The Secretary shall establish a national end stage renal disease
registry the purpose of which shall be to assemble and analyze the data
reported by network organizations, transplant centers, and other sources
on all end stage renal disease patients in a manner that will permit --
(A) the preparation of the annual report to the Congress required
under subsection (g) of this section;
(B) an identification of the economic impact, cost-effectiveness, and
medical efficacy of alternative modalities of treatment;
(C) an evaluation with respect to the most appropriate allocation of
resources for the treatment and research into the cause of end stage
renal disease;
(D) the determination of patient mortality and morbidity rates, and
trends in such rates, and other indices of quality of care; and
(E) such other analyses relating to the treatment and management of
end stage renal disease as will assist the Congress in evaluating the
end stage renal disease program under this section.
The Secretary shall provide for such coordination of data collection
activities, and such consolidation of existing end stage renal disease
data systems, as is necessary to achieve the purpose of such registry,
shall determine the appropriate location of the registry, and shall
provide for the appointment of a professional advisory group to assist
the Secretary in the formulation of policies and procedures relevant to
the management of such registry.
(8) The provisions of sections 1320c-6 and 1320c-9 of this title
shall apply with respect to network administrative organizations
(including such organizations as medical review boards) with which the
Secretary has entered into agreements under this subsection.
(d) Donors of kidney for transplant surgery
Notwithstanding any provision to the contrary in section 426 of this
title any individual who donates a kidney for transplant surgery shall
be entitled to benefits under parts A and B of this subchapter with
respect to such donation. Reimbursement for the reasonable expenses
incurred by such an individual with respect to a kidney donation shall
be made (without regard to the deductible, premium, and coinsurance
provisions of this subchapter), in such manner as may be prescribed by
the Secretary in regulations, for all reasonable preparatory, operation,
and postoperation recovery expenses associated with such donation,
including but not limited to the expenses for which payment could be
made if he were an eligible individual for purposes of parts A and B of
this subchapter without regard to this subsection. Payments for
postoperation recovery expenses shall be limited to the actual period of
recovery.
(e) Reimbursement of providers, facilities, and nonprofit entities
for costs of artificial kidney and automated dialysis peritoneal
machines for home dialysis
(1) Notwithstanding any other provision of this subchapter, the
Secretary may, pursuant to agreements with approved providers of
services, renal dialysis facilities, and nonprofit entities which the
Secretary finds can furnish equipment economically and efficiently,
reimburse such providers, facilities, and nonprofit entities (without
regard to the deductible and coinsurance provisions of this subchapter)
for the reasonable cost of the purchase, installation, maintenance and
reconditioning for subsequent use of artificial kidney and automated
dialysis peritoneal machines (including supportive equipment) which are
to be used exclusively by entitled individuals dialyzing at home.
(2) An agreement under this subsection shall require that the
provider, facility, or other entity will --
(A) make the equipment available for use only by entitled individuals
dialyzing at home;
(B) recondition the equipment, as needed, for reuse by such
individuals throughout the useful life of the equipment, including
modification of the equipment consistent with advances in research and
technology;
(C) provide for full access for the Secretary to all records and
information relating to the purchase, maintenance, and use of the
equipment; and
(D) submit such reports, data, and information as the Secretary may
require with respect to the cost, management, and use of the equipment.
(3) For purposes of this section, the term ''supportive equipment''
includes blood pumps, heparin pumps, bubble detectors, other alarm
systems, and such other items as the Secretary may determine are
medically necessary.
(f) Experiments, studies, and pilot projects
(1) The Secretary shall initiate and carry out, at selected locations
in the United States, pilot projects under which financial assistance in
the purchase of new or used durable medical equipment for renal dialysis
is provided to individuals suffering from end stage renal disease at the
time home dialysis is begun, with provision for a trial period to assure
successful adaptation to home dialysis before the actual purchase of
such equipment.
(2) The Secretary shall conduct experiments to evaluate methods for
reducing the costs of the end stage renal disease program. Such
experiments shall include (without being limited to) reimbursement for
nurses and dialysis technicians to assist with home dialysis, and
reimbursement to family members assisting with home dialysis.
(3) The Secretary shall conduct experiments to evaluate methods of
dietary control for reducing the costs of the end stage renal disease
program, including (without being limited to) the use of
protein-controlled products to delay the necessity for, or reduce the
frequency of, dialysis in the treatment of end stage renal disease.
(4) The Secretary shall conduct a comprehensive study of methods for
increasing public participation in kidney donation and other organ
donation programs.
(5) The Secretary shall conduct a full and complete study of the
reimbursement of physicians for services furnished to patients with end
stage renal disease under this subchapter, giving particular attention
to the range of payments to physicians for such services, the average
amounts of such payments, and the number of hours devoted to furnishing
such services to patients at home, in renal disease facilities, in
hospitals, and elsewhere.
(6) The Secretary shall conduct a study of the number of patients
with end stage renal disease who are not eligible for benefits with
respect to such disease under this subchapter (by reason of this section
or otherwise), and of the economic impact of such noneligibility of such
individuals. Such study shall include consideration of mechanisms
whereby governmental and other health plans might be instituted or
modified to permit the purchase of actuarially sound coverage for the
costs of end stage renal disease.
(7)(A) The Secretary shall establish protocols on standards and
conditions for the reuse of dialyzer filters for those facilities and
providers which voluntarily elect to reuse such filters.
(B) With respect to dialysis services furnished on or after January
1, 1988 (or July 1, 1988, with respect to protocols that relate to the
reuse of bloodlines), no dialysis facility may reuse dialysis supplies
(other than dialyzer filters) unless the Secretary has established a
protocol with respect to the reuse of such supplies and the facility
follows the protocol so established.
(C) The Secretary shall incorporate protocols established under this
paragraph, and the requirement of subparagraph (B), into the
requirements for facilities prescribed under subsection (b)(1)(A) of
this section and failure to follow such a protocol or requirement
subjects such a facility to denial of participation in the program
established under this section and to denial of payment for dialysis
treatment not furnished in compliance with such a protocol or in
violation of such requirement.
(8) The Secretary shall submit to the Congress no later than October
1, 1979, a full report on the experiments conducted under paragraphs
(1), (2), (3), and (7), and the studies under paragraphs (4), (5), (6),
and (7). Such report shall include any recommendations for legislative
changes which the Secretary finds necessary or desirable as a result of
such experiments and studies.
(g) Conditional approval of dialysis facilities;
restriction-of-payments notice to public and facility; notice and
hearing; judicial review
(1) In any case where the Secretary --
(A) finds that a renal dialysis facility is not in substantial
compliance with requirements for such facilities prescribed under
subsection (b)(1)(A) of this section,
(B) finds that the facility's deficiencies do not immediately
jeopardize the health and safety of patients, and
(C) has given the facility a reasonable opportunity to correct its
deficiencies,
the Secretary may, in lieu of terminating approval of the facility,
determine that payment under this subchapter shall be made to the
facility only for services furnished to individuals who were patients of
the facility before the effective date of the notice.
(2) The Secretary's decision to restrict payments under this
subsection shall be made effective only after such notice to the public
and to the facility as may be prescribed in regulations, and shall
remain in effect until (A) the Secretary finds that the facility is in
substantial compliance with the requirements under subsection (b)(1)(A)
of this section, or (B) the Secretary terminates the agreement under
this subchapter with the facility.
(3) A facility dissatisfied with a determination by the Secretary
under paragraph (1) shall be entitled to a hearing thereon by the
Secretary (after reasonable notice) to the same extent as is provided in
section 405(b) of this title, and to judicial review of the Secretary's
final decision after such hearing as is provided in section 405(g) of
this title.
(Aug. 14, 1935, ch. 531, title XVIII, 1881, as added June 13, 1978,
Pub. L. 95-292, 2, 92 Stat. 308, and amended Dec. 5, 1980, Pub. L.
96-499, title IX, 957, 94 Stat. 2648; Aug. 13, 1981, Pub. L. 97-35,
title XXI, 2145(a), 95 Stat. 799; Apr. 20, 1983, Pub. L. 98-21, title
VI, 602(i), 97 Stat. 165; July 18, 1984, Pub. L. 98-369, div. B,
title III, 2323(c), 2352(a), 2354(b)(41), 98 Stat. 1086, 1099, 1102;
Nov. 8, 1984, Pub. L. 98-617, 3(b)(8), 98 Stat. 3296; Oct. 21, 1986,
Pub. L. 99-509, title IX, 9335(a)(2), (d)(1), (e)-(i)(1), (j)(1),
(k)(1), 100 Stat. 2029-2033; Aug. 18, 1987, Pub. L. 100-93, 12, 101
Stat. 697; Dec. 22, 1987, Pub. L. 100-203, title IV, 4036(b), (c)(2),
(d)(5), 4065(b), 101 Stat. 1330-79, 1330-80, 1330-112; Dec. 19, 1989,
Pub. L. 101-239, title VI, 6102(e)(8), 6203(b)(1), (2), 6219(a), (b),
103 Stat. 2188, 2235, 2254; Nov. 5, 1990, Pub. L. 101-508, title IV,
4201(c)(1), (d)(2), (3), 104 Stat. 1388-103, 1388-104.)
1990 -- Subsec. (b)(1). Pub. L. 101-508, 4201(d)(2), added cl.
(C).
Subsec. (b)(11). Pub. L. 101-508, 4201(d)(3), added subpar. (C).
Pub. L. 101-508, 4201(c)(1), designated existing provisions as
subpar. (A) and added subpar. (B).
1989 -- Subsec. (b)(3)(A). Pub. L. 101-239, 6102(e)(8), inserted
''or, for services furnished on or after January 1, 1992, on the basis
described in section 1395w-4 of this title'' after ''comparable
services''.
Subsec. (b)(4). Pub. L. 101-239, 6203(b)(2), designated existing
provisions as subpar. (A) and added subpar. (B).
Subsec. (b)(7). Pub. L. 101-239, 6219(a), substituted
''organizations (designated under subsection (c)(1)(A) of this section)
for such organizations' necessary and proper administrative costs
incurred in carrying out the responsibilities described in subsection
(c)(2) of this section. The Secretary shall provide that amounts paid
under the previous sentence shall be distributed to the organizations
described in subsection (c)(1)(A) of this section to ensure equitable
treatment of all such network organizations. The Secretary in
distributing any such payments to network organizations shall take into
account -- '' and subpars. (A) to (D) for ''network administrative
organization (designated under subsection (c)(1)(A) of this section for
the network area in which the treatment is provided) for its necessary
and proper administrative costs incurred in carrying out its
responsibilities under subsection (c)(2) of this section.'' in last
sentence.
Pub. L. 101-239, 6203(b)(1), inserted after second sentence ''The
amount of a payment made under any method other than a method based on a
single composite weighted formula may not exceed the amount (or, in the
case of continuous cycling peritoneal dialysis, 130 percent of the
amount) of the median payment that would have been made under the
formula for hospital-based facilities.''
Subsec. (c)(8). Pub. L. 101-239, 6219(b), added par. (8).
1987 -- Subsec. (b)(1). Pub. L. 100-203, 4036(b), substituted
''transplantations'' for ''covered procedures and for self-dialysis
training programs''.
Subsec. (b)(2)(C). Pub. L. 100-203, 4065(b), substituted
''facilities (other than hospital outpatient departments)'' for
''facilities''.
Subsec. (c)(2)(F). Pub. L. 100-203, 4036(d)(5)(A), struck out ''and
subsection (g) of this section'' after ''required by subparagraph (H)''.
Subsec. (c)(6). Pub. L. 100-203, 4036(d)(5)(B), struck out at end
''The Secretary shall periodically submit to the Congress such
legislative recommendations as the Secretary finds warranted on the
basis of such consultation and evidence to further the national
objective of maximizing the use of home dialysis and transplantation
consistent with good medical practice.''
Subsec. (f)(7)(B). Pub. L. 100-203, 4036(c)(2), inserted ''(or July
1, 1988, with respect to protocols that relate to the reuse of
bloodlines)'' after ''January 1, 1988''.
Subsec. (g). Pub. L. 100-203, 4036(d)(5)(C), (D), redesignated
subsec. (h) as (g) and struck out former subsec. (g) which directed
the Secretary to submit to Congress on July 1, 1979, and on July 1 of
each year thereafter a report on end stage renal disease program.
Subsec. (h). Pub. L. 100-203, 4036(d)(5)(D), redesignated subsec.
(h) as (g).
Pub. L. 100-93 added subsec. (h).
1986 -- Subsec. (b)(7). Pub. L. 99-509, 9335(j)(1), inserted at end
''The Secretary shall reduce the amount of each composite rate payment
under this paragraph for each treatment by 50 cents (subject to such
adjustments as may be required to reflect modes of dialysis other than
hemodialysis) and provide for payment of such amount to the network
administrative organization (designated under subsection (c)(1)(A) of
this section for the network area in which the treatment is provided)
for its necessary and proper administrative costs incurred in carrying
out its responsibilities under subsection (c)(2) of this section.''
Pub. L. 99-509, 9335(a)(2), inserted ''and of pediatric facilities''
after ''isolated rural areas'' in third sentence, and inserted after
third sentence ''Each application for such an exception shall be deemed
to be approved unless the Secretary disapproves it by not later than 60
working days after the date the application is filed.''
Subsec. (c)(1)(A). Pub. L. 99-509, 9335(d)(1), amended subpar. (A)
generally. Prior to amendment, subpar. (A) read as follows: ''For the
purpose of assuring effective and efficient administration of the
benefits provided under this section, the Secretary shall establish, in
accordance with such criteria as he finds appropriate, renal disease
network areas, such network organizations (including a coordinating
council, an executive committee of such council, and a medical review
board, for each network area) as he finds necessary to accomplish such
purpose, and a national end stage renal disease medical information
system. The Secretary may by regulations provide for such coordination
of network planning and quality assurance activities and such exchange
of data and information among agencies with responsibilities for health
planning and quality assurance activities under Federal law as is
consistent with the economical and efficient administration of this
section and with the responsibilities established for network
organizations under this section.''
Subsec. (c)(1)(B). Pub. L. 99-509, 9335(e), amended subpar. (B)
generally, substituting ''network council and each medical review
board'' for ''coordinating council and executive committee''.
Subsec. (c)(2)(A). Pub. L. 99-509, 9335(f)(1), inserted ''and the
participation of patients, providers of services, and renal disease
facilities in vocational rehabilitation programs'' before the semicolon.
Subsec. (c)(2)(B). Pub. L. 99-509, 9335(f)(2), inserted ''and with
respect to working with patients, facilities, and providers in
encouraging participation in vocational rehabilitation programs'' before
first semicolon.
Subsec. (c)(2)(D) to (F). Pub. L. 99-509, 9335(f)(5), added
subpars. (D) to (F). Former subpars. (D) and (E) redesignated (G) and
(H), respectively.
Subsec. (c)(2)(G). Pub. L. 99-509, 9335(f)(3), (5), redesignated
former subpar. (D) as (G) and inserted ''and reporting to the Secretary
on facilities and providers that are not providing appropriate medical
care'' before the semicolon.
Subsec. (c)(2)(H). Pub. L. 99-509, 9335(f)(4), (5), redesignated
former subpar. (E) as (H) and inserted ''and encouraging participation
in vocational rehabilitation programs'' after ''and transplantation''.
Subsec. (c)(3). Pub. L. 99-509, 9335(g), inserted ''or to follow the
recommendations of the medical review board'' after ''network plans and
goals''.
Subsec. (c)(6). Pub. L. 99-509, 9335(h), inserted ''and that the
maximum practical number of patients who are suitable candidates for
vocational rehabilitation services be given access to such services and
encouraged to return to gainful employment'' at end of first sentence.
Subsec. (c)(7). Pub. L. 99-509, 9335(i)(1), added par. (7).
Subsec. (f)(7). Pub. L. 99-509, 9335(k)(1), amended par. (7)
generally. Prior to amendment, par. (7) read as follows: ''The
Secretary shall conduct a study of the medical appropriateness and
safety of cleaning and reusing dialysis filters by home dialysis
patients. In such cases in which the Secretary determines that such
home cleaning and reuse of filters is a medically sound procedure, the
Secretary shall conduct experiments to evaluate such home cleaning and
reuse as a method of reducing the costs of the end stage renal disease
program.''
1984 -- Subsecs. (a), (b)(1), (2)(A), (B), (3), (8). Pub. L.
98-369, 2354(b)(41), substituted ''end stage'' for ''end-stage''
wherever appearing.
Subsec. (b)(11). Pub. L. 98-617 realigned margin of par. (11).
Pub. L. 98-369, 2323(c), added par. (11).
Subsec. (c)(3). Pub. L. 98-369, 2352(a), inserted provision that if
the Secretary determines that the facility's or provider's failure to
cooperate with network plans and goals does not jeopardize patient
health or safety or justify termination of certification, he may
instead, after reasonable notice to the provider or facility and to the
public, impose such other sanctions as he determines to be appropriate,
which sanctions may include denial of reimbursement with respect to some
or all patients admitted to the facility after the date of notice to the
facility or provider, and graduated reduction in reimbursement for all
patients.
1983 -- Subsec. (b)(2)(A). Pub. L. 98-21 inserted ''or section
1395ww of this title (if applicable)'' after ''section 1395x(v) of this
title''.
1981 -- Subsec. (b)(2)(B). Pub. L. 97-35, 2145(a)(1), (2),
substituted ''section 1395x(v) of this title) and consistent with any
regulations promulgated under paragraph (7)'' for ''section 1395x(v) of
this title)'' and struck out provisions that such regulations provide
for the implementation of appropriate incentives for encouraging more
efficient and effective delivery of services, and include a system for
classifying comparable providers and facilities, and prospectively set
rates or target rates with arrangements for sharing such reductions in
costs as may be attributable to more efficient and effective delivery of
services.
Subsec. (b)(3)(B). Pub. L. 97-35, 2145(a)(3), substituted ''or other
basis (which effectively encourages the efficient delivery of dialysis
services and provides incentives for the increased use of home
dialysis)'' for ''or other basis''.
Subsec. (b)(4). Pub. L. 97-35, 2145(a)(4), inserted reference to
alternative basis of a method established under par. (7).
Subsec. (b)(6). Pub. L. 97-35, 2145(a)(5), (6), substituted
''(except as may be provided in regulations under paragraph (7)) shall
such target rate exceed 75 percent'' and ''any other procedure
(including methods established under paragraph (7)) which the
Secretary'' for ''shall such target rate exceed 70 percent'' and ''any
other procedure which the Secretary'', respectively.
Subsec. (b)(7) to (10). Pub. L. 97-35, 2145(a)(7), (8), added par.
(7) and redesignated former pars. (7) to (9) as (8) to (10),
respectively.
1980 -- Subsec. (e)(1). Pub. L. 96-499, 957(a)(1)-(3), substituted
''services, renal dialysis facilities, and nonprofit entities which the
Secretary finds can furnish equipment economically and efficiently,''
for ''services and renal dialysis facilities'' and ''such providers,
facilities, and nonprofit entities'' for ''such providers and
facilities''.
Subsec. (e)(2). Pub. L. 96-499, 957(a)(4), substituted '', facility,
or other entity will'' for ''or facility will''.
Subsec. (g). Pub. L. 96-499, 957(b), substituted ''July'' for
''April'' in two places.
Section 4201(c)(2) of Pub. L. 101-508 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
erythropoietin furnished on or after January 1, 1991.''
Amendment by section 4201(d)(2) of Pub. L. 101-508 applicable to
items and services furnished on or after July 1, 1991, see section
4201(d)(3)((4)) of Pub. L. 101-508, set out as a note under section
1395x of this title.
Section 6203(b)(3) of Pub. L. 101-239 provided that: ''The
amendments made by this subsection (amending this section) shall apply
with respect to dialysis services, supplies, and equipment furnished on
or after February 1, 1990.''
Amendment by section 4065(b) of Pub. L. 100-203 effective Jan. 1,
1988, see section 4065(c) of Pub. L. 100-203, set out as a note under
section 1395x of this title.
Amendment by Pub. L. 100-93 effective at end of fourteen-day period
beginning Aug. 18, 1987, and inapplicable to administrative proceedings
commenced before end of such period, see section 15(a) of Pub. L.
100-93, set out as a note under section 1320a-7 of this title.
Section 9335(a)(3) of Pub. L. 99-509 provided that: ''The
amendments made by paragraph (2) (amending this section) shall apply to
applications filed on or after the date of the enactment of this Act
(Oct. 21, 1986).''
Section 9335(j)(2) of Pub. L. 99-509, as amended by Pub. L.
100-203, title IV, 4085(i)(21)(C), Dec. 22, 1987, 101 Stat. 1330-133,
provided that: ''The amendment made by paragraph (1) (amending this
section) shall apply to treatment furnished on or after January 1,
1987(,) except that, until network administrative organizations are
established under section 1881(c)(1)(A) of the Social Security Act
(subsec. (c)(1)(A) of this section) (as amended by subsection (d)(1) of
this section), the distribution of payments described in the last
sentence of section 1881(b)(7) of such Act shall be made based on the
distribution of payments under section 1881 of such Act to network
administrative organizations for fiscal year 1986.''
(Section 4085(i)(21) of Pub. L. 100-203 provided that the amendment
of section 9335(j)(2) of Pub. L. 99-509, set out above, by section
4085(i)(21)(C) of Pub. L. 100-203 is effective as if included in the
enactment of Pub. L. 99-509.)
Section 9335(l) of Pub. L. 99-509 provided that: ''The amendments
made by subsections (e), (f), and (g) (amending this section) shall
apply to network administrative organizations designated for network
areas established under the amendment made by subsection (d)(1)
(amending this section).''
Amendment by Pub. L. 98-617 effective as if originally included in
the Deficit Reduction Act of 1984, Pub. L. 98-369, see section 3(c) of
Pub. L. 98-617, set out as a note under section 1395f of this title.
Amendment by section 2323(c) of Pub. L. 98-369 applicable to
services furnished on or after Sept. 1, 1984, see section 2323(d) of
Pub. L. 98-369, set out as a note under section 1395l of this title.
Section 2352(b) of Pub. L. 98-369 provided that: ''The amendment
made by this section (amending this section) shall apply to
determinations made by the Secretary on or after the date of the
enactment of this Act (July 18, 1984).''
Amendment by section 2354(b)(41) 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 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.
Section 2145(b) of Pub. L. 97-35 provided that: ''The amendments
made by subsection (a) (amending this section) apply to services
furnished on or after October 1, 1981, and the Secretary of Health and
Human Services shall first promulgate regulations to carry out section
1881(b)(7) of the Social Security Act (subsec. (b)(7) of this section)
not later than October 1, 1981.''
Section 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 an Effective Date of
1978 Amendment note under section 426 of this title.
Section 4201(b) of Pub. L. 101-508 provided that:
''(1) In general. --
''(A) Study. -- The Prospective Payment Assessment Commission (in
this subsection referred to as the 'Commission') shall conduct a study
to determine the costs and services and profits associated with various
modalities of dialysis treatments provided to end stage renal disease
patients provided under title XVIII of the Social Security Act (this
subchapter).
''(B) Recommendations. -- Based on information collected for the
study described in subparagraph (A), the Commission shall make
recommendations to Congress regarding the method or methods and the
levels at which the payments made for the facility component of dialysis
services by providers of service and renal dialysis facilities under
title XVIII of the Social Security Act should be established for
dialysis services furnished during fiscal year 1993 and the methodology
to be used to update such payments for subsequent fiscal years. In
making recommendations concerning the appropriate methodology the
Commission shall consider --
''(i) hemodialysis and other modalities of treatment,
''(ii) the appropriate services to be included in such payments,
''(iii) the adjustment factors to be incorporated including facility
characteristics, such as hospital versus free-standing facilities, urban
versus rural, size and mix of services,
''(iv) adjustments for labor and nonlabor costs,
''(v) comparative profit margins for all types of renal dialysis
providers of service and renal dialysis facilities,
''(vi) adjustments for patient complexity, such as age, diagnosis,
case mix, and pediatric services, and
''(vii) efficient costs related to high quality of care and positive
outcomes for all treatment modalities.
''(2) Report. -- Not later than June 1, 1992, the Commission shall
submit a report to the Committee on Finance of the Senate, and the
Committees on Ways and Means and Energy and Commerce of the House of
Representatives on the study conducted under paragraph (1)(A) and shall
include in the report the recommendations described in paragraph (1)(B),
taking into account the factors described in paragraph (1)(B).
''(3) Annual report. -- The Commission, not later than March 1 before
the beginning of each fiscal year (beginning with fiscal year 1993)
shall report its recommendations to the Committee on Finance of the
Senate and the Committees on Ways and Means and Energy and Commerce of
the House of Representatives on an appropriate change factor which
should be used for updating payments for services rendered in that
fiscal year. The Commission in making such report to Congress shall
consider conclusions and recommendations available from the Institute of
Medicine.''
Section 4202 of Pub. L. 101-508 provided that:
''(a) Establishment. --
''(1) In general. -- Not later than 9 months after the date of the
enactment of this Act (Nov. 5, 1990), the Secretary of Health and Human
Services shall establish and carry out a 3-year demonstration project to
determine whether the services of a home dialysis staff assistant
providing services to a patient during hemodialysis treatment at the
patient's home may be covered under the medicare program in a
cost-effective manner that ensures patient safety.
''(2) Number of participants. -- The total number of eligible
patients receiving services under the demonstration project established
under paragraph (1) may not exceed 800.
''(b) Payments to Participating Providers and Facilities. --
''(1) Services for which payment may be made. --
''(A) In general. -- Under the demonstration project established
under subsection (a), the Secretary shall make payments for 3 years
under title XVIII of the Social Security Act (this subchapter) to
providers of services (other than a skilled nursing facility) or renal
dialysis facilities for services of a home hemodialysis staff assistant
provided to an individual described in subsection (c) during
hemodialysis treatment at the individual's home in an amount determined
under paragraph (2).
''(B) Services described. -- For purposes of subparagraph (A), the
term 'services of a home hemodialysis staff assistant' means --
''(i) technical assistance with the operation of a hemodialysis
machine in the patient's home and with such patient's care during
in-home hemodialysis; and
''(ii) administration of medications within the patient's home to
maintain the patency of the extra corporeal circuit.
''(2) Amount of payment. --
''(A) In general. -- Payment to a provider of services or renal
dialysis facility participating in the demonstration project established
under subsection (a) for the services described in paragraph (1) shall
be prospectively determined by the Secretary, made on a per treatment
basis, and shall be in an amount determined under subparagraph (B).
''(B) Determination of payment amount. -- (i) The amount of payment
made under subparagraph (A) shall be the product of --
''(I) the rate determined under clause (ii) with respect to a
provider of services or a renal dialysis facility; and
''(II) the factor by which the labor portion of the composite rate
determined under section 1881(b)(7) of the Social Security Act (subsec.
(b)(7) of this section) is adjusted for differences in area wage levels.
''(ii) The rate determined under this clause, with respect to a
provider of services or renal dialysis facility, shall be equal to the
difference between --
''(I) two-thirds of the labor portion of the composite rate
applicable under section 1881(b)(7) of such Act to the provider or
facility (as adjusted to reflect differences in area wage levels), and
''(II) the product of the national median hourly wage for a home
hemodialysis staff assistant and the national median time expended in
the provision of home hemodialysis staff assistant services (taking into
account time expended in travel and predialysis patient care).
''(iii) For purposes of clause (ii)(II) --
''(I) the national median hourly wage for a home hemodialysis staff
assistant and the national median average time expended for home
hemodialysis staff assistant services shall be determined annually on
the basis of the most recent data available, and
''(II) the national median hourly wage for a home hemodialysis staff
assistant shall be the sum of 65 percent of the national median hourly
wage for a licensed practical nurse and 35 percent of the national
median hourly wage for a registered nurse.
''(C) Payment as add-on to composite rate. -- The amount of payment
determined under this paragraph shall be in addition to the amount of
payment otherwise made to the provider of services or renal dialysis
facility under section 1881(b) of such Act.
''(c) Individuals Eligible to Receive Services Under Project. --
''(1) In general. -- An individual may receive services from a
provider of services or renal dialysis facility participating in the
demonstration project if --
''(A) the individual is not a resident of a skilled nursing facility;
''(B) the individual is an end stage renal disease patient entitled
to benefits under title XVIII of the Social Security Act (this
subchapter);
''(C) the individual's physician certifies that the individual is
confined to a bed or wheelchair and cannot transfer themselves (sic)
from a bed to a chair;
''(D) the individual has a serious medical condition (as specified by
the Secretary) which would be exacerbated by travel to and from a
dialysis facility;
''(E) the individual is eligible for ambulance transportation to
receive routine maintenance dialysis treatments, and, based on the
individual's medical condition, there is reasonable expectation that
such transportation will be used by the individual for a period of at
least 6 consecutive months, such that the cost of ambulance
transportation can reasonably be expected to meet or exceed the cost of
home hemodialysis staff assistance as provided under subsection (b)(4);
and
''(F) no family member or other individual is available to provide
such assistance to the individual.
''(2) Coverage of individuals currently receiving services. -- Any
individual who, on the date of the enactment of this Act (Nov. 5, 1990),
is receiving staff assistance under the experimental authority provided
under section 1881(f)(2) of the Social Security Act (subsec. (f)(2) of
this section) shall be deemed to be an eligible individual for purposes
of this subsection.
''(3) Continuation of coverage upon termination of project. --
Notwithstanding any provision of title XVIII of the Social Security Act,
any individual receiving services under the demonstration project
established under subsection (a) as of the date of the termination of
the project shall continue to be eligible for home hemodialysis staff
assistance after such date under such title on the same terms and
conditions as applied under the demonstration project.
''(d) Qualifications for Home Hemodialysis Staff Assistants. -- For
purposes of subsection (b), a home dialysis aide is qualified if the
aide --
''(1) meets minimum qualifications as specified by the Secretary;
and
''(2) meets any applicable qualifications as specified under the law
of the State in which the home hemodialysis staff assistant is providing
services.
''(e) Reports. --
''(1) Interim status report. -- Not later than December 1, 1992, the
Secretary shall submit to Congress a preliminary report on the status of
the demonstration project established under subsection (a).
''(2) Final report. -- Not later than December 31, 1995, the
Secretary shall submit to Congress a final report evaluating the
project, and shall include in such report recommendations regarding
appropriate eligibility criteria and cost-control mechanisms for
medicare coverage of the services of a home dialysis aide providing
medical assistance to a patient during hemodialysis treatment at the
patient's home.
''(f) Authorization of Appropriations. -- The Secretary shall provide
for the transfer from the Federal Supplementary Medical Insurance Trust
Fund (established under section 1841 of the Social Security Act (section
1395t of this title)) of not more than the following amounts to carry
out the demonstration project established under subsection (a) (without
regard to amounts appropriated in advance in appropriation Acts):
''(1) For fiscal year 1991, $4,000,000.
''(2) For fiscal year 1992, $4,000,000.
''(3) For fiscal year 1993, $3,000,000.
''(4) For fiscal year 1994, $2,000,000.
''(5) For fiscal year 1995, $1,000,000.''
Section 4036(d)(1)-(4) of Pub. L. 100-203 provided that:
''(1) The Secretary of Health and Human Services (in this subsection
referred to as the 'Secretary') shall arrange for a study of the
end-stage renal disease program within the medicare program.
''(2) Among other items, the study shall address --
''(A) access to treatment by both individuals eligible for medicare
benefits and those not eligible for such benefits;
''(B) the quality of care provided to end-stage renal disease
beneficiaries, as measured by clinical indicators, functional status of
patients, and patient satisfaction;
''(C) the effect of reimbursement on quality of treatment;
''(D) major epidemiological and demographic changes in the end-stage
renal disease population that may affect access to treatment, the
quality of care, or the resource requirements of the program; and
''(E) the adequacy of existing data systems to monitor these matters
on a continuing basis.
''(3) The Secretary shall submit to Congress, not later than 3 years
after the date of the enactment of this Act (Dec. 22, 1987), a report on
the study.
''(4) The Secretary shall request the National Academy of Sciences,
acting through the Institute of Medicine, to submit an application to
conduct the study described in this section. If the Academy submits an
acceptable application, the Secretary shall enter into an appropriate
arrangement with the Academy for the conduct of the study. If the
Academy does not submit an acceptable application to conduct the study,
the Secretary may request one or more appropriate nonprofit private
entities to submit an application to conduct the study and may enter
into an appropriate arrangement for the conduct of the study by the
entity which submits the best acceptable application.''
Section 9335(a)(1) of Pub. L. 99-509, as amended by Pub. L.
101-239, title VI, 6203(a)(1), Dec. 19, 1989, 103 Stat. 2235; Pub.
L. 101-508, title IV, 4201(a), Nov. 5, 1990, 104 Stat. 1388-102,
provided that: ''Effective with respect to dialysis services provided
on or after October 1, 1986, and before December 31, 1990, the Secretary
of Health and Human Services shall establish the base rate for routine
dialysis treatment in a free-standing facility and in a hospital-based
facility under section 1881(b)(7) of the Social Security Act (subsec.
(b)(7) of this section) at a level equal to the respective rate in
effect as of May 13, 1986, reduced by $2.00. With respect to services
furnished on or after January 1, 1991, such base rate shall be equal to
the respective rate in effect as of September 30, 1990 (determined
without regard to any reductions imposed pursuant to section 6201 of the
Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239, set out as
a note under section 902 of Title 2, The Congress)), increased by $1.00.
No change may be made in the base rate in effect as of September 30,
1990, unless the Secretary makes such change in accordance with notice
and comment requirements set forth in section 1871(b)(1) of such Act
(subsec. (b)(1) of this section).''
(Section 6203(a)(2) of Pub. L. 101-239 provided that: ''The
amendment made by paragraph (1) (amending section 9335(a)(1) of Pub. L.
99-509, set out above) shall take effect as if included in the enactment
of the Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99-509).'')
Section 9335(b) of Pub. L. 99-509 provided that:
''(1) In general. -- The Secretary of Health and Human Services shall
provide for --
''(A) a study to evaluate the effects of reductions in the rates of
payment for facility and physicians' services under the medicare program
for patients with end stage renal disease on their access to care or on
the quality of care, and
''(B) a report to Congress on the results of the study by not later
than January 1, 1988.
''(2) Arrangements with institute of medicine. -- The Secretary shall
request the National Academy of Sciences, acting through appropriate
units, to submit an application to conduct the study described in
paragraph (1). If the Academy submits an acceptable application, the
Secretary shall enter into an appropriate arrangement with the Academy
for the conduct of the study. If the Academy does not submit an
acceptable application to conduct the study, the Secretary may request
one or more appropriate nonprofit private entities to submit an
application to conduct the study and may enter into an appropriate
arrangement for the conduct of the study by the entity which submits the
best acceptable application.''
Section 9335(d)(2), (3) of Pub. L. 99-509, as amended by Pub. L.
100-203, title IV, 4009(j)(6)(E), Dec. 22, 1987, 101 Stat. 1330-59,
provided that:
''(2) Deadline for establishing new areas. -- The Secretary of Health
and Human Services shall establish end stage renal disease network
areas, pursuant to the amendment made by paragraph (1) (amending this
section), not later than May 1, 1987. The Secretary shall designate
network administrative organizations for such areas by not later than
July 1, 1987.
''(3) Transition. -- If, under the amendment made by paragraph (1),
the Secretary designates a network administrative organization for an
area which was not previously designated for that area, the Secretary
shall offer to continue to fund the previously designated organization
for that area for a period of 30 days after the first date the newly
designated organization assumes the duties of a network administrative
organization for that area.''
Section 9335(i)(2) of Pub. L. 99-509 provided that: ''The Secretary
of Health and Human Services shall submit to the Congress, no later than
April 1, 1987, a full report on the progress made in establishing the
national end stage renal disease registry under the amendment made by
paragraph (1) (amending this section) and shall establish such registry
by not later than January 1, 1988.''
Section 9335(k)(2) of Pub. L. 99-509, as amended by Pub. L.
100-203, title IV, 4036(c)(1)(A), Dec. 22, 1987, 101 Stat. 1330-79,
provided that: ''The Secretary of Health and Human Services shall
establish the protocols described in section 1881(f)(7)(A) of the Social
Security Act (subsec. (f)(7)(A) of this section) by not later than
October 1, 1987 (or July 1, 1988, with respect to protocols that relate
to the reuse of bloodlines).''
(Section 4036(c)(1)(B) of Pub. L. 100-203 provided that: ''The
amendment made by subparagraph (A) (amending section 9335(k)(2) of Pub.
L. 99-509, set out above) shall be effective as if included in the
enactment of section 9335(k)(2) of the Omnibus Budget Reconciliation Act
of 1986 (Pub. L. 99-509).'')
Pub. L. 99-272, title IX, 9214, Apr. 7, 1986, 100 Stat. 180,
provided that: ''The Secretary of Health and Human Services shall
maintain renal disease network organizations as authorized under section
1881(c) of the Social Security Act (subsec. (c) of this section), and
may not merge the network organizations into other organizations or
entities. The Secretary may consolidate such network organizations, but
only if such consolidation does not result in fewer than 14 such
organizations being permitted to exist.''
42 USC 1395ss. Certification of medicare supplemental health insurance
policies
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Submission of policy by insurer
(1) The Secretary shall establish a procedure whereby medicare
supplemental policies (as defined in subsection (g)(1) of this section)
may be certified by the Secretary as meeting minimum standards and
requirements set forth in subsection (c) of this section. Such
procedure shall provide an opportunity for any insurer to submit any
such policy, and such additional data as the Secretary finds necessary,
to the Secretary for his examination and for his certification thereof
as meeting the standards and requirements set forth in subsection (c) of
this section. Subject to subsections (k)(3), (m), and (n) of this
section, such certification shall remain in effect if the insurer files
a notarized statement with the Secretary no later than June 30 of each
year stating that the policy continues to meet such standards and
requirements and if the insurer submits such additional data as the
Secretary finds necessary to independently verify the accuracy of such
notarized statement. Where the Secretary determines such a policy meets
(or continues to meet) such standards and requirements, he shall
authorize the insurer to have printed on such policy (but only in
accordance with such requirements and conditions as the Secretary may
prescribe) an emblem which the Secretary shall cause to be designed for
use as an indication that a policy has received the Secretary's
certification. The Secretary shall provide each State commissioner or
superintendent of insurance with a list of all the policies which have
received his certification.
(2) No medicare supplemental policy may be issued in a State on or
after the date specified in subsection (p)(1)(C) of this section unless
--
(A) the State's regulatory program under subsection (b)(1) of this
section provides for the application and enforcement of the standards
and requirements set forth in such subsection (including the NAIC
standards or the Federal standards (as the case may be)) by the date
specified in subsection (p)(1)(C) of this section; or
(B) if the State's program does not provide for the application and
enforcement of such standards and requirements, the policy has been
certified by the Secretary under paragraph (1) as meeting the standards
and requirements set forth in subsection (c) of this section (including
such applicable standards) by such date.
Any person who issues a medicare supplemental policy, after the
effective date of the NAIC or Federal standards with respect to the
policy, in violation of this paragraph is subject to a civil money
penalty of not to exceed $25,000 for each such violation. The
provisions of section 1320a-7a of this title (other than the first
sentence of subsection (a) and other than subsection (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.
(b) Standards and requirements; periodic review by Secretary
(1) Any medicare supplemental policy issued in any State which the
the /1/ Secretary determines has established under State law a
regulatory program that --
(A) provides for the application and enforcement of standards with
respect to such policies equal to or more stringent than the NAIC Model
Standards (as defined in subsection (g)(2)(A) of this section), except
as otherwise provided by subparagraph (H);
(B) includes requirements equal to or more stringent than the
requirements described in paragraphs (2) through (5) of subsection (c)
of this section;
(C) provides that --
(i) information with respect to the actual ratio of benefits provided
to premiums collected under such policies will be reported to the State
on forms conforming to those developed by the National Association of
Insurance Commissioners for such purpose, or
(ii) such ratios will be monitored under the program in an
alternative manner approved by the Secretary, and that a copy of each
such policy, the most recent premium for each such policy, and a listing
of the ratio of benefits provided to premiums collected for the most
recent 3-year period for each such policy issued or sold in the State is
maintained and made available to interested persons;
(D) provides for application and enforcement of the standards and
requirements described in subparagraphs (A), (B), and (C) to all
medicare supplemental policies (as defined in subsection (g)(1) of this
section) issued in such State,
(E) provides the Secretary periodically (but at least annually) with
a list containing the name and address of the issuer of each such policy
and the name and number of each such policy (including an indication of
policies that have been previously approved, newly approved, or
withdrawn from approval since the previous list was provided),
(F) reports to the Secretary on the implementation and enforcement of
standards and requirements of this paragraph at intervals established by
the Secretary,
(G) provides for a process for approving or disapproving proposed
premium increases with respect to such policies, and establishes a
policy for the holding of public hearings prior to approval of a premium
increase, and
(H) in the case of a policy that meets the standards under
subparagraph (A) except that benefits under the policy are limited to
items and services furnished by certain entities (or reduced benefits
are provided when items or services are furnished by other entities),
provides for the application of requirements equal to or more stringent
than the requirements under subsection (t) of this section,
shall be deemed (subject to subsections (k)(3), (m), and (n) of this
section, for so long as the Secretary finds that such State regulatory
program continues to meet the standards and requirements of this
paragraph) to meet the standards and requirements set forth in
subsection (c) of this section. The report required under subsection
/2/ (F) shall include information on loss ratios of policies sold in the
State, frequency and types of instances in which policies approved by
the State fail to meet the standards of this paragraph, actions taken by
the State to bring such policies into compliance, and /3/ information
regarding State programs implementing consumer protection provisions,
and such further information as the Secretary in consultation with the
National Association of Insurance Commissioners, /4/ may specify.
(2) The Secretary periodically shall review State regulatory programs
to determine if they continue to meet the standards and requirements
specified in paragraph (1). If the Secretary finds that a State
regulatory program no longer meets the standards and requirements,
before making a final determination, the Secretary shall provide the
State an opportunity to adopt such a plan of correction as would permit
the State regulatory program to continue to meet such standards and
requirements. If the Secretary makes a final determination that the
State regulatory program, after such an opportunity, fails to meet such
standards and requirements, the program shall no longer be considered to
have in operation a program meeting such standards and requirements.
(3) Notwithstanding paragraph (1), a medicare supplemental policy
offered in a State shall not be deemed to meet the standards and
requirements set forth in subsection (c) of this section, with respect
to an advertisement (whether through written, radio, or television
medium) used (or, at a State's option, to be used) for the policy in the
State, unless the entity issuing the policy provides a copy of each
advertisement to the Commissioner of Insurance (or comparable officer
identified by the Secretary) of that State for review or approval to the
extent it may be required under State law.
(c) Requisite findings
The Secretary shall certify under this section any medicare
supplemental policy, or continue certification of such a policy, only if
he finds that such policy (or, with respect to paragraph (3) or the
requirement described in subsection (s) of this section, the issuer of
the policy) --
(1) meets or exceeds (either in a single policy or, in the case of
nonprofit hospital and medical service associations, in one or more
policies issued in conjunction with one another) the NAIC Model
Standards (except as otherwise provided by subsection (t) of this
section);
(2) meets the requirements of subsection (r) of this section;
(3)(A) accepts a notice under section 1395u(h)(3)(B) of this title as
a claim form for benefits under such policy in lieu of any claim form
otherwise required and agrees to make a payment determination on the
basis of the information contained in such notice;
(B) where such a notice is received --
(i) provides notice to such physician or supplier and the beneficiary
of the payment determination under the policy, and
(ii) provides any payment covered by such policy directly to the
participating physician or supplier involved;
(C) provides each enrollee at the time of enrollment a card listing
the policy name and number and a single mailing address to which notices
under section 1395u(h)(3)(B) of this title respecting the policy are to
be sent;
(D) agrees to pay any user fees established under section
1395u(h)(3)(B) of this title with respect to information transmitted to
the issuer of the policy; and
(E) provides to the Secretary at least annually, for transmittal to
carriers, a single mailing address to which notices under section
1395u(h)(3)(B) of this title respecting the policy are to be sent;
(4) may, during a period of not less than 30 days after the policy is
issued, be returned for a full refund of any premiums paid (without
regard to the manner in which the purchase of the policy was solicited);
and
(5) meets the applicable requirements of subsections (o) through (t)
of this section.
(d) Criminal penalties; civil penalties for certain violations
(1) Whoever knowingly and willfully makes or causes to be made or
induces or seeks to induce the making of any false statement or
representation of a material fact with respect to the compliance of any
policy with the standards and requirements set forth in subsection (c)
of this section or in regulations promulgated pursuant to such
subsection, or with respect to the use of the emblem designed by the
Secretary under subsection (a) of this section, shall be fined under
title 18 or imprisoned not more than 5 years, or both, and, in addition
to or in lieu of such a criminal penalty, is subject to a civil money
penalty of not to exceed $5,000 for each such prohibited act.
(2) Whoever falsely assumes or pretends to be acting, or
misrepresents in any way that he is acting, under the authority of or in
association with, the program of health insurance established by this
subchapter, or any Federal agency, for the purpose of selling or
attempting to sell insurance, or in such pretended character demands, or
obtains money, paper, documents, or anything of value, shall be fined
under title 18 or imprisoned not more than 5 years, or both, and, in
addition to or in lieu of such a criminal penalty, is subject to a civil
money penalty of not to exceed $5,000 for each such prohibited act.
(3)(A) It is unlawful for a person to sell or issue a health
insurance policy to an individual entitled to benefits under part A of
this subchapter or enrolled under part B of this subchapter, with
knowledge that such policy duplicates health benefits to which such
individual is otherwise entitled, other than benefits to which he is
entitled under a requirement of State or Federal law (other than this
subchapter or subchapter XIX of this chapter). Whoever violates the
previous sentence shall be fined under title 18 or imprisoned not more
than 5 years, or both, and, in addition to or in lieu of such a criminal
penalty, is subject to a civil money penalty of not to exceed $25,000
(or $15,000 in the case of a person other than the issuer of the policy)
for each such prohibited act. A seller (who is not the issuer of a
health insurance policy) shall not be considered to violate the previous
sentence if the policy is sold in compliance with subparagraph (B) and
the statement under such subparagraph indicates on its face that the
sale of the policy will not duplicate health benefits to which the
individual is otherwise entitled. This subsection shall not apply to
such a seller until such date as the Secretary publishes a list of the
standardized benefit packages that may be offered consistent with
subsection (p) of this section.
(B)(i) It is unlawful for a person to issue or sell a medicare
supplemental policy to an individual entitled to benefits under part A
of this subchapter or enrolled under part B of this subchapter, whether
directly, through the mail, or otherwise, unless --
(I) the person obtains from the individual, as part of the
application for the issuance or purchase and on a form described in
clause (ii), a written statement signed by the individual stating, to
the best of the individual's knowledge, what health insurance policies
the individual has, from what source, and whether the individual is
entitled to any medical assistance under subchapter XIX of this chapter,
whether as a qualified medicare beneficiary or otherwise, and
(II) the written statement is accompanied by a written
acknowledgment, signed by the seller of the policy, of the request for
and receipt of such statement.
(ii) The statement required by clause (i) shall be made on a form
that --
(I) states in substance that a medicare-eligible individual does not
need more than one medicare supplemental policy,
(II) states in substance that individuals 65 years of age or older
may be eligible for benefits under the State medicaid program under
subchapter XIX of this chapter and that such individuals who are
entitled to benefits under that program usually do not need a medicare
supplemental policy and that benefits and premiums under any such policy
shall be suspended upon request of the policyholder during the period
(of not longer than 24 months) of entitlement to benefits under such
subchapter and may be reinstituted upon loss of such entitlement, and
(III) states that counseling services may be available in the State
to provide advice concerning the purchase of medicare supplemental
policies and enrollment under the medicaid program and may provide the
telephone number for such services.
(iii)(I) Except as provided in subclauses (II) and (III), if the
statement required by clause (i) is not obtained or indicates that the
individual has another medicare supplemental policy or indicates that
the individual is entitled to any medical assistance under subchapter
XIX of this chapter, the sale of such a policy shall be considered to be
a violation of subparagraph (A).
(II) Subclause (I) shall not apply in the case of an individual who
has another policy, if the individual indicates in writing, as part of
the application for purchase, that the policy being purchased replaces
such other policy and indicates an intent to terminate the policy being
replaced when the new policy becomes effective and the issuer or seller
certifies in writing that such policy will not, to the best of the
issuer /5/ or seller's knowledge, duplicate coverage (taking into
account any such replacement).
(III) Subclause (I) also shall not apply if a State medicaid plan
under subchapter XIX of this chapter pays the premiums for the policy,
or pays less than an individual's (who is described in section
1396d(p)(1) of this title) full liability for medicare cost sharing as
defined in section 1396d(p)(3)(A) of this title.
(iv) Whoever issues or sells a medicare supplemental policy in
violation of this subparagraph shall be fined under title 18, or
imprisoned not more than 5 years, or both, and, in addition to or in
lieu of such a criminal penalty, is subject to a civil money penalty of
not to exceed $25,000 (or $15,000 in the case of a seller who is not the
issuer of a policy) for each such violation.
(C) Subparagraph (A) shall not apply with respect to the selling of a
group policy or plan of one or more employers or labor organizations, or
of the trustees of a fund established by one or more employers or labor
organizations (or combination thereof), for employees or former
employees (or combination thereof) or for members or former members (or
combination thereof) of the labor organizations.
(4)(A) Whoever knowingly, directly or through his agent, mails or
causes to be mailed any matter for a prohibited purpose (as determined
under subparagraph (B)) shall be fined under title 18 or imprisoned not
more than 5 years, or both, and, in addition to or in lieu of such a
criminal penalty, is subject to a civil money penalty of not to exceed
$5,000 for each such prohibited act.
(B) For purposes of subparagraph (A), a prohibited purpose means the
advertising, solicitation, or offer for sale of a medicare supplemental
policy, or the delivery of such a policy, in or into any State in which
such policy has not been approved by the State commissioner or
superintendent of insurance.
(C) Subparagraph (A) shall not apply in the case of a person who
mails or causes to be mailed a medicare supplemental policy into a State
if such person has ascertained that the party insured under such policy
to whom (or on whose behalf) such policy is mailed is located in such
State on a temporary basis.
(D) Subparagraph (A) shall not apply in the case of a person who
mails or causes to be mailed a duplicate copy of a medicare supplemental
policy previously issued to the party to whom (or on whose behalf) such
duplicate copy is mailed, if such policy expires not more than 12 months
after the date on which the duplicate copy is mailed.
(5) The provisions of section 1320a-7a of this title (other than
subsections (a) and (b)) shall apply to civil money penalties under
paragraphs (1), (2), (3)(A), and (4)(A) in the same manner as such
provisions apply to penalties and proceedings under section 1320a-7a(a)
of this title.
(e) Dissemination of information
(1) The Secretary shall provide to all individuals entitled to
benefits under this subchapter (and, to the extent feasible, to
individuals about to become so entitled) such information as will permit
such individuals to evaluate the value of medicare supplemental policies
to them and the relationship of any such policies to benefits provided
under this subchapter.
(2) The Secretary shall --
(A) inform all individuals entitled to benefits under this subchapter
(and, to the extent feasible, individuals about to become so entitled)
of --
(i) the actions and practices that are subject to sanctions under
subsection (d) of this section, and
(ii) the manner in which they may report any such action or practice
to an appropriate official of the Department of Health and Human
Services (or to an appropriate State official), and
(B) publish the toll-free telephone number for individuals to report
suspected violations of the provisions of such subsection.
(3) The Secretary shall provide individuals entitled to benefits
under this subchapter (and, to the extent feasible, individuals about to
become so entitled) with a listing of the addresses and telephone
numbers of State and Federal agencies and offices that provide
information and assistance to individuals with respect to the selection
of medicare supplemental policies.
(f) Study and evaluation of comparative effectiveness of various
State approaches to regulating medicare supplemental policies; report
to Congress no later than January 1, 1982; periodic evaluations
(1)(A) The Secretary shall, in consultation with Federal and State
regulatory agencies, the National Association of Insurance
Commissioners, private insurers, and organizations representing
consumers and the aged, conduct a comprehensive study and evaluation of
the comparative effectiveness of various State approaches to the
regulation of medicare supplemental policies in (i) limiting marketing
and agent abuse, (ii) assuring the dissemination of such information to
individuals entitled to benefits under this subchapter (and to other
consumers) as is necessary to permit informed choice, (iii) promoting
policies which provide reasonable economic benefits for such
individuals, (iv) reducing the purchase of unnecessary duplicative
coverage, (v) improving price competition, and (vi) establishing
effective approved State regulatory programs described in subsection (b)
of this section.
(B) Such study shall also address the need for standards or
certification of health insurance policies, other than medicare
supplemental policies, sold to individuals eligible for benefits under
this subchapter.
(C) The Secretary shall, no later than January 1, 1982, submit a
report to the Congress on the results of such study and evaluation,
accompanied by such recommendations as the Secretary finds warranted by
such results with respect to the need for legislative or administrative
changes to accomplish the objectives set forth in subparagraphs (A) and
(B), including the need for a mandatory Federal regulatory program to
assure the marketing of appropriate types of medicare supplemental
policies, and such other means as he finds may be appropriate to enhance
effective State regulation of such policies.
(2) The Secretary shall submit to the Congress no later than July 1,
1982, and periodically as may be appropriate thereafter (but not less
often than once every 2 years), a report evaluating the effectiveness of
the certification procedure and the criminal penalties established under
this section, and shall include in such reports an analysis of --
(A) the impact of such procedure and penalties on the types, market
share, value, and cost to individuals entitled to benefits under this
subchapter of medicare supplemental policies which have been certified
by the Secretary;
(B) the need for any change in the certification procedure to improve
its administration or effectiveness; and
(C) whether the certification program and criminal penalties should
be continued.
(g) Definitions
(1) For purposes of this section, a medicare supplemental policy is a
health insurance policy or other health benefit plan offered by a
private entity to individuals who are entitled to have payment made
under this subchapter, which provides reimbursement for expenses
incurred for services and items for which payment may be made under this
subchapter but which are not reimbursable by reason of the applicability
of deductibles, coinsurance amounts, or other limitations imposed
pursuant to this subchapter; but does not include any such policy or
plan of one or more employers or labor organizations, or of the trustees
of a fund established by one or more employers or labor organizations
(or combination thereof), for employees or former employees (or
combination thereof) or for members or former members (or combination
thereof) of the labor organizations and does not include a policy or
plan of a health maintenance organization or other direct service
organization which offers benefits under this subchapter, including such
services under a contract under under /6/ section 1395mm of this title
or an agreement under section 1395l of this title. For purposes of this
section, the term ''policy'' includes a certificate issued under such
policy.
(2) For purposes of this section:
(A) The term ''NAIC Model Standards'' means the ''NAIC Model
Regulation to Implement the Individual Accident and Sickness Insurance
Minimum Standards Act'', adopted by the National Association of
Insurance Commissioners on June 6, 1979, as it applies to medicare
supplement /7/ policies.
(B) The term ''State with an approved regulatory program'' means a
State for which the Panel /8/ has made a determination under subsection
(b)(1) of this section.
(C) The State in which a policy is issued means --
(i) in the case of an individual policy, the State in which the
policyholder resides; and
(ii) in the case of a group policy, the State in which the holder of
the master policy resides.
(h) Rules and regulations
The Secretary shall prescribe such regulations as may be necessary
for the effective, efficient, and equitable administration of the
certification procedure established under this section. The Secretary
shall first issue final regulations to implement the certification
procedure established under subsection (a) of this section not later
than March 1, 1981.
(i) Commencement of certification program
(1) No medicare supplemental policy shall be certified and no such
policy may be issued bearing the emblem authorized by the Secretary
under subsection (a) of this section until July 1, 1982. On and after
such date policies certified by the Secretary may bear such emblem,
including policies which were issued prior to such date and were
subsequently certified, and insurers may notify holders of such
certified policies issued prior to such date using such emblem in the
notification.
(2)(A) The Secretary shall not implement the certification program
established under subsection (a) of this section with respect to
policies issued in a State unless the Panel makes a finding that such
State cannot be expected to have established, by July 1, 1982, an
approved State regulatory program meeting the standards and requirements
of subsection (b)(1) of this section. If the Panel makes such a
finding, the Secretary shall implement such program under subsection (a)
of this section with respect to medicare supplemental policies issued in
such State, until such time as the Panel determines that such State has
a program that meets the standards and requirements of subsection (b)(1)
of this section.
(B) Any finding by the Panel under subparagraph (A) shall be
transmitted in writing, not later than January 1, 1982, to the Committee
on Finance of the Senate and to the Committee on Energy and Commerce and
the Committee on Ways and Means of the House of Representatives and
shall not become effective until 60 days after the date of its
transmittal to the Committees of the Congress under this subparagraph.
In counting such days, days on which either House is not in session
because of an adjournment sine die or an adjournment of more than three
days to a day certain are excluded in the computation.
(j) State regulation of policies issued in other States
Nothing in this section shall be construed so as to affect the right
of any State to regulate medicare supplemental policies which, under the
provisions of this section, are considered to be issued in another
State.
(k) Amended NAIC Model Regulation or Federal model standards
applicable; effective date; medicare supplemental policy and State
regulatory program meeting applicable standards
(1)(A) If, within the 90-day period beginning on July 1, 1988, the
National Association of Insurance Commissioners (in this subsection
referred to as the ''Association'') amends the NAIC Model Regulation
adopted on June 6, 1979 (as it relates to medicare supplemental
policies), with respect to matters such as minimum benefit standards,
loss ratios, disclosure requirements, and replacement requirements and
provisions otherwise necessary to reflect the changes in law made by the
Medicare Catastrophic Coverage Act of 1988, except as provided in
subsection (m) of this section, subsection (g)(2)(A) of this section
shall be applied in a State, effective on and after the date specified
in subparagraph (B), as if the reference to the Model Regulation adopted
on June 6, 1979, were a reference to the Model Regulation as amended by
the Association in accordance with this paragraph (in this subsection
and subsection (l) of this section referred to as the ''amended NAIC
Model Regulation'').
(B) The date specified in this subparagraph for a State is the
earlier of the date the State adopts standards equal to or more
stringent than the amended NAIC Model Regulation or 1 year after the
date the Association first adopts such amended Regulation.
(2)(A) If the Association does not amend the NAIC Model Regulation
within the 90-day period specified in paragraph (1)(A), the Secretary
shall promulgate, not later than 60 days after the end of such period,
Federal model standards (in this subsection and subsection (l) of this
section referred to as ''Federal model standards'') for medicare
supplemental policies to reflect the changes in law made by the Medicare
Catastrophic Coverage Act of 1988, and subsection (g)(2)(A) of this
section shall be applied in a State, effective on and after the date
specified in subparagraph (B), as if the reference to the Model
Regulation adopted on June 6, 1979, were a reference to Federal model
standards.
(B) The date specified in this subparagraph for a State is the
earlier of the date the State adopts standards equal to or more
stringent than the Federal model standards or 1 year after the date the
Secretary first promulgates such standards.
(3) Notwithstanding any other provision of this section (except as
provided in subsections (l), (m), and (n) of this section) --
(A) no medicare supplemental policy may be certified by the Secretary
pursuant to subsection (a) of this section,
(B) no certification made pursuant to subsection (a) of this section
shall remain in effect, and
(C) no State regulatory program shall be found to meet (or to
continue to meet) the requirements of subsection (b)(1)(A) of this
section,
unless such policy meets (or such program provides for the
application of standards equal to or more stringent than) the standards
set forth in the amended NAIC Model Regulation or the Federal model
standards (as the case may be) by the date specified in paragraph (1)(B)
or (2)(B) (as the case may be).
(l) Transitional compliance with NAIC Model Transition Regulation;
''qualifying medicare supplemental policy'' and ''NAIC Model Transition
Regulation'' defined; report to Congress respecting State action in
adopting equal or more stringent standards
(1) Until the date specified in paragraph (3), in the case of a
qualifying medicare supplemental policy described in paragraph (2)
issued --
(A) before January 1, 1989, the policy is deemed to remain in
compliance with this section if the insurer issuing the policy complies
with the NAIC Model Transition Regulation (including giving notices to
subscribers and filing for premium adjustments with the State as
described in section 5.B. of such Regulation) by January 1, 1989; or
(B) on or after January 1, 1989, the policy is deemed to be in
compliance with this section if the insurer issuing the policy complies
with the NAIC Model Transition Regulation before the date of the sale of
the policy.
(2) In paragraph (1), the term ''qualifying medicare supplemental
policy'' means a medicare supplemental policy --
(A) issued in a State which --
(i) has not adopted standards equal to or more stringent than the
NAIC Model Transition Regulation by January 1, 1989, and
(ii) has not adopted standards equal to or more stringent than the
amended NAIC Model Regulation (or Federal model standards) by January 1,
1989; and
(B) which has been issued in compliance with this section (as in
effect on June 1, 1988).
(3)(A) The date specified in this paragraph is the earlier of --
(i) the first date a State adopts, after January 1, 1989, standards
equal to or more stringent than the NAIC Model Transition Regulation or
equal to or more stringent than the amended NAIC Model Regulation (or
Federal model standards), as the case may be, or
(ii) the later of (I) the date specified in subsection (k)(1)(B) or
(k)(2)(B) of this section (as the case may be), or (II) the date
specified in subparagraph (B).
(B) In the case of a State which the Secretary identifies as --
(i) requiring State legislation (other than legislation appropriating
funds) in order for medicare supplemental policies to meet standards
described in subparagraph (A)(i), but
(ii) having a legislature which is not scheduled to meet in 1989 in a
legislative session in which such legislation may be considered,
the date specified in this subparagraph is the first day of the first
calendar quarter beginning after the close of the first legislative
session of the State legislature that begins on or after January 1,
1989, and in which legislation described in clause (i) may be
considered. For purposes of the previous sentence, in the case of a
State that has a 2-year legislative session, each year of such session
shall be deemed to be a separate regular session of the State
legislature.
(4) In the case of a medicare supplemental policy in effect on
January 1, 1989, and offered in a State which, as of such date --
(A) has adopted standards equal to or more stringent than the amended
NAIC Model Regulation (or Federal model standards), but
(B) does not have in effect standards equal to or more stringent than
the NAIC Model Transition Regulation (or otherwise requiring notice
substantially the same as the notice required in section 5.B. of such
Regulation),
the policy shall not be deemed to meet the standards in subsection
(c) of this section unless each individual who is entitled to benefits
under this subchapter and is a policyholder under such policy on January
1, 1989, is sent such a notice in any appropriate form by not later than
January 31, 1989, that explains --
(A) the improved benefits under this subchapter contained in the
Medicare Catastrophic Coverage Act of 1988, and
(B) how these improvements affect the benefits contained in the
policies and the premium for the policy.
(5) In this subsection, the term ''NAIC Model Transition Regulation''
refers to the standards contained in the ''Model Regulation to Implement
Transitional Requirements for the Conversion of Medicare Supplement
Insurance Benefits and Premiums to Conform to Medicare Program
Revisions'' (as adopted by the National Association of Insurance
Commissioners in September 1987).
(6) The Secretary shall report to the Congress in March 1989 and in
July 1990 on actions States have taken in adopting standards equal to or
more stringent than the NAIC Model Transition Regulation or the amended
NAIC Model Regulation (or Federal model standards).
(m) Revision of amended NAIC Model Regulation and amended Federal
model standards; effective dates; medicare supplemental policy and
State regulatory program meeting applicable standards
(1)(A) If, within the 90-day period beginning on December 13, 1989,
the National Association of Insurance Commissioners (in this subsection
and subsection (n) of this section referred to as the ''Association'')
revises the amended NAIC Model Regulation (referred to in subsection
(k)(1)(A) of this section and adopted on September 20, 1988) to improve
such regulation and otherwise to reflect the changes in law made by the
Medicare Catastrophic Coverage Repeal Act of 1989, subsection (g)(2)(A)
of this section shall be applied in a State, effective on and after the
date specified in subparagraph (B), as if the reference to the Model
Regulation adopted on June 6, 1979, were a reference to the amended NAIC
Model Regulation (referred to in subsection (k)(1)(A) of this section)
as revised by the Association in accordance with this paragraph (in this
subsection and subsection (n) of this section referred to as the
''revised NAIC Model Regulation'').
(B) The date specified in this subparagraph for a State is the
earlier of the date the State adopts standards equal to or more
stringent than the revised NAIC Model Regulation or 1 year after the
date the Association first adopts such revised Regulation.
(2)(A) If the Association does not revise the amended NAIC Model
Regulation, within the 90-day period specified in paragraph (1)(A), the
Secretary shall promulgate, not later than 60 days after the end of such
period, revised Federal model standards (in this subsection and
subsection (n) of this section referred to as ''revised Federal model
standards'') for medicare supplemental policies to improve such
standards and otherwise to reflect the changes in law made by the
Medicare Catastrophic Coverage Repeal Act of 1989, subsection (g)(2)(A)
of this section shall be applied in a State, effective on and after the
date specified in subparagraph (B), as if the reference to the Model
Regulation adopted on June 6, 1979, were a reference to the revised
Federal model standards.
(B) The date specified in this subparagraph for a State is the
earlier of the date the State adopts standards equal to or more
stringent than the revised Federal model standards or 1 year after the
date the Secretary first promulgates such standards.
(3) Notwithstanding any other provision of this section (except as
provided in subsection (n) of this section) --
(A) no medicare supplemental policy may be certified by the Secretary
pursuant to subsection (a) of this section,
(B) no certification made pursuant to subsection (a) of this section
shall remain in effect, and
(C) no State regulatory program shall be found to meet (or to
continue to meet) the requirements of subsection (b)(1)(A) of this
section,
unless such policy meets (or such program provides for the
application of standards equal to or more stringent than) the standards
set forth in the revised NAIC Model Regulation or the revised Federal
model standards (as the case may be) by the date specified in paragraph
(1)(B) or (2)(B) (as the case may be).
(n) Transition compliance with revision of NAIC Model Regulation and
Federal model standards
(1) Until the date specified in paragraph (4), in the case of a
qualifying medicare supplemental policy described in paragraph (3)
issued in a State --
(A) before the transition deadline, the policy is deemed to remain in
compliance with the standards described in subsection (b)(1)(A) of this
section only if the insurer issuing the policy complies with the
transition provision described in paragraph (2), or
(B) on or after the transition deadline, the policy is deemed to be
in compliance with the standards described in subsection (b)(1)(A) of
this section only if the insurer issuing the policy complies with the
revised NAIC Model Regulation or the revised Federal model standards (as
the case may be) before the date of the sale of the policy.
In this paragraph, the term ''transition deadline'' means 1 year
after the date the Association adopts the revised NAIC Model Regulation
or 1 year after the date the Secretary promulgates revised Federal model
standards (as the case may be).
(2) The transition provision described in this paragraph is --
(A) such transition provision as the Association provides, by not
later than December 15, 1989, so as to provide for an appropriate
transition (i) to restore benefit provisions which are no longer
duplicative as a result of the changes in benefits under this subchapter
made by the Medicare Catastrophic Coverage Repeal Act of 1989 and (ii)
to eliminate the requirement of payment for the first 8 days of
coinsurance for extended care services, or
(B) if the Association does not provide for a transition provision by
the date described in subparagraph (A), such transition provision as the
Secretary shall provide, by January 1, 1990, so as to provide for an
appropriate transition described in subparagraph (A).
(3) In paragraph (1), the term ''qualifying medicare supplemental
policy'' means a medicare supplemental policy which has been issued in
compliance with this section as in effect on the date before December
13, 1989.
(4)(A) The date specified in this paragraph for a policy issued in a
State is --
(i) the first date a State adopts, after December 13, 1989, standards
equal to or more stringent than the revised NAIC Model Regulation (or
revised Federal model standards), as the case may be, or
(ii) the date specified in subparagraph (B),
whichever is earlier.
(B) In the case of a State which the Secretary identifies, in
consultation with the Association, as --
(i) requiring State legislation (other than legislation appropriating
funds) in order for medicare supplemental policies to meet standards
described in subparagraph (A)(i), but
(ii) having a legislature which is not scheduled to meet in 1990 in a
legislative session in which such legislation may be considered,
the date specified in this subparagraph is the first day of the first
calendar quarter beginning after the close of the first legislative
session of the State legislature that begins on or after January 1,
1990. For purposes of the previous sentence, in the case of a State
that has a 2-year legislative session, each year of such session shall
be deemed to be a separate regular session of the State legislature.
(5) In the case of a medicare supplemental policy in effect on
January 1, 1990, the policy shall not be deemed to meet the standards in
subsection (c) of this section unless each individual who is entitled to
benefits under this subchapter and is a policyholder or certificate
holder under such policy on such date is sent a notice in an appropriate
form by not later than January 31, 1990, that explains --
(A) the changes in benefits under this subchapter effected by the
Medicare Catastrophic Coverage Repeal Act of 1989, and
(B) how these changes may affect the benefits contained in such
policy and the premium for the policy.
(6)(A) Except as provided in subparagraph (B), in the case of an
individual who had in effect, as of December 31, 1988, a medicare
supplemental policy with an insurer (as a policyholder or, in the case
of a group policy, as a certificate holder) and the individual
terminated coverage under such policy before December 13, 1989, no
medicare supplemental policy of the insurer shall be deemed to meet the
standards in subsection (c) of this section unless the insurer --
(i) provides written notice, no earlier than December 15, 1989, and
no later than January 30, 1990, to the policyholder or certificate
holder (at the most recent available address) of the offer described in
clause (ii), and
(ii) offers the individual, during a period of at least 60 days
beginning not later than February 1, 1990, reinstitution of coverage
(with coverage effective as of January 1, 1990), under the terms which
(I) do not provide for any waiting period with respect to treatment of
pre-existing conditions, (II) provides for coverage which is
substantially equivalent to coverage in effect before the date of such
termination, and (III) provides for classification of premiums on which
terms are at least as favorable to the policyholder or certificate
holder as the premium classification terms that would have applied to
the policyholder or certificate holder had the coverage never
terminated.
(B) An insurer is not required to make the offer under subparagraph
(A)(ii) in the case of an individual who is a policyholder or
certificate holder in another medicare supplemental policy as of
December 13, 1989, if (as of January 1, 1990) the individual is not
subject to a waiting period with respect to treatment of a pre-existing
condition under such other policy.
(o) Requirements of group benefits; core group benefits; uniform
outline of coverage
The requirements of this subsection are as follows:
(1) Each medicare supplemental policy shall provide for coverage of a
group of benefits consistent with subsection (p) of this section.
(2) If the medicare supplemental policy provides for coverage of a
group of benefits other than the core group of basic benefits described
in subsection (p)(2)(B) of this section, the issuer of the policy must
make available to the individual a medicare supplemental policy with
only such core group of basic benefits.
(3) The issuer of the policy has provided, before the sale of the
policy, an outline of coverage that uses uniform language and format
(including layout and print size) that facilitates comparison among
medicare supplemental policies and comparison with medicare benefits.
(p) Standards for group benefits
(1)(A) If, within 9 months after November 5, 1990, the National
Association of Insurance Commissioners (in this subsection referred to
as the ''Association'') promulgates --
(i) limitations on the groups or packages of benefits that may be
offered under a medicare supplemental policy consistent with paragraphs
(2) and (3) of this subsection,
(ii) uniform language and definitions to be used with respect to such
benefits,
(iii) uniform format to be used in the policy with respect to such
benefits, and
(iv) other standards to meet the additional requirements imposed by
the amendments made by the Omnibus Budget Reconciliation Act of 1990,
(such limitations, language, definitions, format, and standards
referred to collectively in this subsection as ''NAIC standards''),
subsection (g)(2)(A) of this section shall be applied in each State,
effective for policies issued to policyholders on and after the date
specified in subparagraph (C), as if the reference to the Model
Regulation adopted on June 6, 1979, included a reference to the NAIC
standards.
(B) If the Association does not promulgate NAIC standards within the
9-month period specified in subparagraph (A), the Secretary shall
promulgate, not later than 9 months after the end of such period,
limitations, language, definitions, format, and standards described in
clauses (i) through (iv) of such subparagraph (in this subsection
referred to collectively as ''Federal standards'') and subsection
(g)(2)(A) of this section shall be applied in each State, effective for
policies issued to policyholders on and after the date specified in
subparagraph (C), as if the reference to the Model Regulation adopted on
June 6, 1979, included a reference to the Federal standards.
(C)(i) Subject to clause (ii), the date specified in this
subparagraph for a State is the date the State adopts the NAIC standards
or the Federal standards or 1 year after the date the Association or the
Secretary first adopts such standards, whichever is earlier.
(ii) In the case of a State which the Secretary identifies, in
consultation with the Association, as --
(I) requiring State legislation (other than legislation appropriating
funds) in order for medicare supplemental policies to meet the NAIC or
Federal standards, but
(II) having a legislature which is not scheduled to meet in 1992 in a
legislative session in which such legislation may be considered,
the date specified in this subparagraph is the first day of the first
calendar quarter beginning after the close of the first legislative
session of the State legislature that begins on or after January 1,
1992. For purposes of the previous sentence, in the case of a State
that has a 2-year legislative session, each year of such session shall
be deemed to be a separate regular session of the State legislature.
(D) In promulgating standards under this paragraph, the Association
or Secretary shall consult with a working group composed of
representatives of issuers of medicare supplemental policies, consumer
groups, medicare beneficiaries, and other qualified individuals. Such
representatives shall be selected in a manner so as to assure balanced
representation among the interested groups.
(E) If benefits (including deductibles and coinsurance) under this
subchapter are changed and the Secretary determines, in consultation
with the Association, that changes in the NAIC or Federal standards are
needed to reflect such changes, the preceding provisions of this
paragraph shall apply to the modification of standards previously
established in the same manner as they applied to the original
establishment of such standards.
(2) The benefits under the NAIC or Federal standards shall provide --
(A) for such groups or packages of benefits as may be appropriate
taking into account the considerations specified in paragraph (3) and
the requirements of the succeeding subparagraphs;
(B) for identification of a core group of basic benefits common to
all policies, /9/ and
(C) that, subject to paragraph (5)(B), the total number of different
benefit packages (counting the core group of basic benefits described in
subparagraph (B) and each other combination of benefits that may be
offered as a separate benefit package) that may be established in all
the States and by all issuers shall not exceed 10.
(3) The benefits under paragraph (2) shall, to the extent possible --
(A) provide for benefits that offer consumers the ability to purchase
the benefits that are available in the market as of November 5, 1990;
and
(B) balance the objectives of (i) simplifying the market to
facilitate comparisons among policies, (ii) avoiding adverse selection,
(iii) providing consumer choice, (iv) providing market stability, and
(v) promoting competition.
(4)(A)(i) Except as provided in subparagraph (B), no State with a
regulatory program approved under subsection (b)(1) of this section may
provide for or permit the grouping of benefits (or language or format
with respect to such benefits) under a medicare supplemental policy
unless such grouping meets the applicable standards.
(ii) Except as provided in subparagraph (B), the Secretary may not
provide for or permit the grouping of benefits (or language or format
with respect to such benefits) under a medicare supplemental policy
seeking approval by the Secretary unless such grouping meets the
applicable standards.
(B) With the approval of the State (in the case of a policy issued in
a State with an approved regulatory program) or the Secretary (in the
case of any other policy), the issuer of a medicare supplemental policy
may offer new or innovative benefits in addition to the benefits
provided in a policy that otherwise complies with the applicable
standards. Any such new or innovative benefits may include benefits
that are not otherwise available and are cost-effective and shall be
offered in a manner which is consistent with the goal of simplification
of medicare supplemental policies.
(5)(A) Except as provided in subparagraph (B), this subsection shall
not be construed as preventing a State from restricting the groups of
benefits that may be offered in medicare supplemental policies in the
State.
(B) A State with a regulatory program approved under subsection
(b)(1) of this section may not restrict under subparagraph (A) the
offering of a medicare supplemental policy consisting only of the core
group of benefits described in paragraph (2)(B).
(6) The Secretary may waive the application of standards in regard to
the limitation of benefits described in paragraph (4) in those States
that on November 5, 1990, had in place an alternative simplification
program.
(7) This subsection shall not be construed as preventing an issuer of
a medicare supplemental policy who otherwise meets the requirements of
this section from providing, through an arrangement with a vendor, for
discounts from that vendor to policyholder /10/ or certificateholders
for the purchase of items or services not covered under its medicare
supplemental policies.
(8) Any person who sells or issues a medicare supplemental policy,
after the effective date of the NAIC or Federal standards with respect
to the policy, in violation of the previous requirements of this
subsection is subject to a civil money penalty of not to exceed $25,000
(or $15,000 in the case of a seller who is not an issuer of a policy)
for each such violation. The provisions of section 1320a-7a of this
title (other than the first sentence of subsection (a) and other than
subsection (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.
(9)(A) Anyone who sells a medicare supplemental policy to an
individual shall make available for sale to the individual a medicare
supplemental policy with only the core group of basic benefits
(described in paragraph (2)(B)).
(B) Anyone who sells a medicare supplemental policy to an individual
shall provide the individual, before the sale of the policy, an outline
of coverage which describes the benefits under the policy. Such outline
shall be on a standard form approved by the State regulatory program or
the Secretary (as the case may be) consistent with the NAIC or Federal
standards under this subsection.
(C) Whoever sells a medicare supplemental policy in violation of this
paragraph is subject to a civil money penalty of not to exceed $25,000
(or $15,000 in the case of a seller who is not the issuer of the policy)
for each such violation. The provisions of section 1320a-7a of this
title (other than the first sentence of subsection (a) and other than
subsection (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.
(10) No penalty may be imposed under paragraph (8) or (9) in the case
of a seller who is not the issuer of a policy until the Secretary has
published a list of the groups of benefit packages that may be sold or
issued consistent with this subsection.
(q) Guaranteed renewal of policies; termination; suspension
The requirements of this subsection are as follows:
(1) Each medicare supplemental policy shall be guaranteed renewable
and --
(A) the issuer may not cancel or nonrenew the policy solely on the
ground of health status of the individual; and
(B) the issuer shall not cancel or nonrenew the policy for any reason
other than nonpayment of premium or material misrepresentation.
(2) If the medicare supplemental policy is terminated by the group
policyholder and is not replaced as provided under paragraph (2), /11/
the issuer shall offer certificateholders an individual medicare
supplemental policy which (at the option of the certificateholder) --
(A) provides for continuation of the benefits contained in the group
policy, or
(B) provides for such benefits as otherwise meets /12/ the
requirements of this section.
(3) If an individual is a certificateholder in a group medicare
supplemental policy and the individual terminates membership in the
group, the issuer shall --
(A) offer the certificateholder the conversion opportunity described
in paragraph (2), or
(B) at the option of the group policyholder, offer the
certificateholder continuation of coverage under the group policy.
(4) If a group medicare supplemental policy is replaced by another
group medicare supplemental policy purchased by the same policyholder,
the succeeding issuer shall offer coverage to all persons covered under
the old group policy on its date of termination. Coverage under the new
group policy shall not result in any exclusion for preexisting
conditions that would have been covered under the group policy being
replaced.
(5)(A) Each medicare supplemental policy shall provide that benefits
and premiums under the policy shall be suspended at the request of the
policyholder for the period (not to exceed 24 months) in which the
policyholder has applied for and is determined to be entitled to medical
assistance under subchapter XIX of this chapter, but only if the
policyholder notifies the issuer of such policy within 90 days after the
date the individual becomes entitled to such assistance. If such
suspension occurs and if the policyholder or certificate holder loses
entitlement to such medical assistance, such policy shall be
automatically reinstituted (effective as of the date of termination of
such entitlement) under terms described in subsection (n)(6)(A)(ii) of
this section as of the termination of such entitlement if the
policyholder provides notice of loss of such entitlement within 90 days
after the date of such loss.
(B) Nothing in this section shall be construed as affecting the
authority of a State, under subchapter XIX of this chapter, to purchase
a medicare supplemental policy for an individual otherwise entitled to
assistance under such subchapter.
(C) Any person who issues a medicare supplemental policy and fails to
comply with the requirements of this paragraph is subject to a civil
money penalty of not to exceed $25,000 for each such violation. The
provisions of section 1320a-7a of this title (other than the first
sentence of subsection (a) and other than subsection (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.
(r) Required ratio of aggregate benefits to aggregate premiums
(1) A medicare supplemental policy may not be issued or sold in any
State unless --
(A) the policy can be expected (as estimated for the entire period
for which rates are computed to provide coverage, on the basis of
incurred claims experience and earned premiums for such periods and in
accordance with a uniform methodology, including uniform reporting
standards, developed by the National Association of Insurance
Commissioners, /13/ to return to policyholders in the form of aggregate
benefits provided under the policy, at least 75 percent of the aggregate
amount of premiums collected in the case of group policies and at least
65 percent in the case of individual policies; and
(B) the issuer of the policy provides for the issuance of a
proportional refund, or a credit against future premiums of a
proportional amount, based on the premium paid and in accordance with
paragraph (2), of the amount of premiums received necessary to assure
that the ratio of aggregate benefits provided to the aggregate premiums
collected (net of such refunds or credits) complies with the expectation
required under subparagraph (A).
For purposes of applying subparagraph (A) only, policies issued as a
result of solicitations of individuals through the mails or by mass
media advertising (including both print and broadcast advertising) shall
be deemed to be individual policies.
(2)(A) Paragraph (1)(B) shall be applied with respect to each type of
policy by policy number. Paragraph (1)(B) shall not apply to a policy
with respect to the first 2 years in which it is in effect. The
Comptroller General, in consultation with the National Association of
Insurance Commissioners, shall submit to Congress a report containing
recommendations on adjustments in the percentages under paragraph (1)(A)
that may be appropriate in order to apply paragraph (1)(B) to the first
2 years in which policies are effective.
(B) A refund or credit required under paragraph (1)(B) shall be made
to each policyholder insured under the applicable policy as of the last
day of the year involved.
(C) Such a refund or credit shall include interest from the end of
the policy year involved until the date of the refund or credit at a
rate as specified by the Secretary for this purpose from time to time
which is not less than the average rate of interest for 13-week Treasury
notes.
(D) For purposes of this paragraph and paragraph (1)(B), refunds or
credits against premiums due shall be made, with respect to a policy
year, not later than the third quarter of the succeeding policy year.
(3) The provisions of this subsection do not preempt a State from
requiring a higher percentage than that specified in paragraph (1)(A).
(4) The Secretary shall submit in February of each year (beginning
with 1993) a report to the Committees on Energy and Commerce and Ways
and Means of the House of Representatives and the Committee on Finance
of the Senate on loss-ratios under medicare supplemental policies and
the use of sanctions, such as a required rebate or credit or the
disllowance /14/ of premium increases, for policies that fail to meet
the requirements of this subsection (relating to loss-ratios). Such
report shall include a list of the policies that failed to comply with
such loss-ratio requirements or other requirements of this section.
(5)(A) The Comptroller General shall periodically, not less often
than once every 3 years, perform audits with respect to the compliance
of medicare supplemental policies with the loss ratio requirements of
this subsection and shall report the results of such audits to the State
involved and to the Secretary.
(B) The Secretary may independently perform such compliance audits.
(6)(A) A person who issues a policy in violation of the loss ratio
requirements of this subsection is subject to a civil money penalty of
not to exceed $25,000 for each such violation. The provisions of
section 1320a-7a of this title (other than the first sentence of
subsection (a) and other than subsection (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.
(B) Each issuer of a policy subject to the requirements of paragraph
(1)(B) shall be liable to policyholders for credits required under such
paragraph.
(s) Coverage for pre-existing conditions
(1) If a medicare supplemental policy replaces another medicare
supplemental policy, the issuer of the replacing policy shall waive any
time periods applicable to preexisting conditions, waiting period,
elimination periods and probationary periods in the new medicare
supplemental policy for similar benefits to the extent such time was
spent under the original policy.
(2)(A) The issuer of a medicare supplemental policy may not deny or
condition the issuance or effectiveness of a medicare supplemental
policy, or discriminate in the pricing of the policy, because of health
status, claims experience, receipt of health care, or medical condition
for which an application is submitted during the 6 month period
beginning with the first month in which the individual (who is 65 years
of age or older) first is enrolled for benefits under part B of this
subchapter.
(B) Subject to subparagraph (C), subparagraph (A) shall not be
construed as preventing the exclusion of benefits under a policy, during
its first 6 months, based on a pre-existing condition for which the
policyholder received treatment or was otherwise diagnosed during the 6
months before it became effective.
(C) If a medicare supplemental policy or certificate replaces another
such policy or certificate which has been in effect for 6 months or
longer, the replacing policy may not provide any time period applicable
to pre-existing conditions, waiting periods, elimination periods, and
probationary periods in the new policy or certificate for similar
benefits.
(3) Any issuer of a medicare supplemental policy that fails to meet
the requirements of paragraphs (1) and (2) is subject to a civil money
penalty of not to exceed $5,000 for each such failure. The provisions
of section 1320a-7a of this title (other than the first sentence of
subsection (a) and other than subsection (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.
(t) Medicare select policies
(1) If a policy meets the NAIC Model Standards and otherwise complies
with the requirements of this section except that benefits under the
policy are restricted to items and services furnished by certain
entities (or reduced benefits are provided when items or services are
furnished by other entities), the policy shall nevertheless be treated
as meeting those standards if --
(A) full benefits are provided for items and services furnished
through a network of entities which have entered into contracts with the
issuer of the policy;
(B) full benefits are provided for items and services furnished by
other entities if the services are medically necessary and immediately
required because of an unforeseen illness, injury, or condition and it
is not reasonable given the circumstances to obtain the services through
the network;
(C) the network offers sufficient access;
(D) the issuer of the policy has arrangements for an ongoing quality
assurance program for items and services furnished through the network;
(E)(i) the issuer of the policy provides to each enrollee at the time
of enrollment an explanation of (I) the restrictions on payment under
the policy for services furnished other than by or through the network,
(II) out of area coverage under the policy, (III) the policy's coverage
of emergency services and urgently needed care, and (IV) the
availability of a policy through the entity that meets the NAIC
standards without reference to this subsection and the premium charged
for such policy, and
(ii) each enrollee prior to enrollment acknowledges receipt of the
explanation provided under clause (i); and
(F) the issuer of the policy makes available to individuals, in
addition to the policy described in this subsection, any policy
(otherwise offered by the issuer to individuals in the State) that meets
the NAIC standards and other requirements of this section without
reference to this subsection.
(2) If the Secretary determines that an issuer of a policy approved
under paragraph (1) --
(A) fails substantially to provide medically necessary items and
services to enrollees seeking such items and services through the
issuer's network, if the failure has adversely affected (or has
substantial likelihood of adversely affecting) the individual,
(B) imposes premiums on enrollees in excess of the premiums approved
by the State,
(C) acts to expel an enrollee for reasons other than nonpayment of
premiums, or
(D) does not provide the explanation required under paragraph
(1)(E)(i) or does not obtain the acknowledgment required under paragraph
(1)(E)(ii),
is /15/ subject to a civil money penalty in an amount not to exceed
$25,000 for each such violation. The provisions of section 1320a-7a of
this title (other than the first sentence of subsection (a) and other
than subsection (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.
(3) The Secretary may enter into a contract with an entity whose
policy has been certified under paragraph (1) or has been approved by a
State under subsection (b)(1)(H) of this section to determine whether
items and services (furnished to individuals entitled to benefits under
this subchapter and under that policy) are not allowable under section
1395y(a)(1) of this title. Payments to the entity shall be in such
amounts as the Secretary may determine, taking into account estimated
savings under contracts with carriers and fiscal intermediaries and
other factors that the Secretary finds appropriate. Paragraph (1), the
first sentence of paragraph (2)(A), paragraph (2)(B), paragraph (3)(C),
paragraph (3)(D), and paragraph (3)(E) of section 1395u(b) of this title
shall apply to the entity.
(Aug. 14, 1935, ch. 531, title XVIII, 1882, as added June 9, 1980,
Pub. L. 96-265, title V, 507(a), 94 Stat. 476, and amended H. Res.
549, Mar. 25, 1980; Aug. 18, 1987, Pub. L. 100-93, 13, 101 Stat. 697;
Dec. 22, 1987, Pub. L. 100-203, title IV, 4081(b), 101 Stat. 1330-127;
July 1, 1988, Pub. L. 100-360, title II, 221(a)-(f), title IV,
411(i)(1)(B), (C), 428(b), 102 Stat. 742-746, 788, 817; Dec. 13, 1989,
Pub. L. 101-234, title II, 203(a)(1), 103 Stat. 1982; Nov. 5, 1990,
Pub. L. 101-508, title IV, 4027(4207)(k)(1), 4351(a), 4352,
4353(a)-(d)(1), 4354(a), (b), 4355(a)-(c), 4356(a), 4357(a), 4358(a),
(b)(1), (2), 104 Stat. 1388-124, 1388-125, 1388-129, 1388-130, 1388-132,
1388-134 to 1388-137.)
Parts A and B of this subchapter, referred to in subsecs. (d)(3)(A),
(B)(i) and (s)(2)(A), are classified to sections 1395c et seq. and
1395j et seq., respectively, of this title.
The Medicare Catastrophic Coverage Act of 1988, referred to in
subsecs. (k)(1)(A), (2)(A) and (l)(4)(A), is Pub. L. 100-360, July 1,
1988, 102 Stat. 683, as amended. For complete classification of this
Act to the Code, see Short Title of 1988 Amendment note set out under
section 1305 of this title and Tables.
The Medicare Catastrophic Coverage Repeal Act of 1989, referred to in
subsecs. (m)(1)(A), (2)(A) and (n)(2)(A), (5)(A), is Pub. L. 101-234,
Dec. 13, 1989, 103 Stat. 1979. For complete classification of this Act
to the Code, see Short Title of 1989 Amendment note set out under
section 1305 of this title and Tables.
The Omnibus Budget Reconciliation Act of 1990, referred to in subsec.
(p)(1)(A)(iv), is Pub. L. 101-508, Nov. 5, 1990, 104 Stat. 1388. For
complete classification of this Act to the Code, see Tables.
1990 -- Pub. L. 101-508, 4353(a)(1), struck out ''Voluntary'' at
beginning of section catchline.
Subsec. (a). Pub. L. 101-508, 4353(a)(2), designated existing
provisions as par. (1) and added par. (2).
Pub. L. 101-508, 4027(4207)(k)(1), struck out ''(k)(4),'' after
''subsections (k)(3),'' in third sentence.
Subsec. (b)(1). Pub. L. 101-508, 4353(c)(5), inserted at end ''The
report required under subsection (F) shall include information on loss
ratios of policies sold in the State, frequency and types of instances
in which policies approved by the State fail to meet the standards of
this paragraph, actions taken by the State to bring such policies into
compliance, and information regarding State programs implementing
consumer protection provisions, and such further information as the
Secretary in consultation with the National Association of Insurance
Commissioners, may specify.''
Pub. L. 101-508, 4353(b)(1), (2), substituted ''the Secretary'' for
''Supplemental Health Insurance Panel (established under paragraph
(2))'' in introductory provisions and for ''the Panel'' in concluding
provisions.
Pub. L. 101-508, 4027(4207)(k)(1), which directed the amendment of
third sentence of par. (1) by striking out ''(k)(4),'' was executed by
making the deletion after ''subsections (k)(3),'' in concluding
provisions to reflect the probable intent of Congress.
Subsec. (b)(1)(A). Pub. L. 101-508, 4358(b)(2)(A), inserted before
semicolon at end '', except as otherwise provided by subparagraph (H)''.
Pub. L. 101-508, 4353(b)(3), inserted ''and enforcement'' after
''application''.
Subsec. (b)(1)(B). Pub. L. 101-508, 4351(a)(1), substituted
''through (5)'' for ''through (4)''.
Subsec. (b)(1)(C). Pub. L. 101-508, 4355(b), substituted for
semicolon at end '', and that a copy of each such policy, the most
recent premium for each such policy, and a listing of the ratio of
benefits provided to premiums collected for the most recent 3-year
period for each such policy issued or sold in the State is maintained
and made available to interested persons;''.
Subsec. (b)(1)(D). Pub. L. 101-508, 4353(b)(3), inserted ''and
enforcement'' after ''application''.
Subsec. (b)(1)(F). Pub. L. 101-508, 4353(c)(1)-(3), added subpar.
(F).
Subsec. (b)(1)(G). Pub. L. 101-508, 4355(c), which directed
amendment of par. (1) by adding at the end thereof a new subpar. (G),
was executed by adding the new subpar. (G) immediately after subpar.
(F) to reflect the probable intent of Congress.
Subsec. (b)(1)(H). Pub. L. 101-508, 4358(b)(2)(B)-(D), added subpar.
(H).
Subsec. (b)(2). Pub. L. 101-508, 4353(b)(4), amended par. (2)
generally. Prior to amendment, par. (2) read as follows:
''(A) There is hereby established a panel (hereinafter in this
section referred to as the 'Panel') to be known as the Supplemental
Health Insurance Panel. The Panel shall consist of the Secretary, who
shall serve as the Chairman, and four State commissioners or
superintendents of insurance, who shall be appointed by the Secretary
and serve at his pleasure. Such members shall first be appointed not
later than December 31, 1980.
''(B) A majority of the members of the Panel shall constitute a
quorum, but a lesser number may conduct hearings.
''(C) The Secretary shall provide such technical, secretarial,
clerical, and other assistance as the Panel may require.
''(D) There are authorized to be appropriated such sums as may be
necessary to carry out this paragraph.
''(E) Members of the Panel shall be allowed, while away from their
homes or regular places of business in the performance of services for
the Panel, travel expenses (including per diem in lieu of subsistence)
in the same manner as persons employed intermittently in the Government
service are allowed expenses under section 5703 of title 5.''
Subsec. (c). Pub. L. 101-508, 4357(a)(1), inserted ''or the
requirement described in subsection (s) of this section'' after
''paragraph (3)'' in introductory provisions.
Pub. L. 101-508, 4355(a)(2), struck out at end ''For purposes of
paragraph (2), policies issued as a result of solicitations of
individuals through the mails or by mass media advertising (including
both print and broadcast advertising) shall be deemed to be individual
policies.''
Subsec. (c)(1). Pub. L. 101-508, 4358(b)(1), inserted before
semicolon at end ''(except as otherwise provided by subsection (t) of
this section)''.
Subsec. (c)(2). Pub. L. 101-508, 4355(a)(1), amended par. (2)
generally. Prior to amendment, par. (2) read as follows: ''can be
expected (as estimated for the entire period for which rates are
computed to provide coverage, on the basis of incurred claims experience
and earned premiums for such period and in accordance with accepted
actuarial principles and practices) to return to policyholders in the
form of aggregate benefits provided under the policy, at least 75
percent of the aggregate amount of premiums collected in the case of
group policies and at least 60 percent of the aggregate amount of
premiums collected in the case of individual policies;''.
Subsec. (c)(5). Pub. L. 101-508, 4351(a)(2), added par. (5).
Subsec. (d)(3)(A). Pub. L. 101-508, 4354(a)(1), substituted ''It is
unlawful for a person to sell or issue'' for ''Whoever knowingly
sells'', ''duplicates health benefits'' for ''substantially duplicates
health benefits'', ''. Whoever violates the previous sentence shall be
fined'' for '', shall be fined'', ''(other than this subchapter or
subchapter XIX of this chapter)'' for ''(other than this subchapter)'',
and ''$25,000 (or $15,000 in the case of a person other than the issuer
of the policy)'' for ''$5,000'' and inserted at end ''A seller (who is
not the issuer of a health insurance policy) shall not be considered to
violate the previous sentence if the policy is sold in compliance with
subparagraph (B) and the statement under such subparagraph indicates on
its face that the sale of the policy will not duplicate health benefits
to which the individual is otherwise entitled. This subsection shall
not apply to such a seller until such date as the Secretary publishes a
list of the standardized benefit packages that may be offered consistent
with subsection (p) of this section.''
Subsec. (d)(3)(B). Pub. L. 101-508, 4354(a)(2), amended subpar. (B)
generally. Prior to amendment, subpar. (B) read as follows: ''For
purposes of this paragraph, benefits which are payable to or on behalf
of an individual without regard to other health benefit coverage of such
individual, shall not be considered as duplicative.''
Subsec. (d)(4)(B). Pub. L. 101-508, 4353(d)(1), struck out at end
''For purposes of this paragraph, a medicare supplemental policy shall
be deemed to be approved by the commissioner or superintendent of
insurance of a State if --
''(i) the policy has been certified by the Secretary pursuant to
subsection (c) of this section or was issued in a State with an approved
regulatory program (as defined in subsection (g)(2)(B) of this section);
''(ii) the policy has been approved by the commissioners or
superintendents of insurance in States in which more than 30 percent of
such policies are sold; or
''(iii) the State has in effect a law which the commissioner or
superintendent of insurance of the State has determined gives him the
authority to review, and to approve, or effectively bar from sale in the
State, such policy;
except that such a policy shall not be deemed to be approved by a
State commissioner or superintendent of insurance if the State notifies
the Secretary that such policy has been submitted for approval to the
State and has been specifically disapproved by such State after
providing appropriate notice and opportunity for hearing pursuant to the
procedures (if any) of the State.''
Subsec. (g)(1). Pub. L. 101-508, 4356(a), inserted before period at
end of first sentence ''and does not include a policy or plan of a
health maintenance organization or other direct service organization
which offers benefits under this subchapter, including such services
under a contract under under section 1395mm of this title or an
agreement under section 1395l of this title''.
Subsecs. (o), (p). Pub. L. 101-508, 4351(a)(3), added subsecs. (o)
and (p).
Subsec. (q). Pub. L. 101-508, 4352, added subsec. (q).
Subsec. (q)(5). Pub. L. 101-508, 4354(b), added par. (5).
Subsec. (r). Pub. L. 101-508, 4355(a)(3), added subsec. (r).
Subsec. (s). Pub. L. 101-508, 4357(a)(2), added subsec. (s).
Subsec. (t). Pub. L. 101-508, 4358(a), added subsec. (t).
1989 -- Subsecs. (a), (b)(1). Pub. L. 101-234, 203(a)(1)(A),
substituted ''subsections (k)(3), (k)(4), (m), and (n) of this section''
for ''subsection (k)(3) of this section''.
Subsec. (k)(1)(A). Pub. L. 101-234, 203(a)(1)(B)(i), inserted
''except as provided in subsection (m) of this section,'' before
''subsection (g)(2)(A)''.
Subsec. (k)(3). Pub. L. 101-234, 203(a)(1)(B)(ii), substituted
''subsections (l), (m), and (n) of this section'' for ''subsection (l)
of this section''.
Subsecs. (m), (n). Pub. L. 101-234, 203(a)(1)(C), added subsecs.
(m) and (n).
1988 -- Subsec. (a). Pub. L. 100-360, 221(d)(1), substituted
''Subject to subsection (k)(3) of this section, such'' for ''Such''.
Subsec. (b)(1). Pub. L. 100-360, 221(d)(2), substituted ''(subject
to subsection (k)(3) of this section, for so long as'' for ''(for so
long as'' in concluding provisions.
Subsec. (b)(1)(B). Pub. L. 100-360, 221(a)(1), substituted ''through
(4)'' for ''and (3)''.
Subsec. (b)(1)(C). Pub. L. 100-360, 221(b)(2), (3), added subpar.
(C). Former subpar. (C) redesignated (D).
Pub. L. 100-360, 221(b)(1), substituted ''(A), (B), and (C)'' for
''(A) and (B)''.
Subsec. (b)(1)(D), (E). Pub. L. 100-360, 221(b)(2), redesignated
former subpars. (C) and (D) as (D) and (E), respectively.
Subsec. (b)(2)(A). Pub. L. 100-360, 221(f), substituted ''appointed
by the Secretary'' for ''appointed by the President''.
Subsec. (b)(3). Pub. L. 100-360, 221(e), added par. (3).
Subsec. (c). Pub. L. 100-360, 411(i)(1)(B), added Pub. L. 100-203,
4081(b)(2)(A), see 1987 Amendment note below.
Subsec. (c)(3). Pub. L. 100-360, 411(i)(1)(B), redesignated Pub. L.
100-203, 4081(b)(2)(B)-(D), see 1987 Amendment note below.
Subsec. (c)(3)(A). Pub. L. 100-360, 411(i)(1)(C)(i), substituted
''claim form'' for ''claims form'' in two places and ''such notice'' for
''such claims form''.
Subsec. (c)(3)(B)(i). Pub. L. 100-360, 411(i)(1)(C)(ii), inserted
''under the policy'' after ''payment determination''.
Subsec. (c)(3)(B)(ii). Pub. L. 100-360, 411(i)(1)(C)(iii),
substituted ''payment covered by such policy'' for ''appropriate
payment''.
Subsec. (c)(4). Pub. L. 100-360, 221(a)(2), added par. (4).
Subsec. (d). Pub. L. 100-360, 428(b)(1), substituted ''shall be
fined under title 18 or imprisoned not more than 5 years, or both, and,
in addition to or in lieu of such a criminal penalty, is subject to a
civil money penalty of not to exceed $5,000 for each such prohibited
act'' for ''shall be guilty of a felony and upon conviction thereof
shall be fined not more than $25,000 or imprisoned for not more than 5
years, or both'' in pars. (1), (2), (3)(A), and (4)(A).
Subsec. (d)(5). Pub. L. 100-360, 428(b)(2), added par. (5).
Subsec. (e). Pub. L. 100-360, 221(c), designated existing provision
as par. (1) and added pars. (2) and (3).
Subsecs. (k), (l). Pub. L. 100-360, 221(d)(3), added subsecs. (k)
and (l).
1987 -- Subsec. (b)(1)(B). Pub. L. 100-203, 4081(b)(1)(A), amended
subpar. (B) generally. Prior to amendment, subpar. (B) read as
follows: ''includes a requirement equal to or more stringent than the
requirement described in subsection (c)(2) of this section; and''.
Subsec. (b)(1)(D). Pub. L. 100-203, 4081(b)(1)(B), (C), added
subpar. (D).
Subsec. (c). Pub. L. 100-203, 4081(b)(2)(A), as added by Pub. L.
100-360, 411(i)(1)(B), inserted ''(or, with respect to paragraph (3),
the issuer of the policy)'' in introductory provisions.
Subsec. (c)(3). Pub. L. 100-203, 4081(b)(2)(B)-(D), formerly
4081(b)(2), as redesignated by Pub. L. 100-360, 411(i)(1)(B), added
par. (3).
Subsec. (d)(1). Pub. L. 100-93 substituted ''knowingly and
willfully'' for ''knowingly or willfully''.
The name of the Committee on Interstate and Foreign Commerce of the
House of Representatives was changed to Committee on Energy and Commerce
immediately prior to noon on Jan. 3, 1981, by House Resolution 549,
Ninety-sixth Congress, Mar. 25, 1980.
Section 4353(d)(2) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply to
policies mailed, or caused to be mailed, on and after July 1, 1991.''
Section 4354(c) of Pub. L. 101-508 provided that: ''The amendments
made by this section (amending this section) shall apply to policies
issued or sold more than 1 year after the date of the enactment of this
Act (Nov. 5, 1990).''
Section 4355(d) of Pub. L. 101-508 provided that: ''The amendments
made by this section (amending this section) shall apply to policies
sold or issued more than 1 year after the date of the enactment of this
Act (Nov. 5, 1990).''
Section 4356(b) of Pub. L. 101-508 provided that: ''The amendment
made by subsection (a) (amending this section) shall take effect on the
date of the enactment of this Act (Nov. 5, 1990).''
Section 4357(b) of Pub. L. 101-508 provided that: ''The amendments
made by subsection (a) (amending this section) shall take effect 1 year
after the date of the enactment of this Act (Nov. 5, 1990).''
Amendment by section 4358(a), (b)(1), (2) of Pub. L. 101-508 only
applicable in 15 States (as determined by Secretary of Health and Human
Services) and only during 3-year period beginning with 1992, see section
4358(c) of Pub. L. 101-508, set out as a note under section 1320c-3 of
this title.
Section 203(e) of Pub. L. 101-234 provided that: ''The provisions
of this section (amending this section, enacting provisions set out as
notes under sections 1395b-2 and 1395mm of this title, and amending
provisions set out as a note under this section) shall take effect
January 1, 1990, except that the amendment made by subsection (d)
(amending provisions set out as an Effective Date of 1988 Amendment note
under this section) shall be effective as if included in the enactment
of MCCA (Pub. L. 100-360).''
Section 221(g) of Pub. L. 100-360, as amended by Pub. L. 100-485,
title VI, 608(d)(12), Oct. 13, 1988, 102 Stat. 2415; Pub. L.
101-234, title II, 203(d), Dec. 13, 1989, 103 Stat. 1985, provided
that:
''(1) Except as provided in paragraphs (2) and (3), the amendments
made by this section (amending this section) shall take effect on the
date of the enactment of this Act (July 1, 1988).
''(2) The amendments made by subsections (a) and (b) (amending this
section) shall become effective on the date specified in subsection
(k)(1)(B) or (k)(2)(B) of section 1882 of the Social Security Act
(subsec. (k)(1)(B) or (k)(2)(B) of this section) (as added by subsection
(d) of this section).
''(3) The amendment made by subsection (e) (amending this section)
shall apply to medicare supplemental policies as of January 1, 1989,
with respect to advertising used on or after such date.
''(4) The Secretary of Health and Human Services shall provide for
the reappointment of members to the Supplemental Health Insurance Panel
(under section 1882(b)(2) of the Social Security Act (subsec. (b)(2) of
this section)) by not later than 90 days after the date of the enactment
of this Act (July 1, 1988).''
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(i)(1)(B), (C) 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.
Amendment by section 428(b) of Pub. L. 100-360 effective July 1,
1988, and applicable only with respect to violations occurring on or
after such date, see section 428(c) of Pub. L. 100-360, set out as an
Effective Date note under section 1320b-10 of this title.
Section 4081(c)(2) of Pub. L. 100-203, as amended by Pub. L.
100-360, title IV, 411(i)(1)(D), (E), July 1, 1988, 102 Stat. 788;
Pub. L. 100-485, title VI, 608(d)(24)(A), Oct. 13, 1988, 102 Stat.
2421, provided that:
''(A) The amendments made by subsection (b) (amending this section)
shall apply to medicare supplemental policies as of January 1, 1989 (or,
if applicable, the date established under subparagraph (B)).
''(B) In the case of a State which the Secretary of Health and Human
Services identifies as --
''(i) requiring State legislation (other than legislation
appropriating funds) in order for medicare supplemental policies to be
changed to meet the requirements of section 1882(c)(3) of the Social
Security Act (subsec. (c)(3) of this section), and
''(ii) having a legislature which is not scheduled to meet in 1988 in
a legislative session in which such legislation may be considered or
which has not enacted such legislation before July 1, 1988,
the date specified in this subparagraph is the first day of the first
calendar quarter beginning after the close of the first legislative
session of the State legislature that begins on or after January 1,
1989, and in which legislation described in clause (i) may be
considered.''
Amendment by Pub. L. 100-93 effective at end of fourteen-day period
beginning Aug. 18, 1987, and inapplicable to administrative proceedings
commenced before end of such period, see section 15(a) of Pub. L.
100-93, set out as a note under section 1320a-7 of this title.
Section 507(b) of Pub. L. 96-265 provided that: ''The amendment
made by this section (enacting this section) shall become effective on
the date of the enactment of this Act (June 9, 1980), except that the
provisions of paragraph (4) of section 1882(d) of the Social Security
Act (subsec. (d)(4) of this section) (as added by this section) shall
become effective on July 1, 1982.''
Section 4358(d) of Pub. L. 101-508 provided that: ''The Secretary
of Health and Human Services shall conduct an evaluation of the
amendments made by this section (amending this section and section
1320c-3 of this title) and shall report to Congress on such evaluation
by not later than January 1, 1995.''
/1/ So in original.
/2/ So in original. Probably should be ''subparagraph''.
/3/ So in original. The word ''and'' probably should not appear.
/4/ So in original. The comma probably should not appear.
/5/ So in original. Probably should be ''issuer's''.
/6/ So in original.
/7/ So in original. Probably should be ''supplemental''.
/8/ So in original. Probably should be ''Secretary''.
/9/ So in original. The comma probably should be a semicolon.
/10/ So in original. Probably should be ''policyholders''.
/11/ So in original. Probably should be paragraph ''(4),''.
/12/ So in original. Probably should be ''meet''.
/13/ So in original. The comma probably should be a closing
parenthesis.
/14/ So in original. Probably should be ''disallowance''.
/15/ So in original. Probably should be ''the insurer is''.
42 USC 1395tt. Hospital providers of extended care services
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Hospital facility agreements; reasonable costs of services
(1) Any hospital (other than a hospital which has in effect a waiver
under subparagraph (A) of the last sentence of section 1395x(e) of this
title) which has an agreement under section 1395cc of this title may
(subject to subsection (b) of this section) enter into an agreement with
the Secretary under which its inpatient hospital facilities may be used
for the furnishing of services of the type which, if furnished by a
skilled nursing facility, would constitute extended care services.
(2)(A) Notwithstanding any other provision of this subchapter,
payment to any hospital for services furnished under an agreement
entered into under this section shall be based upon the reasonable cost
of the services as determined under subparagraph (B).
(B)(i) The reasonable cost of the services consists of the reasonable
cost of routine services (determined under clause (ii)) and the
reasonable cost of ancillary services (determined under clause (iii)).
(ii) The reasonable cost of routine services furnished during any
calendar year by a hospital under an agreement under this section is
equal to the product of --
(I) the number of patient-days during the year for which the services
were furnished, and
(II) the average reasonable cost per patient-day, such average
reasonable cost per patient-day being the average rate per patient-day
paid for routine services during the most recent year for which cost
reporting data are available with respect to such services (increased in
a compounded manner by the applicable increase for payments for routine
service costs of skilled nursing facilities under section 1395yy of this
title for subsequent cost reporting periods and up to and including such
calendar year) under this subchapter to freestanding skilled nursing
facilities in the region (as defined in section 1395ww(d)(2)(D) of this
title) in which the facility is located.
(iii) The reasonable cost of ancillary services shall be determined
in the same manner as the reasonable cost of ancillary services provided
for inpatient hospital services.
(b) Eligible facilities
The Secretary may not enter into an agreement under this section with
any hospital unless --
(1) except as provided under subsection (g) of this section, the
hospital is located in a rural area and has less than 100 beds, and
(2) the hospital has been granted a certificate of need for the
provision of long-term care services from the State health planning and
development agency (designated under section 300m /1/ of this title) for
the State in which the hospital is located.
(c) Terms and conditions of facility agreements
An agreement with a hospital under this section shall, except as
otherwise provided under regulations of the Secretary, be of the same
duration and subject to termination on the same conditions as are
agreements with skilled nursing facilities under section 1395cc of this
title and shall, where not inconsistent with any provision of this
section, impose the same duties, responsibilities, conditions, and
limitations, as those imposed under such agreements entered into under
section 1395cc of this title; except that no such agreement with any
hospital shall be in effect for any period during which the hospital
does not have in effect an agreement under section 1395cc of this title,
or during which there is in effect for the hospital a waiver under
subparagraph (A) of the last sentence of section 1395x(e) of this title.
A hospital with respect to which an agreement under this section has
been terminated shall not be eligible to enter into a new agreement
until a two-year period has elapsed from the termination date.
(d) Post-hospital extended care services
(1) Any agreement with a hospital under this section shall provide
that payment for services will be made only for services for which
payment would be made as post-hospital extended care services if those
services had been furnished by a skilled nursing facility under an
agreement entered into under section 1395cc of this title; and any
individual who is furnished services, for which payment may be made
under an agreement under this section, shall, for purposes of this
subchapter (other than this section), be deemed to have received
post-hospital extended care services in like manner and to the same
extent as if the services furnished to him had been post-hospital
extended care services furnished by a skilled nursing facility under an
agreement under section 1395cc of this title.
(2)(A) Any agreement under this section with a hospital with more
than 49 beds shall provide that no payment may be made for extended care
services which are furnished to an extended care patient after the end
of the 5-day period (excluding weekends and holidays) beginning on an
availability date for a skilled nursing facility, unless the patient's
physician certifies, within such 5-day period, that the transfer of that
patient to that facility is not medically appropriate on the
availability date. The Secretary shall prescribe regulations to provide
for notice by skilled nursing facilities of availability dates to
hospitals which have agreements under this section and which are located
within the same geographic region (as defined by the Secretary).
(B) In this paragraph:
(i) The term ''availability date'' means, with respect to an extended
care patient at a hospital, any date on which a bed is available for the
patient in a skilled nursing facility located within the geographic
region in which the hospital is located.
(ii) The term ''extended care patient'' means an individual being
furnished extended care services at a hospital pursuant to an agreement
with the Secretary under this section.
(3) In the case of an agreement for a cost reporting period under
this section with a hospital that has more than 49 beds, payment may not
be made in the period for patient-days of extended care services that
exceed 15 percent of the product of the number of days in the period and
the average number of licensed beds in the hospital in the period,
except that such payment shall continue to be made in the period for
those patients who are receiving extended care services at the time the
hospital reaches the limit specified in this paragraph.
(e) Reimbursement for routine hospital services
During a period for which a hospital has in effect an agreement under
this section, in order to allocate routine costs between hospital and
long-term care services for purposes of determining payment for
inpatient hospital services, the total reimbursement due for routine
services from all classes of long-term care patients (including this
subchapter, subchapter XIX of this chapter, and private pay patients)
shall be subtracted from the hospital's total routine costs before
calculations are made to determine this subchapter reimbursement for
routine hospital services.
(f) Conditions applicable to skilled nursing facilities
A hospital which enters into an agreement with the Secretary under
this section shall be required to meet those conditions applicable to
skilled nursing facilities relating to discharge planning and the social
services function (and staffing requirements to satisfy it) which are
promulgated by the Secretary under section 1395i-3 of this title.
Services furnished by such a hospital which would otherwise constitute
post-hospital extended care services if furnished by a skilled nursing
facility shall be subject to the same requirements applicable to such
services when furnished by a skilled nursing facility except for those
requirements the Secretary determines are inappropriate in the case of
these services being furnished by a hospital under this section.
(g) Agreements on demonstration basis
The Secretary may enter into an agreement under this section on a
demonstration basis with any hospital which does not meet the
requirement of subsection (b)(1) of this section, if the hospital
otherwise meets the requirements of this section.
(Aug. 14, 1935, ch. 531, title XVIII, 1883, as added Dec. 5, 1980,
Pub. L. 96-499, title IX, 904(a)(1), 94 Stat. 2615, and amended Dec.
22, 1987, Pub. L. 100-203, title IV, 4005(b)(1), (2), 4201(d)(3), 101
Stat. 1330-48, as amended July 1, 1988, Pub. L. 100-360, title IV,
411(l)(1)(C), as added Oct. 13, 1988, Pub. L. 100-485, title VI,
608(d)(27)(B), 102 Stat. 2422; July 1, 1988, Pub. L. 100-360, title I,
104(d)(6), title IV, 411(b)(4)(D), 102 Stat. 689, 770; Dec. 13,
1989, Pub. L. 101-234, title I, 101(a), 103 Stat. 1979; Nov. 5, 1990,
Pub. L. 101-508, title IV, 4008(j)(1), 104 Stat. 1388-51.)
Section 300m of this title, referred to in subsec. (b)(2), was
repealed effective Jan. 1, 1987, by Pub. L. 99-660, title VII,
701(a), Nov. 14, 1986, 100 Stat. 3799.
1990 -- Subsec. (a)(2)(B)(ii)(II). Pub. L. 101-508 substituted ''the
most recent year for which cost reporting data are available with
respect to such services (increased in a compounded manner by the
applicable increase for payments for routine service costs of skilled
nursing facilities under section 1395yy of this title for subsequent
cost reporting periods and up to and including such calendar year) under
this subchapter to freestanding skilled nursing facilities in the region
(as defined in section 1395ww(d)(2)(D) of this title) in which the
facility is located.'' for ''the previous calendar year'' and all that
follows through the period, which was executed by making the
substitution for ''the previous calendar year under the State plan (of
the State in which the hospital is located) under subchapter XIX of this
chapter to skilled nursing facilities located in the State and which
meet the requirements specified in section 1396a(a)(28) of this title,
or, in the case of a hospital located in a State which does not have
such a State plan, the average rate per patient-day paid for routine
services during the previous calendar year under this subchapter to
skilled nursing facilities in such State.''
1989 -- Subsecs. (d)(1), (f). Pub. L. 101-234 repealed Pub. L.
100-360, 104(d)(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. (d)(1). Pub. L. 100-360, 104(d)(6), struck out
''post-hospital'' before ''extended care services'' wherever appearing.
Subsec. (d)(3). Pub. L. 100-360, 411(b)(4)(D), inserted before
period at end '', except that such payment shall continue to be made in
the period for those patients who are receiving extended care services
at the time the hospital reaches the limit specified in this
paragraph''.
Subsec. (f). Pub. L. 100-360, 411(l)(1)(C), as added by Pub. L.
100-485, 608(d)(27)(B), added Pub. L. 100-203, 4201(d)(3), see 1987
Amendment note below.
Pub. L. 100-360, 104(d)(6), struck out ''post-hospital'' before
''extended care services''.
1987 -- Subsec. (b)(1). Pub. L. 100-203, 4005(b)(1), substituted
''100'' for ''50''.
Subsec. (d). Pub. L. 100-203, 4005(b)(2), designated existing
provisions as par. (1) and added pars. (2) and (3).
Subsec. (f). Pub. L. 100-203, 4201(d)(3), as added by Pub. L.
100-360, 411(l)(1)(C), and Pub. L. 100-485, 608(d)(27)(B),
substituted ''section 1395i-3'' for ''section 1395x(j)(15)''.
Section 4008(j)(4) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply to
services furnished on or after October 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.
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 104(d)(6) 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)(4)(D), (l)(1)(C) 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.
Section 4005(b)(4) of Pub. L. 100-203 provided that: ''The
amendments made by paragraphs (1) and (2) (amending this section) shall
apply to agreements under section 1883 of the Social Security Act (this
section) entered into after March 31, 1988.''
Amendment by section 4201(d)(3) of Pub. L. 100-203 applicable to
services furnished on or after Oct. 1, 1990, without regard to whether
regulations to implement such amendment are promulgated by such date,
except as otherwise specifically provided in section 1395i-3 of this
title, see section 4204(a) of Pub. L. 100-203, as amended, set out as
an Effective Date note under section 1395i-3 of this title.
Section 904(d) of Pub. L. 96-499 provided that: ''The amendments
made by this section (enacting this section and section 1396l of this
title) shall become effective on the date on which final regulations,
promulgated by the Secretary to implement such amendments, are first
issued; and those regulations shall be issued not later than the first
day of the sixth month following the month in which this Act is enacted
(December 1980).''
Section 4008(j)(2) of Pub. L. 101-508 provided that: ''If, as a
result of the amendment made by paragraph (1) (amending this section),
the reasonable cost of routine services furnished by a hospital during a
calendar year (as determined under section 1883 of the Social Security
Act (this section)) is less than the reasonable cost of such services
determined under such section for the previous calendar year, the
reasonable cost of such services furnished by the hospital during the
calendar year under such section shall be equal to the reasonable cost
determined under such section for the previous calendar year.''
Section 4008(j)(3) of Pub. L. 101-508 provided that:
''Notwithstanding the requirement of section 1883(b)(1) of the Social
Security Act (subsec. (b)(1) of this section) that the Secretary may not
enter into an agreement under such section with a hospital that is not
located in a rural area, any agreement entered into under such section
on or before May 1, 1987, between the Secretary of Health and Human
Services and a hospital located in an urban area shall remain in
effect.''
Section 4005(b)(3) of Pub. L. 100-203, as amended by Pub. L.
100-360, title IV, 411(b)(4)(E), as added by Pub. L. 100-485, title
VI, 608(d)(18)(C), Oct. 13, 1988, 102 Stat. 2419, provided that:
''The Secretary of Health and Human Services shall report to Congress,
not later than February 1, 1989, concerning --
''(A) the proportion of admissions to hospitals for extended care
services under section 1883 of the Social Security Act (this section)
which are denied or approved by a peer review organization under section
1154(a)(1) of such Act (section 1320c-3(a)(1) of this title), and
''(B) recommendations for methods of encouraging hospitals that --
''(i) have a low occupancy rate,
''(ii) are eligible to enter (but have not entered) into an agreement
under section 1883 of such Act, and
''(iii) are located in areas with a need for additional providers of
extended care services,
to enter into such agreements.''
Section 904(c) of Pub. L. 96-499 provided that: ''Within three
years after the date of the enactment of this Act (Dec. 5, 1980), the
Secretary of Health and Human Services shall submit to the Congress a
report evaluating the programs established by the amendments made by
this section (enacting this section and section 1396l of this title) and
shall include in such report an analysis of --
''(1) the extent and effect of the agreements under such programs on
availability and effective and economical provision of long-term care
services,
''(2) whether such programs should be continued,
''(3) the results of any demonstration projects conducted under such
programs, and
''(4) whether eligibility to participate in such programs should be
extended to other hospitals, regardless of bed size or geographic
location, where there is a shortage of long-term care beds.''
/1/ See References in Text note below.
42 USC 1395uu. Payments to promote closing or conversion of
underutilized hospital facilities
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Transitional allowances; procedures applicable
Any hospital may file an application with the Secretary (in such form
and including such data and information as the Secretary may require)
for establishment of a transitional allowance under this subchapter with
respect to the closing or conversion of an underutilized hospital
facility. The Secretary also may establish procedures, consistent with
this section, by which a hospital, before undergoing an actual closure
or conversion of a hospital facility, can have a determination made as
to whether or not it will be eligible for a transitional allowance under
this section with respect to such closure or conversion.
(b) Allowable costs as transitional allowances; findings and
determinations
If the Secretary finds, after consideration of an application under
subsection (a) of this section, that --
(1) the hospital's closure or conversion --
(A) is formally initiated after September 30, 1981,
(B) is expected to benefit the program under this subchapter by (i)
eliminating excess bed capacity, (ii) discontinuing an underutilized
service for which there are adequate alternative sources, or (iii)
substituting for the underutilized service some other service which is
needed in the area, and
(C) is consistent with the findings of an appropriate health planning
agency and with any applicable State program for reduction in the number
of hospital beds in the State, and
(2) in the case of a complete closure of a hospital --
(A) the hospital is a private nonprofit hospital or a local
governmental hospital, and
(B) the closure is not for replacement of the hospital,
the Secretary may include as an allowable cost in the hospital's
reasonable cost (for the purpose of making payments to the hospital
under this subchapter) an amount (in this section referred to as a
''transitional allowance''), as provided in subsection (c) of this
section.
(c) Factors determinative of transitional allowance
(1) Each transitional allowance established shall be reasonably
related to the prior or prospective use of the facility involved under
this subchapter and shall recognize --
(A) in the case of a facility conversion or closure (other than a
complete closure of a hospital) --
(i) in the case of a private nonprofit or local governmental
hospital, that portion of the hospital's costs attributable to capital
assets of the facility which have been taken into account in determining
reasonable cost for purposes of determining the amount of payment to the
hospital under this subchapter, and
(ii) in the case of any hospital, transitional operating cost
increases related to the conversion or closure to the extent that such
operating costs exceed amounts ordinarily reimbursable under this
subchapter; and
(B) in the case of complete closure of a hospital, the outstanding
portion of actual debt obligations previously recognized as reasonable
for purposes of reimbursement under this subchapter, less any salvage
value of the hospital.
(2) A transitional allowance shall be for a period (not to exceed 20
years) specified by the Secretary, except that, in the case of a
complete closure described in paragraph (1)(B), the Secretary may
provide for a lump-sum allowance where the Secretary determines that
such a one-time allowance is more efficient and economical.
(3) A transitional allowance shall take effect on a date established
by the Secretary, but not earlier than the date of completion of the
closure or conversion concerned.
(4) A transitional allowance shall not be considered in applying the
limits to costs recognized as reasonable pursuant to the third sentence
of subparagraph (A) and subparagraph (L)(i) of section 1395x(v)(1) of
this title, or in determining whether the reasonable cost exceeds the
customary charges for a service for purposes of determining the amount
to be paid to a provider pursuant to sections 1395f(b) and 1395l(a)(2)
of this title.
(d) Hearing to review determination
A hospital dissatisfied with a determination of the Secretary on its
application under this section may obtain an informal or formal hearing,
at the discretion of the Secretary, by filing (in such form and within
such time period as the Secretary establishes) a request for such a
hearing. The Secretary shall make a final determination on such
application within 30 days after the last day of such hearing.
(Aug. 14, 1935, ch. 531, title XVIII, 1884, as added Aug. 13, 1981,
Pub. L. 97-35, title XXI, 2101(a)((1)), 95 Stat. 785, and amended Sept.
3, 1982, Pub. L. 97-248, title I, 128(a)(6), 96 Stat. 366.)
1982 -- Subsec. (d). Pub. L. 97-248 redesignated second subsec.
(c), relating to hearing to review determination, as subsec. (d).
Amendment by Pub. L. 97-248 effective as if originally included as
part of this section as this section was enacted by the Omnibus Budget
Reconciliation Act of 1981, Pub. L. 97-35, see section 128(e)(2) of
Pub. L. 97-248, set out as a note under section 1395x of this title.
Section 2101(c) of Pub. L. 97-35 provided that: ''The amendment
made by subsection (a) (enacting this section and amending section 1396b
of this title) shall apply only to services furnished by a hospital
during any accounting year beginning on or after October 1, 1981.''
Pub. L. 98-369, div. B, title III, 2353, July 18, 1984, 98 Stat.
1099, provided that:
''(a) The Secretary of Health and Human Services shall carry out a
study and report to the Congress on the modifications required in
section 1884 of the Social Security Act (this section) in order to
conform the closure and conversion program authorized in that section to
the prospective payment system under section 1886(d) of such Act
(section 1395ww(d) of this title), so as to provide assistance to
hospitals which may have particular problems in converting facilities
(or parts thereof) from acute care to less intensive care or in closing
facilities (or parts thereof). The report shall include recommendations
as to how, and whether, implementation of section 1884 (this section) as
modified may result in reductions in total hospital inpatient costs and
total expenditures under title XVIII of the Social Security Act (this
subchapter). The Secretary shall submit the report prior to March 31,
1985.
''(b) During the period prior to March 31, 1985, and notwithstanding
section 2101(c) of the Omnibus Budget Reconciliation Act of 1981 (Public
Law 97-35) (set out above), the Secretary shall not implement section
1884 of the Social Security Act (this section).''
Section 2101(b) of Pub. L. 97-35 provided that:
''(1) Notwithstanding section 1884(a) of the Social Security Act
(subsec. (a) of this section), the Secretary of Health and Human
Services may not establish under such section transitional allowances
with respect to more than 50 hospitals prior to January 1, 1984.
''(2) The Secretary of Health and Human Services shall evaluate the
effectiveness of the program of transitional allowances established
under section 1884 of the Social Security Act (this section) and shall,
not later than January 1, 1983, report to the Congress on such
evaluation and include in such report such recommendations for such
legislative changes as he deems appropriate.''
42 USC 1395vv. Withholding payments from certain medicaid providers
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Adjustments by Secretary
The Secretary may adjust, in accordance with this section, payments
under parts A and B to any institution which has in effect an agreement
with the Secretary under section 1395cc of this title, and any person
who has accepted payment on the basis of an assignment under section
1395u(b)(3)(B)(ii) of this title, where such institution or person --
(1) has (or previously had) in effect an agreement with a State
agency to furnish medical care and services under a State plan approved
under subchapter XIX of this chapter, and
(2) from which (or from whom) such State agency (A) has been unable
to recover overpayments made under the State plan, or (B) has been
unable to collect the information necessary to enable it to determine
the amount (if any) of the overpayments made to such institution or
person under the State plan.
(b) Implementing regulations; notice, opportunity to be heard, etc.
The Secretary shall by regulation provide procedures for
implementation of this section, which procedures shall --
(1) assure that the authority under this section is exercised only on
behalf of a State agency which demonstrates to the Secretary's
satisfaction that it has provided adequate notice of a determination or
of a need for information, and an opportunity to appeal such
determination or to provide such information,
(2) determine the amount of the payment to which the institution or
person would otherwise be entitled under this subchapter which shall be
treated as a setoff against overpayments under subchapter XIX of this
chapter, and
(3) assure the restoration to the institution or person of amounts
withheld under this section which are ultimately determined to be in
excess of overpayments under subchapter XIX of this chapter and to which
the institution or person would otherwise be entitled under this
subchapter.
(c) Payment to States of amounts recovered
Notwithstanding any other provision of this chapter, from the trust
funds established under sections 1395i and 1395t of this title, as
appropriate, the Secretary shall pay to the appropriate State agency
amounts recovered under this section to offset the State agency's
overpayment under subchapter XIX of this chapter. Such payments shall
be accounted for by the State agency as recoveries of overpayments under
the State plan.
(Aug. 14, 1935, ch. 531, title XVIII, 1885, as added Aug. 13, 1981,
Pub. L. 97-35, title XXI, 2104, 95 Stat. 788.)
42 USC 1395ww. Payments to hospitals for inpatient hospital services
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Determination of costs for inpatient hospital services;
limitations; exemptions; ''operating costs of inpatient hospital
services'' defined
(1)(A)(i) The Secretary, in determining the amount of the payments
that may be made under this subchapter with respect to operating costs
of inpatient hospital services (as defined in paragraph (4)) shall not
recognize as reasonable (in the efficient delivery of health services)
costs for the provision of such services by a hospital for a cost
reporting period to the extent such costs exceed the applicable
percentage (as determined under clause (ii)) of the average of such
costs for all hospitals in the same grouping as such hospital for
comparable time periods.
(ii) For purposes of clause (i), the applicable percentage for
hospital cost reporting periods beginning --
(I) on or after October 1, 1982, and before October 1, 1983, is 120
percent;
(II) on or after October 1, 1983, and before October 1, 1984, is 115
percent; and
(III) on or after October 1, 1984, is 110 percent.
(B)(i) For purposes of subparagraph (A) the Secretary shall establish
case mix indexes for all short-term hospitals, and shall set limits for
each hospital based upon the general mix of types of medical cases with
respect to which such hospital provides services for which payment may
be made under this subchapter.
(ii) The Secretary shall set such limits for a cost reporting period
of a hospital --
(I) by updating available data for a previous period to the immediate
preceding cost reporting period by the estimated average rate of change
of hospital costs industry-wide, and
(II) by projecting for the cost reporting period by the applicable
percentage increase (as defined in subsection (b)(3)(B) of this
section).
(C) The limitation established under subparagraph (A) for any
hospital shall in no event be lower than the allowable operating costs
of inpatient hospital services (as defined in paragraph (4)) recognized
under this subchapter for such hospital for such hospital's last cost
reporting period prior to the hospital's first cost reporting period for
which this section is in effect.
(D) Subparagraph (A) shall not apply to cost reporting periods
beginning on or after October 1, 1983.
(2) The Secretary shall provide for such exemptions from, and
exceptions and adjustments to, the limitation established under
paragraph (1)(A) as he deems appropriate, including those which he deems
necessary to take into account --
(A) the special needs of sole community hospitals, of new hospitals,
of risk based health maintenance organizations, and of hospitals which
provide atypical services or essential community services, and to take
into account extraordinary circumstances beyond the hospital's control,
medical and paramedical education costs, significantly fluctuating
population in the service area of the hospital, and unusual labor costs,
(B) the special needs of psychiatric hospitals and of public or other
hospitals that serve a significantly disproportionate number of patients
who have low income or are entitled to benefits under part A of this
subchapter, and
(C) a decrease in the inpatient hospital services that a hospital
provides and that are customarily provided directly by similar hospitals
which results in a significant distortion in the operating costs of
inpatient hospital services.
(3) The limitation established under paragraph (1)(A) shall not apply
with respect to any hospital which --
(A) is located outside of a standard metropolitan statistical area,
and
(B)(i) has less than 50 beds, and
(ii) was in operation and had less than 50 beds on September 3, 1982.
(4) For purposes of this section, the term ''operating costs of
inpatient hospital services'' includes all routine operating costs,
ancillary service operating costs, and special care unit operating costs
with respect to inpatient hospital services as such costs are determined
on an average per admission or per discharge basis (as determined by the
Secretary), and includes the costs of all services for which payment may
be made under this subchapter that are provided by the hospital (or by
an entity wholly owned or operated by the hospital) to the patient
during the 3 days immediately preceding the date of the patient's
admission if such services are diagnostic services (including clinical
diagnostic laboratory tests) or are other services related to the
admission (as defined by the Secretary). Such term does not include
costs of approved educational activities, a return on equity capital,
or, /1/ other capital-related costs (as defined by the Secretary for
periods before October 1, 1987).
(b) Computation of payment; definitions; exemptions; adjustments
(1) Notwithstanding section 1395f(b) of this title but subject to the
provisions of section 1395e of this title, if the operating costs of
inpatient hospital services (as defined in subsection (a)(4) of this
section) of a hospital (other than a subsection (d) hospital, as defined
in subsection (d)(1)(B) of this section) for a cost reporting period
subject to this paragraph --
(A) are less than or equal to the target amount (as defined in
paragraph (3)) for that hospital for that period, the amount of the
payment with respect to such operating costs payable under part A of
this subchapter on a per discharge or per admission basis (as the case
may be) shall be equal to the amount of such operating costs, plus --
(i) 50 percent of the amount by which the target amount exceeds the
amount of the operating costs, or
(ii) 5 percent of the target amount,
whichever is less; or
(B) are greater than the target amount, the amount of the payment
with respect to such operating costs payable under part A of this
subchapter on a per discharge or per admission basis (as the case may
be) shall be equal to (i) the target amount, plus (ii) in the case of
cost reporting periods beginning on or after October 1, 1991, an
additional amount equal to 50 percent of the amount by which the
operating costs exceed the target amount (except that such additional
amount may not exceed 10 percent of the target amount) after any
exceptions or adjustments are made to such target amount for the cost
reporting period;
except that in no case may the amount payable under this subchapter
(other than on the basis of a DRG prospective payment rate determined
under subsection (d) of this section) with respect to operating costs of
inpatient hospital services exceed the maximum amount payable with
respect to such costs pursuant to subsection (a) of this section.
(2) Repealed. Pub. L. 98-21, title VI, 601(b)(4), Apr. 20, 1983,
97 Stat. 150.
(3)(A) Except as provided in subparagraphs (C), (D), and (E), for
purposes of this subsection, the term ''target amount'' means, with
respect to a hospital for a particular 12-month cost reporting period --
(i) in the case of the first such reporting period for which this
subsection is in effect, the allowable operating costs of inpatient
hospital services (as defined in subsection (a)(4) of this section)
recognized under this subchapter for such hospital for the preceding
12-month cost reporting period, and
(ii) in the case of a later reporting period, the target amount for
the preceding 12-month cost reporting period,
increased by the applicable percentage increase under subparagraph
(B) for that particular cost reporting period.
(B)(i) For purposes of subsection (d) of this section for discharges
occurring during a fiscal year, the ''applicable percentage increase''
shall be --
(I) for fiscal year 1986, 1/2 percent,
(II) for fiscal year 1987, 1.15 percent,
(III) for fiscal year 1988, 3.0 percent for hospitals located in a
rural area, 1.5 percent for hospitals located in a large urban area (as
defined in subsection (d)(2)(D) of this section), and 1.0 percent for
hospitals located in other urban areas,
(IV) for fiscal year 1989, the market basket percentage increase
minus 1.5 percent for hospitals located in a rural area, the market
basket percentage increase minus 2.0 percentage points for hospitals
located in a large urban area, and the market basket percentage increase
minus 2.5 percentage points for hospitals located in other urban areas,
(V) for fiscal year 1990, the market basket percentage increase plus
4.22 percentage points for hospitals located in a rural area, the market
basket percentage increase plus 0.12 percentage points for hospitals
located in a large urban area, and the market basket percentage increase
minus 0.53 percentage points for hospitals located in other urban areas,
(VI) for fiscal year 1991, the market basket percentage increase
minus 2.0 percentage points for hospitals in a large urban or other
urban area, and the market basket percentage increase minus 0.7
percentage point for hospitals located in a rural area,
(VII) for fiscal year 1992, the market basket percentage increase
minus 1.6 percentage points for hospitals in a large urban or other
urban area, and the market basket percentage increase minus 0.6
percentage point for hospitals located in a rural area,
(VIII) for fiscal year 1993, the market basket percentage increase
minus 1.55 percentage point for hospitals in a large urban or other
urban area, and the market basket percentage increase minus 0.55 /2/
for hospitals located in a rural area,
(IX) for fiscal year 1994, the market basket percentage increase for
hospitals located in a large urban or other urban area, and the market
basket percentage increase plus 1.5 percentage points for hospitals
located in a rural area,
(X) for fiscal year 1995, the market basket percentage increase for
hospitals located in a large urban or other urban area, and such
percentage increase for hospitals located in a rural area as will
provide for the average standardized amount determined under subsection
(d)(3)(A) of this section for hospitals located in a rural area being
equal to such average standardized amount for hospitals located in an
urban area (other than a large urban area), and
(XI) for fiscal year 1996 and each subsequent fiscal year, the market
basket percentage increase for hospitals in all areas.
(ii) For purposes of subparagraphs (A), (C), (D), and (E), the
''applicable percentage increase'' for 12-month cost reporting periods
beginning during --
(I) fiscal year 1986, is 0.5 percent,
(II) fiscal year 1987, is 1.15 percent,
(III) fiscal year 1988, is the market basket percentage increase
minus 2.0 percentage points, and
(IV) subsequent fiscal years is the market basket percentage
increase.
(iii) For purposes of this subparagraph, the term ''market basket
percentage increase'' means, with respect to cost reporting periods and
discharges occurring in a fiscal year, the percentage, estimated by the
Secretary before the beginning of the period or fiscal year, by which
the cost of the mix of goods and services (including personnel costs but
excluding nonoperating costs) comprising routine, ancillary, and special
care unit inpatient hospital services, based on an index of
appropriately weighted indicators of changes in wages and prices which
are representative of the mix of goods and services included in such
inpatient hospital services, for the period or fiscal year will exceed
the cost of such mix of goods and services for the preceding 12-month
cost reporting period or fiscal year.
(C) In the case of a hospital that is a sole community hospital (as
defined in subsection (d)(5)(D)(iii) of this section), the term ''target
amount'' means --
(i) with respect to the first 12-month cost reporting period in which
this subparagraph is applied to the hospital --
(I) the allowable operating costs of inpatient hospital services (as
defined in subsection (a)(4) of this section) recognized under this
subchapter for the hospital for the 12-month cost reporting period (in
this subparagraph referred to as the ''base cost reporting period'')
preceding the first cost reporting period for which this subsection was
in effect with respect to such hospital, increased (in a compounded
manner) by --
(II) the applicable percentage increases applied to such hospital
under this paragraph for cost reporting periods after the base cost
reporting period and up to and including such first 12-month cost
reporting period, or
(ii) with respect to a later cost reporting period, the target amount
for the preceding 12-month cost reporting period, increased by the
applicable percentage increase under subparagraph (B)(ii) for discharges
occurring in the fiscal year in which that later cost reporting period
begins.
There shall be substituted for the base cost reporting period
described in clause (i) a hospital's cost reporting period (if any)
beginning during fiscal year 1987 if such substitution results in an
increase in the target amount for the hospital.
(D) For cost reporting periods ending on or before March 31, 1993, in
the case of a hospital that is a medicare-dependent, small rural
hospital (as defined in subsection (d)(5)(G) of this section), the term
''target amount'' means --
(i) with respect to the first 12-month cost reporting period in which
this subparagraph is applied to the hospital --
(I) the allowable operating costs of inpatient hospital services (as
defined in subsection (a)(4) of this section) recognized under this
subchapter for the hospital for the 12-month cost reporting period (in
this subparagraph referred to as the ''base cost reporting period'')
preceding the first cost reporting period for which this subsection was
in effect with respect to such hospital, increased (in a compounded
manner) by --
(II) the applicable percentage increases applied to such hospital
under this paragraph for cost reporting periods after the base cost
reporting period and up to and including such first 12-month cost
reporting period, or
(ii) with respect to a later cost reporting period, the target amount
for the preceding 12-month cost reporting period, increased by the
applicable percentage increase under subparagraph (B)(ii) for discharges
occurring in the fiscal year in which that later cost reporting period
begins.
There shall be substituted for the base cost reporting period
described in clause (i) a hospital's cost reporting period (if any)
beginning during fiscal year 1987 if such substitution results in an
increase in the target amount for the hospital.
(E) In the case of a hospital described in clause (v) of subsection
(d)(1)(B) of this section, the term ''target amount'' means --
(i) with respect to the first 12-month cost reporting period in which
this subparagraph is applied to the hospital --
(I) the allowable operating costs of inpatient hospital services (as
defined in subsection (a)(4) of this section) recognized under this
subchapter for the hospital for the 12-month cost reporting period (in
this subparagraph referred to as the ''base cost reporting period'')
preceding the first cost reporting period for which this subsection was
in effect with respect to such hospital, increased (in a compounded
manner) by --
(II) the sum of the applicable percentage increases applied to such
hospital under this paragraph for cost reporting periods after the base
cost reporting period and up to and including such first 12-month cost
reporting period, or
(ii) with respect to a later cost reporting period, the target amount
for the preceding 12-month cost reporting period, increased by the
applicable percentage increase under subparagraph (B)(ii) for that later
cost reporting period.
There shall be substituted for the base cost reporting period
described in clause (i) a hospital's cost reporting period (if any)
beginning during fiscal year 1987 if such substitution results in an
increase in the target amount for the hospital.
(4)(A) The Secretary shall provide for an exemption from, or an
exception and adjustment to, the method under this subsection for
determining the amount of payment to a hospital where events beyond the
hospital's control or extraordinary circumstances, including changes in
the case mix of such hospital, create a distortion in the increase in
costs for a cost reporting period (including any distortion in the costs
for the base period against which such increase is measured). The
Secretary may provide for such other exemptions from, and exceptions and
adjustments to, such method as the Secretary deems appropriate,
including the assignment of a new base period which is more
representative, as determined by the Secretary, of the reasonable and
necessary cost of inpatient services and including those which he deems
necessary to take into account a decrease in the inpatient hospital
services that a hospital provides and that are customarily provided
directly by similar hospitals which results in a significant distortion
in the operating costs of inpatient hospital services. The Secretary
shall announce a decision on any request for an exemption, exception, or
adjustment under this paragraph not later than 180 days after receiving
a completed application from the intermediary for such exemption,
exception, or adjustment, and shall include in such decision a detailed
explanation of the grounds on which such request was approved or denied.
(B) In determining under subparagraph (A) whether to assign a new
base period which is more representative of the reasonable and necessary
cost to a hospital of providing inpatient services, the Secretary shall
take into consideration --
(i) changes in applicable technologies and medical practices, or
differences in the severity of illness among patients, that increase the
hospital's costs;
(ii) whether increases in wages and wage-related costs for hospitals
located in the geographic area in which the hospital is located exceed
the average of the increases in such costs paid by hospitals in the
United States; and
(iii) such other factors as the Secretary considers appropriate in
determining increases in the hospital's costs of providing inpatient
services.
(C) Paragraph (1) shall not apply to payment of hospitals which is
otherwise determined under paragraph (3) of section 1395f(b) of this
title.
(5) In the case of any hospital having any cost reporting period of
other than a 12-month period, the Secretary shall determine the 12-month
period which shall be used for purposes of this section.
(6) In the case of any hospital which becomes subject to the taxes
under section 3111 of the Internal Revenue Code of 1986, with respect to
any or all of its employees, for part or all of a cost reporting period,
and was not subject to such taxes with respect to any or all of its
employees for all or part of the 12-month base cost reporting period
referred to in subsection (b)(3)(A)(i) of this section, the Secretary
shall provide for an adjustment by increasing the base period amount
described in such subsection for such hospital by an amount equal to the
amount of such taxes which would have been paid or accrued by such
hospital for such base period if such hospital had been subject to such
taxes for all of such base period with respect to all its employees,
minus the amount of any such taxes actually paid or accrued for such
base period.
(c) Payment in accordance with State hospital reimbursement control
system; amount of payment; discontinuance of payments
(1) The Secretary may provide, in his discretion, that payment with
respect to services provided by a hospital in a State may be made in
accordance with a hospital reimbursement control system in a State,
rather than in accordance with the other provisions of this title, if
the chief executive officer of the State requests such treatment and if
--
(A) the Secretary determines that the system, if approved under this
subsection, will apply (i) to substantially all non-Federal acute care
hospitals (as defined by the Secretary) in the State and (ii) to the
review of at least 75 percent of all revenues or expenses in the State
for inpatient hospital services and of revenues or expenses for
inpatient hospital services provided under the State's plan approved
under subchapter XIX of this chapter;
(B) the Secretary has been provided satisfactory assurances as to the
equitable treatment under the system of all entities (including Federal
and State programs) that pay hospitals for inpatient hospital services,
of hospital employees, and of hospital patients;
(C) the Secretary has been provided satisfactory assurances that
under the system, over 36-month periods (the first such period beginning
with the first month in which this subsection applies to that system in
the State), the amount of payments made under this subchapter under such
system will not exceed the amount of payments which would otherwise have
been made under this subchapter not using such system;
(D) the Secretary determines that the system will not preclude an
eligible organization (as defined in section 1395mm(b) of this title)
from negotiating directly with hospitals with respect to the
organization's rate of payment for inpatient hospital services; and
(E) the Secretary determines that the system requires hospitals to
meet the requirement of section 1395cc(a)(1)(G) of this title and the
system provides for the exclusion of certain costs in accordance with
section 1395y(a)(14) of this title (except for such waivers thereof as
the Secretary provides by regulation).
The Secretary cannot deny the application of a State under this
subsection on the ground that the State's hospital reimbursement control
system is based on a payment methodology other than on the basis of a
diagnosis-related group or on the ground that the amount of payments
made under this subchapter under such system must be less than the
amount of payments which would otherwise have been made under this
subchapter not using such system. If the Secretary determines that the
conditions described in subparagraph (C) are based on maintaining
payment amounts at no more than a specified percentage increase above
the payment amounts in a base period, the State has the option of
applying such test (for inpatient hospital services under part A of this
subchapter) on an aggregate payment basis or on the basis of the amount
of payment per inpatient discharge or admission. If the Secretary
determines that the conditions described in subparagraph (C) are based
on maintaining aggregate payment amounts below a national average
percentage increase in total payments under part A of this subchapter
for inpatient hospital services, the Secretary cannot deny the
application of a State under this subsection on the ground that the
State's rate of increase in such payments for such services must be less
than such national average rate of increase.
(2) In determining under paragraph (1)(C) the amount of payment which
would otherwise have been made under this subchapter for a State, the
Secretary may provide for appropriate adjustment of such amount to take
into account previous reductions effected in the amount of payments made
under this subchapter in the State due to the operation of the hospital
reimbursement control system in the State if the system has resulted in
an aggregate rate of increase in operating costs of inpatient hospital
services (as defined in subsection (a)(4) of this section) under this
subchapter for hospitals in the State which is less than the aggregate
rate of increase in such costs under this subchapter for hospitals in
the United States.
(3) The Secretary shall discontinue payments under a system described
in paragraph (1) if the Secretary --
(A) determines that the system no longer meets the requirements of
subparagraphs (A), (D), and (E) of paragraph (1) and, if applicable, the
requirements of paragraph (5), or
(B) has reason to believe that the assurances described in
subparagraph (B) or (C) of paragraph (1) (or, if applicable, in
paragraph (5)) are not being (or will not be) met.
(4) The Secretary shall approve the request of a State under
paragraph (1) with respect to a hospital reimbursement control system if
--
(A) the requirements of subparagraphs (A), (B), (C), (D), and (E) of
paragraph (1) have been met with respect to the system, and
(B) with respect to that system a waiver of certain requirements of
this subchapter has been approved on or before (and which is in effect
as of) April 20, 1983, pursuant to section 1395b-1(a) of this title or
section 222(a) of the Social Security Amendments of 1972.
With respect to a State system described in this paragraph, the
Secretary shall judge the effectiveness of such system on the basis of
its rate of increase or inflation in inpatient hospital payments for
individuals under this subchapter, as compared to the national rate of
increase or inflation for such payments, with the State retaining the
option to have the test applied on the basis of the aggregate payments
under the State system as compared to aggregate payments which would
have been made under the national system since October 1, 1984, to the
most recent date for which annual data are available.
(5) The Secretary shall approve the request of a State under
paragraph (1) with respect to a hospital reimbursement control system if
--
(A) the requirements of subparagraphs (A), (B), (C), (D), and (E) of
paragraph (1) have been met with respect to the system;
(B) the Secretary determines that the system --
(i) is operated directly by the State or by an entity designated
pursuant to State law,
(ii) provides for payment of hospitals covered under the system under
a methodology (which sets forth exceptions and adjustments, as well as
any method for changes in the methodology) by which rates or amounts to
be paid for hospital services during a specified period are established
under the system prior to the defined rate period, and
(iii) hospitals covered under the system will make such reports (in
lieu of cost and other reports, identified by the Secretary, otherwise
required under this subchapter) as the Secretary may require in order to
properly monitor assurances provided under this subsection;
(C) the State has provided the Secretary with satisfactory assurances
that operation of the system will not result in any change in hospital
admission practices which result in --
(i) a significant reduction in the proportion of patients (receiving
hospital services covered under the system) who have no third-party
coverage and who are unable to pay for hospital services,
(ii) a significant reduction in the proportion of individuals
admitted to hospitals for inpatient hospital services for which payment
is (or is likely to be) less than the anticipated charges for or costs
of such services,
(iii) the refusal to admit patients who would be expected to require
unusually costly or prolonged treatment for reasons other than those
related to the appropriateness of the care available at the hospital, or
(iv) the refusal to provide emergency services to any person who is
in need of emergency services if the hospital provides such services;
(D) any change by the State in the system which has the effect of
materially reducing payments to hospitals can only take effect upon 60
days notice to the Secretary and to the hospitals the payment to which
is likely to be materially affected by the change; and
(E) the State has provided the Secretary with satisfactory assurances
that in the development of the system the State has consulted with local
governmental officials concerning the impact of the system on public
hospitals.
The Secretary shall respond to requests of States under this
paragraph within 60 days of the date the request is submitted to the
Secretary.
(6) If the Secretary determines that the assurances described in
paragraph (1)(C) have not been met with respect to any 36-month period,
the Secretary may reduce payments under this subchapter to hospitals
under the system in an amount equal to the amount by which the payment
under this subchapter under such system for such period exceeded the
amount of payments which would otherwise have been made under this
subchapter not using such system.
(7) In the case of a State which made a request under paragraph (5)
before December 31, 1984, for the approval of a State hospital
reimbursement control system and which request was approved --
(A) in applying paragraphs (1)(C) and (6), a reference to a
''36-month period'' is deemed a reference to a ''48-month period'', and
(B) in order to allow the State the opportunity to provide the
assurances described in paragraph (1)(C) for a 48-month period, the
Secretary may not discontinue payments under the system, under the
authority of paragraph (3)(A) because the Secretary has reason to
believe that such assurances are not being (or will not be) met, before
July 1, 1986.
(d) Inpatient hospital service payments on basis of prospective
rates; Medicare Geographical Classification Review Board
(1)(A) Notwithstanding section 1395f(b) of this title but subject to
the provisions of section 1395e of this title, the amount of the payment
with respect to the operating costs of inpatient hospital services (as
defined in subsection (a)(4) of this section) of a subsection (d)
hospital (as defined in subparagraph (B)) for inpatient hospital
discharges in a cost reporting period or in a fiscal year --
(i) beginning on or after October 1, 1983, and before October 1,
1984, is equal to the sum of --
(I) the target percentage (as defined in subparagraph (C)) of the
hospital's target amount for the cost reporting period (as defined in
subsection (b)(3)(A) of this section, but determined without the
application of subsection (a) of this section), and
(II) the DRG percentage (as defined in subparagraph (C)) of the
regional adjusted DRG prospective payment rate determined under
paragraph (2) for such discharges;
(ii) beginning on or after October 1, 1984, and before October 1,
1987, is equal to the sum of --
(I) the target percentage (as defined in subparagraph (C)) of the
hospital's target amount for the cost reporting period (as defined in
subsection (b)(3)(A) of this section, but determined without the
application of subsection (a) of this section), and
(II) the DRG percentage (as defined in subparagraph (C)) of the
applicable combined adjusted DRG prospective payment rate determined
under subparagraph (D) for such discharges; or
(iii) beginning on or after April 1, 1988, and ending on September
30, 1993,, /3/ the sum of (I) 85 percent of the national adjusted DRG
prospective payment rate determined under paragraph (3) for such
discharges, and (II) 15 percent of the regional adjusted DRG prospective
payment rate determined under such paragraph.
(B) As used in this section, the term ''subsection (d) hospital''
means a hospital located in one of the fifty States or the District of
Columbia other than --
(i) a psychiatric hospital (as defined in section 1395x(f) of this
title),
(ii) a rehabilitation hospital (as defined by the Secretary),
(iii) a hospital whose inpatients are predominantly individuals under
18 years of age,
(iv) a hospital which has an average inpatient length of stay (as
determined by the Secretary) of greater than 25 days, or
(v) a hospital that the Secretary has classified, at any time on or
before December 31, 1990, /4/ (or, in the case of a hospital that, as of
December 19, 1989, is located in a State operating a demonstration
project under section 1395f(b) of this title, on or before December 31,
1991) for purposes of applying exceptions and adjustments to payment
amounts under this subsection, as a hospital involved extensively in
treatment for or research on cancer;
and, in accordance with regulations of the Secretary, does not
include a psychiatric or rehabilitation unit of the hospital which is a
distinct part of the hospital (as defined by the Secretary).
(C) For purposes of this subsection, for cost reporting periods
beginning --
(i) on or after October 1, 1983, and before October 1, 1984, the
''target percentage'' is 75 percent and the ''DRG percentage'' is 25
percent;
(ii) on or after October 1, 1984, and before October 1, 1985, the
''target percentage'' is 50 percent and the ''DRG percentage'' is 50
percent;
(iii) on or after October 1, 1985, and before October 1, 1986, the
''target percentage'' is 45 percent and the ''DRG percentage'' is 55
percent; and
(iv) on or after October 1, 1986, and before October 1, 1987, the
''target percentage'' is 25 percent and the ''DRG percentage'' is 75
percent.
(D) For purposes of subparagraph (A)(ii)(II), the ''applicable
combined adjusted DRG prospective payment rate'' for discharges
occurring --
(i) on or after October 1, 1984, and before October 1, 1986, is a
combined rate consisting of 25 percent of the national adjusted DRG
prospective payment rate, and 75 percent of the regional adjusted DRG
prospective payment rate, determined under paragraph (3) for such
discharges; and
(ii) on or after October 1, 1986, and before October 1, 1987, is a
combined rate consisting of 50 percent of the national adjusted DRG
prospective payment rate, and 50 percent of the regional adjusted DRG
prospective payment rate, determined under paragraph (3) for such
discharges.
(2) The Secretary shall determine a national adjusted DRG prospective
payment rate, for each inpatient hospital discharge in fiscal year 1984
involving inpatient hospital services of a subsection (d) hospital in
the United States, and shall determine a regional adjusted DRG
prospective payment rate for such discharges in each region, for which
payment may be made under part A of this subchapter. Each such rate
shall be determined for hospitals located in urban or rural areas within
the United States or within each such region, respectively, as follows:
(A) The Secretary shall determine the allowable operating costs per
discharge of inpatient hospital services for the hospital for the most
recent cost reporting period for which data are available.
(B) The Secretary shall update each amount determined under
subparagraph (A) for fiscal year 1984 by --
(i) updating for fiscal year 1983 by the estimated average rate of
change of hospital costs industry-wide between the cost reporting period
used under such subparagraph and fiscal year 1983 and the most recent
case-mix data available, and
(ii) projecting for fiscal year 1984 by the applicable percentage
increase (as defined in subsection (b)(3)(B) of this section) for fiscal
year 1984.
(C) The Secretary shall standardize the amount updated under
subparagraph (B) for each hospital by --
(i) excluding an estimate of indirect medical education costs (taking
into account, for discharges occurring after September 30, 1986, the
amendments made by section 9104(a) of the Medicare and Medicaid Budget
Reconciliation Amendments of 1985),
(ii) adjusting for variations among hospitals by area in the average
hospital wage level,
(iii) adjusting for variations in case mix among hospitals, and
(iv) for discharges occurring on or after October 1, 1986, excluding
an estimate of the additional payments to certain hospitals to be made
under paragraph (5)(F), except that the Secretary shall not exclude
additional payments under such paragraph made as a result of the
enactment of section 6003(c) of the Omnibus Budget Reconciliation Act of
1989 or the enactment of section 4002(b) of the Omnibus Budget
Reconciliation Act of 1990.
(D) The Secretary shall compute an average of the standardized
amounts determined under subparagraph (C) for the United States and for
each region --
(i) for all subsection (d) hospitals located in an urban area within
the United States or that region, respectively, and
(ii) for all subsection (d) hospitals located in a rural area within
the United States or that region, respectively.
For purposes of this subsection, the term ''region'' means one of the
nine census divisions, comprising the fifty States and the District of
Columbia, established by the Bureau of the Census for statistical and
reporting purposes; the term ''urban area'' means an area within a
Metropolitan Statistical Area (as defined by the Office of Management
and Budget) or within such similar area as the Secretary has recognized
under subsection (a) of this section by regulation; the term ''large
urban area'' means, with respect to a fiscal year, such an urban area
which the Secretary determines (in the publications described in
subsection (e)(5) of this section before the fiscal year) has a
population of more than 1,000,000 (as determined by the Secretary based
on the most recent available population data published by the Bureau of
the Census); and the term ''rural area'' means any area outside such an
area or similar area. A hospital located in a Metropolitan Statistical
Area shall be deemed to be located in the region in which the largest
number of the hospitals in the same Metropolitan Statistical Area are
located, or, at the option of the Secretary, the region in which the
majority of the inpatient discharges (with respect to which payments are
made under this subchapter) from hospitals in the same Metropolitan
Statistical Area are made.
(E) The Secretary shall reduce each of the average standardized
amounts determined under subparagraph (D) by a proportion equal to the
proportion (estimated by the Secretary) of the amount of payments under
this subsection based on DRG prospective payment rates which are
additional payments described in paragraph (5)(A) (relating to outlier
payments).
(F) The Secretary shall adjust each of such average standardized
amounts as may be required under subsection (e)(1)(B) of this section
for that fiscal year.
(G) For each discharge classified within a diagnosis-related group,
the Secretary shall establish a national DRG prospective payment rate
and shall establish a regional DRG prospective payment rate for each
region, each of which is equal --
(i) for hospitals located in an urban area in the United States or
that region (respectively), to the product of --
(I) the average standardized amount (computed under subparagraph (D),
reduced under subparagraph (E), and adjusted under subparagraph (F)) for
hospitals located in an urban area in the United States or that region,
and
(II) the weighting factor (determined under paragraph (4)(B)) for
that diagnosis-related group; and
(ii) for hospitals located in a rural area in the United States or
that region (respectively), to the product of --
(I) the average standardized amount (computed under subparagraph (D),
reduced under subparagraph (E), and adjusted under subparagraph (F)) for
hospitals located in a rural area in the United States or that region,
and
(II) the weighting factor (determined under paragraph (4)(B)) for
that diagnosis-related group.
(H) The Secretary shall adjust the proportion, (as estimated by the
Secretary from time to time) of hospitals' costs which are attributable
to wages and wage-related costs, of the national and regional DRG
prospective payment rates computed under subparagraph (G) for area
differences in hospital wage levels by a factor (established by the
Secretary) reflecting the relative hospital wage level in the geographic
area of the hospital compared to the national average hospital wage
level.
(3) The Secretary shall determine a national adjusted DRG prospective
payment rate, for each inpatient hospital discharge in a fiscal year
after fiscal year 1984 involving inpatient hospital services of a
subsection (d) hospital in the United States, and shall determine a
regional adjusted DRG prospective payment rate for such discharges in
each region for which payment may be made under part A of this
subchapter. Each such rate shall be determined for hospitals located in
large urban, other urban, or rural areas within the United States and
within each such region, respectively, as follows:
(A)(i) For discharges occurring in a fiscal year beginning before
October 1, 1987, the Secretary shall compute an average standardized
amount for hospitals located in an urban area and for hospitals located
in a rural area within the United States and for hospitals located in an
urban area and for hospitals located in a rural area within each region,
equal to the respective average standardized amount computed for the
previous fiscal year under paragraph (2)(D) or under this subparagraph,
increased for the fiscal year involved by the applicable percentage
increase under subsection (b)(3)(B) of this section. With respect to
discharges occurring on or after October 1, 1987, the Secretary shall
compute urban and rural averages on the basis of discharge weighting
rather than hospital weighting, making appropriate adjustments to ensure
that computation on such basis does not result in total payments under
this section that are greater or less than the total payments that would
have been made under this section but for this sentence, and making
appropriate changes in the manner of determining the reductions under
subparagraph (C)(ii).
(ii) For discharges occurring in a fiscal year beginning on or after
October 1, 1987, the Secretary shall compute an average standardized
amount for hospitals located in a large urban area, for hospitals
located in a rural area, and for hospitals located in other urban areas,
within the United States and within each region, equal to the respective
average standardized amount computed for the previous fiscal year under
this subparagraph increased by the applicable percentage increase under
subsection (b)(3)(B)(i) of this section with respect to hospitals
located in the respective areas for the fiscal year involved.
(iii) Average standardized amounts computed under this paragraph
shall be adjusted to reflect the most recent case-mix data available.
(B) The Secretary shall reduce each of the average standardized
amounts determined under subparagraph (A) for hospitals located in an
urban area and for hospitals located in a rural area by a proportion
equal to the proportion (estimated by the Secretary) of the amount of
payments under this subsection based on DRG prospective payment amounts
which are additional payments described in paragraph (5)(A) (relating to
outlier payments) for hospitals located in such respective area.
(C)(i) For discharges occurring in fiscal year 1985, the Secretary
shall adjust each of such average standardized amounts as may be
required under subsection (e)(1)(B) of this section for that fiscal
year.
(ii) For discharges occurring after September 30, 1986, the Secretary
shall further reduce each of the average standardized amounts (in a
proportion which takes into account the differing effects of the
standardization effected under paragraph (2)(C)(i)) so as to provide for
a reduction in the total of the payments (attributable to this
paragraph) made for discharges occurring on or after October 1, 1986, of
an amount equal to the estimated reduction in the payment amounts under
paragraph (5)(B) that would have resulted from the enactment of the
amendments made by section 9104 of the Medicare and Medicaid Budget
Reconciliation Amendments of 1985 and by section 4003(a)(1) of the
Omnibus Budget Reconciliation Act of 1987 if the factor described in
clause (ii)(II) of paragraph (5)(B) (determined without regard to
amendments made by the Omnibus Budget Reconciliation Act of 1990) were
applied for discharges occurring on or after such date instead of the
factor described in clause (ii) of that paragraph.
(D) For each discharge classified within a diagnosis-related group,
the Secretary shall establish for the fiscal year a national DRG
prospective payment rate and shall establish a regional DRG prospective
payment rate for each region, each of which is equal --
(i) for hospitals located in an urban area (or, for discharges
occurring on or after April 1, 1988, in a large urban area or other
urban area) in the United States or that region (respectively), to the
product of --
(I) the average standardized amount (computed under subparagraph (A),
reduced under subparagraph (B), and adjusted or reduced under
subparagraph (C)) for the fiscal year for hospitals located in such an
urban area in the United States or that region, and
(II) the weighting factor (determined under paragraph (4)(B)) for
that diagnosis-related group; and
(ii) for hospitals located in a rural area in the United States or
that region (respectively), to the product of --
(I) the average standardized amount (computed under subparagraph (A),
reduced under subparagraph (B), and adjusted or reduced under
subparagraph (C)) for the fiscal year for hospitals located in a rural
area in the United States or that region, and
(II) the weighting factor (determined under paragraph (4)(B)) for
that diagnosis-related group.
(E) The Secretary shall adjust the proportion, (as estimated by the
Secretary from time to time) of hospitals' costs which are attributable
to wages and wage-related costs, of the DRG prospective payment rates
computed under subparagraph (D) for area differences in hospital wage
levels by a factor (established by the Secretary) reflecting the
relative hospital wage level in the geographic area of the hospital
compared to the national average hospital wage level. Not later than
October 1, 1990, and October 1, 1993 (and at least every 12 months
thereafter), the Secretary shall update the factor under the preceding
sentence on the basis of a survey conducted by the Secretary (and
updated as appropriate) of the wages and wage-related costs of
subsection (d) hospitals in the United States. To the extent determined
feasible by the Secretary, such survey shall measure the earnings and
paid hours of employment by occupational category and shall exclude data
with respect to the wages and wage-related costs incurred in furnishing
skilled nursing facility services. Any adjustments or updates made
under this subparagraph for a fiscal year (beginning with fiscal year
1991) shall be made in a manner that assures that the aggregate payments
under this subsection in the fiscal year are not greater or less than
those that would have been made in the year without such adjustment.
(4)(A) The Secretary shall establish a classification of inpatient
hospital discharges by diagnosis-related groups and a methodology for
classifying specific hospital discharges within these groups.
(B) For each such diagnosis-related group the Secretary shall assign
an appropriate weighting factor which reflects the relative hospital
resources used with respect to discharges classified within that group
compared to discharges classified within other groups.
(C)(i) The Secretary shall adjust the classifications and weighting
factors established under subparagraphs (A) and (B), for discharges in
fiscal year 1988 and at least annually thereafter, to reflect changes in
treatment patterns, technology, and other factors which may change the
relative use of hospital resources.
(ii) For discharges in fiscal year 1990, the Secretary shall reduce
the weighting factor for each diagnosis-related group by 1.22 percent.
(iii) Any such adjustment under clause (i) for discharges in a fiscal
year (beginning with fiscal year 1991) shall be made in a manner that
assures that the aggregate payments under this subsection for discharges
in the fiscal year are not greater or less than those that would have
been made for discharges in the year without such adjustment.
(iv) The Secretary shall include recommendations with respect to
adjustments to weighting factors under clause (i) in the annual report
to Congress required under subsection (e)(3)(B) of this section.
(5)(A)(i) The Secretary shall provide for an additional payment for a
subsection (d) hospital for any discharge in a diagnosis-related group,
the length of stay of which exceeds the mean length of stay for
discharges within that group by a fixed number of days, or exceeds such
mean length of stay by some fixed number of standard deviations,
whichever is the fewer number of days.
(ii) For cases which are not included in clause (i), a subsection (d)
hospital may request additional payments in any case where charges,
adjusted to cost, exceed a fixed multiple of the applicable DRG
prospective payment rate, or exceed such other fixed dollar amount,
whichever is greater.
(iii) The amount of such additional payment under clauses (i) and
(ii) shall be determined by the Secretary and shall approximate the
marginal cost of care beyond the cutoff point applicable under clause
(i) or (ii).
(iv) The total amount of the additional payments made under this
subparagraph for discharges in a fiscal year may not be less than 5
percent nor more than 6 percent of the total payments projected or
estimated to be made based on DRG prospective payment rates for
discharges in that year.
(B) The Secretary shall provide for an additional payment amount for
subsection (d) hospitals with indirect costs of medical education, in an
amount computed in the same manner as the adjustment for such costs
under regulations (in effect as of January 1, 1983) under subsection
(a)(2) of this section, except as follows:
(i) The amount of such additional payment shall be determined by
multiplying (I) the sum of the amount determined under paragraph
(1)(A)(ii)(II) (or, if applicable, the amount determined under paragraph
(1)(A)(iii)) and the amount paid to the hospital under subparagraph (A),
by (II) the indirect teaching adjustment factor described in clause
(ii).
(ii) For purposes of clause (i)(II), the indirect teaching adjustment
factor for discharges occurring on or after May 1, 1986, is equal to
1.89 (((1 + r) to the nth power)^1), where ''r'' is the ratio of the
hospital's full-time equivalent interns and residents to beds and ''n''
equals .405.
(iii) In determining such adjustment the Secretary shall not
distinguish between those interns and residents who are employees of a
hospital and those interns and residents who furnish services to a
hospital but are not employees of such hospital.
(iv) In determining such adjustment, the Secretary shall continue to
count interns and residents assigned to outpatient services of the
hospital as part of the calculation of the full-time-equivalent number
of interns and residents.
(C)(i) The Secretary shall provide for such exceptions and
adjustments to the payment amounts established under this subsection
(other than under paragraph (9)) as the Secretary deems appropriate to
take into account the special needs of regional and national referral
centers (including those hospitals of 275 or more beds located in rural
areas). A hospital which is classified as a rural hospital may appeal
to the Secretary to be classified as a rural referral center under this
clause on the basis of criteria (established by the Secretary) which
shall allow the hospital to demonstrate that it should be so
reclassified by reason of certain of its operating characteristics being
similar to those of a typical urban hospital located in the same census
region and which shall not require a rural osteopathic hospital to have
more than 3,000 discharges in a year in order to be classified as a
rural referral center. Such characteristics may include wages, scope of
services, service area, and the mix of medical specialties. The
Secretary shall publish the criteria not later than August 17, 1984, for
implementation by October 1, 1984. An appeal allowed under this clause
must be submitted to the Secretary (in such form and manner as the
Secretary may prescribe) during the quarter before the first quarter of
the hospital's cost reporting period (or, in the case of a cost
reporting period beginning during October 1984, during the first quarter
of that period), and the Secretary must make a final determination with
respect to such appeal within 60 days after the date the appeal was
submitted. Any payment adjustments necessitated by a reclassification
based upon the appeal shall be effective at the beginning of such cost
reporting period.
(ii) The Secretary shall provide, under clause (i), for the
classification of a rural hospital as a regional referral center if the
hospital has a case mix index equal to or greater than the median case
mix index for hospitals (other than hospitals with approved teaching
programs) located in an urban area in the same region (as defined in
paragraph (2)(D)), has at least 5,000 discharges a year or, if less, the
median number of discharges in urban hospitals in the region in which
the hospital is located (or, in the case of a rural osteopathic
hospital, meets the criterion established by the Secretary under clause
(i) with respect to the annual number of discharges for such hospitals),
and meets any other criteria established by the Secretary under clause
(i).
(D)(i) For any cost reporting period beginning on or after April 1,
1990, with respect to a subsection (d) hospital which is a sole
community hospital, payment under paragraph (1)(A) shall be --
(I) an amount based on 100 percent of the hospital's target amount
for the cost reporting period, as defined in subsection (b)(3)(C) of
this section, or
(II) the amount determined under paragraph (1)(A)(iii),
whichever results in greater payment to the hospital.
(ii) In the case of a sole community hospital that experiences, in a
cost reporting period compared to the previous cost reporting period, a
decrease of more than 5 percent in its total number of inpatient cases
due to circumstances beyond its control, the Secretary shall provide for
such adjustment to the payment amounts under this subsection (other than
under paragraph (9)) as may be necessary to fully compensate the
hospital for the fixed costs it incurs in the period in providing
inpatient hospital services, including the reasonable cost of
maintaining necessary core staff and services.
(iii) For purposes of this subchapter, the term ''sole community
hospital'' means any hospital --
(I) that the Secretary determines is located more than 35 road miles
from another hospital,
(II) that, by reason of factors such as the time required for an
individual to travel to the nearest alternative source of appropriate
inpatient care (in accordance with standards promulgated by the
Secretary), location, weather conditions, travel conditions, or absence
of other like hospitals (as determined by the Secretary), is the sole
source of inpatient hospital services reasonably available to
individuals in a geographic area who are entitled to benefits under part
A of this subchapter, or
(III) that is designated by the Secretary as an essential access
community hospital under section 1395i-4(i)(1) of this title.
(iv) The Secretary shall promulgate a standard for determining
whether a hospital meets the criteria for classification as a sole
community hospital under clause (iii)(II) because of the time required
for an individual to travel to the nearest alternative source of
appropriate inpatient care.
(v) If the Secretary determines that, in the case of a hospital
designated by the Secretary as an essential access community hospital
under section 1395i-4(i)(1) of this title, the hospital has incurred
increases in reasonable costs during a cost reporting period as a result
of becoming a member of a rural health network (as defined in section
1395i-4(g) of this title) in the State in which it is located, and in
incurring such increases, the hospital will increase its costs for
subsequent cost reporting periods, the Secretary shall increase the
hospital's target amount under subsection (b)(3)(C) of this section to
account for such incurred increases.
(E)(i) The Secretary shall estimate the amount of reimbursement made
for services described in section 1395y(a)(14) of this title with
respect to which payment was made under part B of this subchapter in the
base reporting periods referred to in paragraph (2)(A) and with respect
to which payment is no longer being made.
(ii) The Secretary shall provide for an adjustment to the payment for
subsection (d) hospitals in each fiscal year so as appropriately to
reflect the net amount described in clause (i).
(F)(i) For discharges occurring on or after May 1, 1986, the
Secretary shall provide, in accordance with this subparagraph, for an
additional payment amount for each subsection (d) hospital which --
(I) serves a significantly disproportionate number of low-income
patients (as defined in clause (v)), or
(II) is located in an urban area, has 100 or more beds, and can
demonstrate that its net inpatient care revenues (excluding any of such
revenues attributable to this subchapter or State plans approved under
subchapter XIX of this chapter), during the cost reporting period in
which the discharges occur, for indigent care from State and local
government sources exceed 30 percent of its total of such net inpatient
care revenues during the period.
(ii) The amount of such payment for each discharge shall be
determined by multiplying (I) the sum of the amount determined under
paragraph (1)(A)(ii)(II) (or, if applicable, the amount determined under
paragraph (1)(A)(iii)) and the amount paid to the hospital under
subparagraph (A) for that discharge, by (II) the disproportionate share
adjustment percentage established under clause (iii) or (iv) for the
cost reporting period in which the discharge occurs.
(iii) The disproportionate share adjustment percentage for a cost
reporting period for a hospital described in clause (i)(II) is equal to
35 percent.
(iv) The disproportionate share adjustment percentage for a cost
reporting period for a hospital that is not described in clause (i)(II)
and that --
(I) is located in an urban area and has 100 or more beds or is
described in the second sentence of clause (v), is equal to the percent
determined in accordance with the applicable formula described in clause
(vii);
(II) is located in an urban area and has less than 100 beds, is equal
to 5 percent;
(III) is located in a rural area and is not described in subclause
(IV) or (V) or in the second sentence of clause (v), is equal to 4
percent;
(IV) is located in a rural area, is classified as a rural referral
center under subparagraph (C), and is classified as a sole community
hospital under subparagraph (D), is equal to 10 percent or, if greater,
the percent determined in accordance with the applicable formula
described in clause (viii);
(V) is located in a rural area, is classified as a rural referral
center under subparagraph (C), and is not classified as a sole community
hospital under subparagraph (D), is equal to the percent determined in
accordance with the applicable formula described in clause (viii); or
(VI) is located in a rural area, is classified as a sole community
hospital under subparagraph (D), and is not classified as a rural
referral center under subparagraph (C), is 10 percent.
(v) In this subparagraph, a hospital ''serves a significantly
disproportionate number of low income patients'' for a cost reporting
period if the hospital has a disproportionate patient percentage (as
defined in clause (vi)) for that period which equals, or exceeds --
(I) 15 percent, if the hospital is located in an urban area and has
100 or more beds,
(II) 30 percent, if the hospital is located in a rural area and has
more than 100 beds, or is located in a rural area and is classified as a
sole community hospital under subparagraph (D),
(III) 40 percent, if the hospital is located in an urban area and has
less than 100 beds, or
(IV) 45 percent, if the hospital is located in a rural area and is
not described in subclause (II).
A hospital located in a rural area and with 500 or more beds also
''serves a significantly disproportionate number of low income
patients'' for a cost reporting period if the hospital has a
disproportionate patient percentage (as defined in clause (vi)) for that
period which equals or exceeds a percentage specified by the Secretary.
(vi) In this subparagraph, the term ''disproportionate patient
percentage'' means, with respect to a cost reporting period of a
hospital, the sum of --
(I) the fraction (expressed as a percentage), the numerator of which
is the number of such hospital's patient days for such period which were
made up of patients who (for such days) were entitled to benefits under
part A of this subchapter and were entitled to supplementary security
income benefits (excluding any State supplementation) under subchapter
XVI of this chapter, and the denominator of which is the number of such
hospital's patient days for such fiscal year which were made up of
patients who (for such days) were entitled to benefits under part A of
this subchapter, and
(II) the fraction (expressed as a percentage), the numerator of which
is the number of the hospital's patient days for such period which
consist of patients who (for such days) were eligible for medical
assistance under a State plan approved under subchapter XIX of this
chapter, but who were not entitled to benefits under part A of this
subchapter, and the denominator of which is the total number of the
hospital's patient days for such period.
(vii) The formula used to determine the disproportionate share
adjustment percentage for a cost reporting period for a hospital
described in clause (iv)(I) is --
(I) in the case of such a hospital with a disproportionate patient
percentage (as defined in clause (vi)) greater than 20.2 --
(a) for discharges occurring on or after April 1, 1990, and on or
before December 31, 1990, (P^20.2)(.65) + 5.62,
(b) for discharges occurring on or after January 1, 1991, and on or
before September 30, 1993, (P^20.2)(.7) + 5.62,
(c) for discharges occurring on or after October 1, 1993, and on or
before September 30, 1994, (P^20.2)(.8) + 5.88, and
(d) for discharges occurring on or after October 1, 1994,
(P^20.2)(.825) + 5.88; or
(II) in the case of any other such hospital --
(a) for discharges occurring on or after April 1, 1990, and on or
before December 31, 1990, (P^15)(.6) + 2.5,
(b) for discharges occurring on or after January 1, 1991, and on or
before September 30, 1993, (P^15)(.6) + 2.5, /5/
(c) for discharges occurring on or after October 1, 1993, (P^15)(.65)
+ 2.5,
where ''P'' is the hospital's disproportionate patient percentage (as
defined in clause (vi)).
(viii) The formula used to determine the disproportionate share
adjustment percentage for a cost reporting period for a hospital
described in clause (iv)(IV) or (iv)(V) is the percentage determined in
accordance with the following formula: (P^30)(.6)+4.0, where ''P'' is
the hospital's disproportionate patient percentage (as defined in clause
(vi)).
(G)(i) For any cost reporting period beginning on or after April 1,
1990, and ending on or before March 31, 1993, with respect to a
subsection (d) of this section hospital which is a medicare-dependent,
small rural hospital, payment under paragraph (1)(A) shall be --
(I) an amount based on 100 percent of the hospital's target amount
for the cost reporting period, as defined in subsection (b)(3)(D) of
this section, or
(II) the amount determined under paragraph (1)(A)(iii),
whichever results in the greater payment to the hospital.
(ii) In the case of a medicare dependent, small rural hospital that
experiences, in a cost reporting period compared to the previous cost
reporting period, a decrease of more than 5 percent in its total number
of inpatient cases due to circumstances beyond its control, the
Secretary shall provide for such adjustment to the payment amounts under
this subsection (other than under paragraph (9)) as may be necessary to
fully compensate the hospital for the fixed costs it incurs in the
period in providing inpatient hospital services, including the
reasonable cost of maintaining necessary core staff and services.
(iii) The term ''medicare-dependent, small rural hospital'' means,
with respect to any cost reporting period to which clause (i) applies,
any hospital --
(I) located in a rural area,
(II) that has not more than 100 beds,
(III) that is not classified as a sole community hospital under
subparagraph (D), and
(IV) for which not less than 60 percent of its inpatient days or
discharges during the cost reporting period beginning in fiscal year
1987 were attributable to inpatients entitled to benefits under part A
of this subchapter.
(H) The Secretary may provide for such adjustments to the payment
amounts under this subsection as the Secretary deems appropriate to take
into account the unique circumstances of hospitals located in Alaska and
Hawaii.
(I) The Secretary shall provide by regulation for such other
exceptions and adjustments to such payment amounts under this subsection
as the Secretary deems appropriate.
(6) The Secretary shall provide for publication in the Federal
Register, on or before the September 1 before each fiscal year
(beginning with fiscal year 1984), of a description of the methodology
and data used in computing the adjusted DRG prospective payment rates
under this subsection, including any adjustments required under
subsection (e)(1)(B) of this section.
(7) There shall be no administrative or judicial review under section
1395oo of this title or otherwise of --
(A) the determination of the requirement, or the proportional amount,
of any adjustment effected pursuant to subsection (e)(1) of this
section, and
(B) the establishment of diagnosis-related groups, of the methodology
for the classification of discharges within such groups, and of the
appropriate weighting factors thereof under paragraph (4).
(8)(A) In the case of any hospital which is located in an area which
is, at any time after April 20, 1983, reclassified from an urban to a
rural area, payments to such hospital for the first two cost reporting
periods for which such reclassification is effective shall be made as
follows:
(i) For the first such cost reporting period, payment shall be equal
to the amount payable to such hospital for such reporting period on the
basis of the rural classification, plus an amount equal to two-thirds of
the amount (if any) by which --
(I) the amount which would have been payable to such hospital for
such reporting period on the basis of an urban classification, exceeds
(II) the amount payable to such hospital for such reporting period on
the basis of the rural classification.
(ii) For the second such cost reporting period, payment shall be
equal to the amount payable to such hospital for such reporting period
on the basis of the rural classification, plus an amount equal to
one-third of the amount (if any) by which --
(I) the amount which would have been payable to such hospital for
such reporting period on the basis of an urban classification, exceeds
(II) the amount payable to such hospital for such reporting period on
the basis of the rural classification.
(B) For purposes of this subsection, the Secretary shall treat a
hospital located in a rural county adjacent to one or more urban areas
as being located in the urban metropolitan statistical area to which the
greatest number of workers in the county commute, if the rural county
would otherwise be considered part of an urban area, under the standards
for designating Metropolitan Statistical Areas (and for designating New
England County Metropolitan Areas) published in the Federal Register on
January 3, 1980, if the commuting rates used in determining outlying
counties (or, for New England, similar recognized areas) were determined
on the basis of the aggregate number of resident workers who commute to
(and, if applicable under the standards, from) the central county or
counties of all contiguous Metropolitan Statistical Areas (or New
England County Metropolitan Areas).
(C)(i) If the application of subparagraph (B) or a decision of the
Medicare Geographic Classification Review Board or the Secretary under
paragraph (10), by treating hospitals located in a rural county or
counties as being located in an urban area, or by treating hospitals
located in one urban area as being located in another urban area --
(I) reduces the wage index for that urban area (as applied under this
subsection) by 1 percentage point or less, the Secretary, in calculating
such wage index under this subsection, shall exclude those hospitals so
treated, or
(II) reduces the wage index for that urban area by more than 1
percentage point (as applied under this subsection), the Secretary shall
calculate and apply such wage index under this subsection separately to
hospitals located in such urban area (excluding all the hospitals so
treated) and to the hospitals so treated (as if such hospitals were
located in such urban area).
(ii) If the application of subparagraph (B) or a decision of the
Medicare Geographic Classification Review Board or the Secretary under
paragraph (10), by treating hospitals located in a rural county or
counties as not being located in the rural area in a State, reduces the
wage index for that rural area (as applied under this subsection), the
Secretary shall calculate and apply such wage index under this
subsection as if the hospitals so treated had not been excluded from
calculation of the wage index for that rural area.
(iii) The application of subparagraph (B) or a decision of the
Medicare Geographic Classification Review Board or the Secretary under
paragraph (10) may not result in the reduction of any county's wage
index to a level below the wage index for rural areas in the State in
which the county is located.
(D) The Secretary shall make a proportional adjustment in the
standardized amounts determined under paragraph (3) for hospitals
located in an urban area to assure that the provisions of subparagraphs
(B) and (C) or a decision of the Medicare Geographic Classification
Review Board or the Secretary under paragraph (10) do not result in
aggregate payments under this section that are greater or less than
those that would otherwise be made. The Secretary shall make such
adjustment in payments under this section to hospitals located in rural
areas as are necessary to assure that the aggregate of payments to rural
hospitals not affected by subparagraphs (B) and (C) or a decision of the
Medicare Geographic Classification Review Board or the Secretary under
paragraph (10) are not changed as a result of the application of
subparagraphs (B) and (C) or a decision of the Medicare Geographic
Classification Review Board or the Secretary under paragraph (10).
(9)(A) Notwithstanding section 1395f(b) of this title but subject to
the provisions of section 1395e of this title, the amount of the payment
with respect to the operating costs of inpatient hospital services of a
subsection (d) Puerto Rico hospital for inpatient hospital discharges in
a fiscal year beginning on or after October 1, 1987, is equal to the sum
of --
(i) 75 percent of the Puerto Rico adjusted DRG prospective payment
rate (determined under subparagraph (B) or (C)) for such discharges, and
(ii) 25 percent of the discharge-weighted average of --
(I) the national adjusted DRG prospective payment rate (determined
under paragraph (3)(D)) for hospitals located in a large urban area,
(II) such rate for hospitals located in other urban areas, and
(III) such rate for hospitals located in a rural area,
for such discharges, adjusted in the manner provided in paragraph
(3)(E) for different area wage levels. As used in this section, the
term ''subsection (d) Puerto Rico hospital'' means a hospital that is
located in Puerto Rico and that would be a subsection (d) hospital (as
defined in paragraph (1)(B)) if it were located in one of the fifty
States.
(B) The Secretary shall determine a Puerto Rico adjusted DRG
prospective payment rate, for each inpatient hospital discharge in
fiscal year 1988 involving inpatient hospital services of a subsection
(d) Puerto Rico hospital for which payment may be made under part A of
this subchapter. Such rate shall be determined for such hospitals
located in urban or rural areas within Puerto Rico, as follows:
(i) The Secretary shall determine the target amount (as defined in
subsection (b)(3)(A) of this section) for the hospital for the cost
reporting period beginning in fiscal year 1987 and increase such amount
by prorating the applicable percentage increase (as defined in
subsection (b)(3)(B) of this section) to update the amount to the
midpoint in fiscal year 1988.
(ii) The Secretary shall standardize the amount determined under
clause (i) for each hospital by --
(I) excluding an estimate of indirect medical education costs,
(II) adjusting for variations among hospitals by area in the average
hospital wage level,
(III) adjusting for variations in case mix among hospitals, and
(IV) excluding an estimate of the additional payments to certain
subsection (d) Puerto Rico hospitals to be made under subparagraph
(D)(iii) (relating to disproportionate share payments).
(iii) The Secretary shall compute a discharge weighted average of the
standardized amounts determined under clause (ii) for all hospitals
located in an urban area and for all hospitals located in a rural area
(as such terms are defined in paragraph (2)(D)).
(iv) The Secretary shall reduce the average standardized amount by a
proportion equal to the proportion (estimated by the Secretary) of the
amount of payments under this paragraph which are additional payments
described in subparagraph (D)(i) (relating to outlier payments).
(v) For each discharge classified within a diagnosis-related group
for hospitals located in an urban or rural area, respectively, the
Secretary shall establish a Puerto Rico DRG prospective payment rate
equal to the product of --
(I) the average standardized amount (computed under clause (iii) and
reduced under clause (iv)) for hospitals located in an urban or rural
area, respectively, and
(II) the weighting factor (determined under paragraph (4)(B)) for
that diagnosis-related group.
(vi) The Secretary shall adjust the proportion (as estimated by the
Secretary from time to time) of hospitals' costs which are attributable
to wages and wage-related costs, of the Puerto Rico DRG prospective
payment rate computed under clause (v) for area differences in hospital
wage levels by a factor (established by the Secretary) reflecting the
relative hospital wage level in the geographic area of the hospital
compared to the Puerto Rican average hospital wage level.
(C) The Secretary shall determine a Puerto Rico adjusted DRG
prospective payment rate, for each inpatient hospital discharge after
fiscal year 1988 involving inpatient hospital services of a subsection
(d) Puerto Rico hospital for which payment may be made under part A of
this subchapter. Such rate shall be determined for hospitals located in
urban or rural areas within Puerto Rico as follows:
(i) The Secretary shall compute an average standardized amount for
hospitals located in an urban area and for hospitals located in a rural
area equal to the respective average standardized amount computed for
the previous fiscal year under subparagraph (B)(iii) or under this
clause, increased for fiscal year 1989 by the applicable percentage
increase under subsection (b)(3)(B) of this section, and adjusted for
subsequent fiscal years in accordance with the final determination of
the Secretary under subsection (e)(4) of this section, and adjusted to
reflect the most recent case-mix data available.
(ii) The Secretary shall reduce each of the average standardized
amounts by a proportion equal to the proportion (estimated by the
Secretary) of the amount of payments under this paragraph which are
additional payments described in subparagraph (D)(i) (relating to
outlier payments).
(iii) For each discharge classified within a diagnosis-related group
for hospitals located in an urban or rural area, respectively, the
Secretary shall establish a Puerto Rico DRG prospective payment rate
equal to the product of --
(I) the average standardized amount (computed under clause (i) and
reduced under clause (ii)) for hospitals located in an urban or rural
area, respectively, and
(II) the weighting factor (determined under paragraph (4)(B)) for
that diagnosis-related group.
(iv) The Secretary shall adjust the proportion (as estimated by the
Secretary from time to time) of hospitals' costs which are attributable
to wages and wage-related costs, of the Puerto Rico DRG prospective
payment rate computed under clause (iii) for area differences in
hospital wage levels by a factor (established by the Secretary)
reflecting the relative hospital wage level in the geographic area of
the hospital compared to the Puerto Rico average hospital wage level.
The second and third sentences of paragraph (3)(E) shall apply to
subsection (d) Puerto Rico hospitals under this clause in the same
manner as they apply to subsection (d) hospitals under such paragraph
and, for purposes of this clause, any reference in such paragraph to a
subsection (d) hospital is deemed a reference to a subsection (d) Puerto
Rico hospital.
(D) The following provisions of paragraph (5) shall apply to
subsection (d) Puerto Rico hospitals receiving payment under this
paragraph in the same manner and to the extent as they apply to
subsection (d) hospitals receiving payment under this subsection:
(i) Subparagraph (A) (relating to outlier payments).
(ii) Subparagraph (B) (relating to payments for indirect medical
education costs), except that for this purpose the sum of the amount
determined under subparagraph (A) of this paragraph and the amount paid
to the hospital under clause (i) of this subparagraph shall be
substituted for the sum referred to in paragraph (5)(B)(i)(I).
(iii) Subparagraph (F) (relating to disproportionate share payments),
except that for this purpose the sum described in clause (ii) of this
subparagraph shall be substituted for the sum referred to in paragraph
(5)(F)(ii)(I).
(iv) Subparagraph (H) (relating to exceptions and adjustments).
(10)(A) There is hereby established the Medicare Geographic
Classification Review Board (hereinafter in this paragraph referred to
as the ''Board'').
(B)(i) The Board shall be composed of 5 members appointed by the
Secretary without regard to the provisions of title 5, governing
appointments in the competitive service. Two of such members shall be
representative of subsection (d) hospitals located in a rural area under
paragraph (2)(D). At least 1 member shall be knowledgeable in the field
of analyzing costs with respect to the provision of inpatient hospital
services.
(ii) The Secretary shall make initial appointments to the Board as
provided in this paragraph within 180 days after December 19, 1989.
(C)(i) The Board shall consider the application of any subsection (d)
hospital requesting that the Secretary change the hospital's geographic
classification for purposes of determining for a fiscal year --
(I) the hospital's average standardized amount under paragraph
(2)(D), or
(II) the area wage index applicable to such hospital under paragraph
(3)(E).
(ii) A hospital requesting a change in geographic classification
under clause (i) for a fiscal year shall submit its application to the
Board not later than the first day of the preceding fiscal year.
(iii)(I) The Board shall render a decision on an application
submitted under clause (i) not later than 180 days after the deadline
referred to in clause (ii).
(II) Appeal of decisions of the Board shall be subject to the
provisions of section 557b /6/ of title 5. The Secretary shall issue a
decision on such an appeal not later than 90 days after the date on
which the appeal is filed. The decision of the Secretary shall be final
and shall not be subject to judicial review.
(D)(i) The Secretary shall publish guidelines to be utilized by the
Board in rendering decisions on applications submitted under this
paragraph, and shall include in such guidelines the following:
(I) Guidelines for comparing wages, taking into account occupational
mix, in the area in which the hospital is classified and the area in
which the hospital is applying to be classified.
(II) Guidelines for determining whether the county in which the
hospital is located should be treated as being a part of a particular
Metropolitan Statistical Area.
(III) Guidelines for considering information provided by an applicant
with respect to the effects of the hospital's geographic classification
on access to inpatient hospital services by medicare beneficiaries.
(IV) Guidelines for considering the appropriateness of the criteria
used to define New England County Metropolitan Areas.
(ii) The Secretary shall publish the guidelines described in clause
(i) by July 1, 1990.
(E)(i) The Board shall have full power and authority to make rules
and establish procedures, not inconsistent with the provisions of this
subchapter or regulations of the Secretary, which are necessary or
appropriate to carry out the provisions of this paragraph. In the
course of any hearing the Board may administer oaths and affirmations.
The provisions of subsections (d) and (e) of section 405 of this title
with respect to subpenas shall apply to the Board to the same extent as
such provisions apply to the Secretary with respect to subchapter II of
this chapter.
(ii) The Board is authorized to engage such technical assistance and
to receive such information as may be required to carry out its
functions, and the Secretary shall, in addition, make available to the
Board such secretarial, clerical, and other assistance as the Board may
require to carry out its functions.
(F)(i) Each member of the Board who is not an officer or employee of
the Federal Government shall be compensated at a rate equal to the daily
equivalent of the annual rate of basic pay prescribed for grade GS-18 of
the General Schedule under section 5332 of title 5 for each day
(including travel time) during which such member is engaged in the
performance of the duties of the Board. Each member of the Board who is
an officer or employee of the United States shall serve without
compensation in addition to that received for service as an officer or
employee of the United States.
(ii) Members of the Board shall be allowed travel expenses, including
per diem in lieu of subsistence, at rates authorized for employees of
agencies under subchapter I of chapter 57 of title 5, while away from
their homes or regular places of business in the performance of services
for the Board.
(e) Proportional adjustments in applicable percentage increases;
Prospective Payment Assessment Commission
(1)(A) For cost reporting periods of hospitals beginning in fiscal
year 1984 or fiscal year 1985, the Secretary shall provide for such
proportional adjustment in the applicable percentage increase (otherwise
applicable to the periods under subsection (b)(3)(B) of this section) as
may be necessary to assure that --
(i) the aggregate payment amounts otherwise provided under subsection
(d)(1)(A)(i)(I) of this section for that fiscal year for operating costs
of inpatient hospital services of hospitals (excluding payments made
under section 1395cc(a)(1)(F) of this title),
are not greater or less than --
(ii) the target percentage (as defined in subsection (d)(1)(C) of
this section) of the payment amounts which would have been payable for
such services for those same hospitals for that fiscal year under this
section under the law as in effect before April 20, 1983 (excluding
payments made under section 1395cc(a)(1)(F) of this title);
except that the adjustment made under this subparagraph shall apply
only to subsection (d) hospitals and shall not apply for purposes of
making computations under subsection (d)(2)(B)(ii) of this section or
subsection (d)(3)(A) of this section.
(B) For discharges occurring in fiscal year 1984 or fiscal year 1985,
the Secretary shall provide under subsections (d)(2)(F) and (d)(3)(C) of
this section for such equal proportional adjustment in each of the
average standardized amounts otherwise computed for that fiscal year as
may be necessary to assure that --
(i) the aggregate payment amounts otherwise provided under subsection
(d)(1)(A)(i)(II) and (d)(5) of this section for that fiscal year for
operating costs of inpatient hospital services of hospitals (excluding
payments made under section 1395cc(a)(1)(F) of this title),
are not greater or less than --
(ii) the DRG percentage (as defined in subsection (d)(1)(C) of this
section) of the payment amounts which would have been payable for such
services for those same hospitals for that fiscal year under this
section under the law as in effect before April 20, 1983 (excluding
payments made under section 1395cc(a)(1)(F) of this title).
(C) For discharges occurring in fiscal year 1988, the Secretary shall
provide for such equal proportional adjustment in each of the average
standardized amounts otherwise computed under subsection (d)(3) of this
section for that fiscal year as may be necessary to assure that --
(i) the aggregate payment amounts otherwise provided under
subsections (d)(1)(A)(iii), (d)(5), and (d)(9) of this section for that
fiscal year for operating costs of inpatient hospital services of
subsection (d) hospitals and subsection (d) Puerto Rico hospitals,
are not greater or less than --
(ii) the payment amounts that would have been payable for such
services for those same hospitals for that fiscal year but for the
enactment of the amendments made by section 9304 of the Omnibus Budget
Reconciliation Act of 1986.
(2)(A) The Director of the Congressional Office of Technology
Assessment (hereinafter in this subsection referred to as the
''Director'' and the ''Office'', respectively) shall provide for
appointment of a Prospective Payment Assessment Commission (hereinafter
in this subsection referred to as the ''Commission''), to be composed of
independent experts appointed by the Director (without regard to the
provisions of title 5 governing appointments in the competitive
service). The Commission shall review the applicable percentage
increase factor described in subsection (b)(3)(B) of this section and
make recommendations to the Secretary on the appropriate percentage
change which should be effected for hospital inpatient discharges under
subsections (b) and (d) of this section for fiscal years beginning with
fiscal year 1986. In making its recommendations, the Commission shall
take into account changes in the hospital market-basket described in
subsection (b)(3)(B) of this section, hospital productivity,
technological and scientific advances, the quality of health care
provided in hospitals (including the quality and skill level of
professional nursing required to maintain quality care), and long-term
cost-effectiveness in the provision of inpatient hospital services.
(B) In order to promote the efficient and effective delivery of
high-quality health care services, the Commission shall, in addition to
carrying out its functions under subparagraph (A), study and make
recommendations for each fiscal year regarding changes in each existing
reimbursement policy under this subchapter under which payments to an
institution are based upon prospectively determined rates and the
development of new institutional reimbursement policies under this
subchapter, including recommendations relating to payments during such
fiscal year under the prospective payment system established under this
section for determining payments for the operating costs of inpatient
hospital services, including changes in the number of diagnosis-related
groups used to classify inpatient hospital discharges under subsection
(d) of this section, adjustments to such groups to reflect severity of
illness, and changes in the methods by which hospitals are reimbursed
for capital-related costs, together with general recommendations on the
effectiveness and quality of health care delivery systems in the United
States and the effects on such systems of institutional reimbursements
under this subchapter.
(C) By not later than June 1 of each year, the Commission shall
submit a report to Congress containing an examination of issues
affecting health care delivery in the United States, including issues
relating to --
(i) trends in health care costs;
(ii) the financial condition of hospitals and the effect of the level
of payments made to hospitals under this subchapter on such condition;
(iii) trends in the use of health care services; and
(iv) new methods used by employers, insurers, and others to constrain
growth in health care costs.
(3)(A) The Commission, not later than the March 1 before the
beginning of each fiscal year (beginning with fiscal year 1986), shall
report its recommendations to Congress on an appropriate change factor
which should be used for inpatient hospital services for discharges in
that fiscal year, together with its general recommendations under
paragraph (2)(B) regarding the effectiveness and quality of health care
delivery systems in the United States.
(B) The Secretary, not later than April 1, 1987, for fiscal year 1988
and not later than March 1 before the beginning of each fiscal year
(beginning with fiscal year 1989), shall report to the Congress the
Secretary's initial estimate of the percentage change that the Secretary
will recommend under paragraph (4) with respect to that fiscal year.
(4)(A) Taking into consideration the recommendations of the
Commission, the Secretary shall recommend for each fiscal year
(beginning with fiscal year 1988) an appropriate change factor for
inpatient hospital services for discharges in that fiscal year which
will take into account amounts necessary for the efficient and effective
delivery of medically appropriate and necessary care of high quality.
The appropriate change factor may be different for all large urban
subsection (d) hospitals, other urban subsection (d) hospitals, urban
subsection (d) Puerto Rico hospitals, rural subsection (d) hospitals,
and rural subsection (d) Puerto Rico hospitals, and all other hospitals
and units not paid under subsection (d) of this section, and may vary
among such other hospitals and units.
(B) In addition to the recommendation made under subparagraph (A),
the Secretary shall, taking into consideration the recommendations of
the Commission under paragraph (2)(B), recommend for each fiscal year
(beginning with fiscal year 1992) other appropriate changes in each
existing reimbursement policy under this subchapter under which payments
to an institution are based upon prospectively determined rates.
(5) The Secretary shall cause to have published in the Federal
Register, not later than --
(A) the May 1 before each fiscal year (beginning with fiscal year
1986), the Secretary's proposed recommendations under paragraph (4) for
that fiscal year for public comment, and
(B) the September 1 before such fiscal year after such consideration
of public comment on the proposal as is feasible in the time available,
the Secretary's final recommendations under such paragraph for that
year.
The Secretary shall include in the publication referred to in
subparagraph (A) for a fiscal year the report of the Commission's
recommendations submitted under paragraph (3) for that fiscal year. To
the extent that the Secretary's recommendations under paragraph (4)
differ from the Commission's recommendations for that fiscal year, the
Secretary shall include in the publication referred to in subparagraph
(A) an explanation of the Secretary's grounds for not following the
Commission's recommendations.
(6)(A) The Commission shall consist of 17 individuals. Members of
the Commission shall first be appointed no later than April 1, 1984, for
a term of three years, except that the Director may provide initially
for such shorter terms as will insure that (on a continuing basis) the
terms of no more than seven members expire in any one year.
(B) The membership of the Commission shall include individuals with
national recognition for their expertise in health economics, hospital
reimbursement, hospital financial management, and other related fields,
who provide a mix of different professionals, broad geographic
representation, and a balance between urban and rural representatives,
including physicians and registered professional nurses, employers,
third party payors, individuals skilled in the conduct and
interpretation of biomedical, health services, and health economics
research, and individuals having expertise in the research and
development of technological and scientific advances in health care.
(C) Subject to such review as the Office deems necessary to assure
the efficient administration of the Commission, the Commission may --
(i) employ and fix the compensation of an Executive Director (subject
to the approval of the Director of the Office) and such other personnel
(not to exceed 25) as may be necessary to carry out its duties (without
regard to the provisions of title 5 governing appointments in the
competitive service);
(ii) seek such assistance and support as may be required in the
performance of its duties from appropriate Federal departments and
agencies;
(iii) 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);
(iv) make advance, progress, and other payments which relate to the
work of the Commission;
(v) provide transportation and subsistence for persons serving
without compensation; and
(vi) prescribe such rules and regulations as it deems necessary with
respect to the internal organization and operation of the Commission.
Section 10(a)(1) of the Federal Advisory Committee Act shall not
apply to any portion of a Commission meeting if the Commission, by
majority vote, determines that such portion of such meeting should be
closed.
(D) 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 his 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 /7/ 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.
(E) In order to identify medically appropriate patterns of health
resources use in accordance with paragraph (2), the Commission shall
collect and assess information on medical and surgical procedures and
services, including information on regional variations of medical
practice and lengths of hospitalization and on other patient-care data,
giving special attention to treatment patterns for conditions which
appear to involve excessively costly or inappropriate services not
adding to the quality of care provided. In order to assess the safety,
efficacy, and cost-effectiveness of new and existing medical and
surgical procedures, the Commission shall, in coordination to the extent
possible with the Secretary, collect and assess factual information,
giving special attention to the needs of updating existing
diagnosis-related groups, establishing new diagnosis-related groups, and
making recommendations on relative weighting factors for such groups to
reflect appropriate differences in resource consumption in delivering
safe, efficacious, and cost-effective care. In collecting and assessing
information, the Commission shall --
(i) 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 paragraph;
(ii) carry out, or award grants or contracts for, original research
and experimentation, including clinical research, where existing
information is inadequate for the development of useful and valid
guidelines by the Commission; and
(iii) adopt procedures allowing any interested party to submit
information with respect to medical and surgical procedures and services
(including new practices, such as the use of new technologies and
treatment modalities), which information the Commission shall consider
in making reports and recommendations to the Secretary and Congress.
(F) The Commission shall have access to such relevant information and
data as may be available from appropriate Federal agencies and shall
assure that its activities, especially the conduct of original research
and medical studies, are coordinated with the activities of Federal
agencies.
(G)(i) The Office shall have unrestricted access to all
deliberations, records, and data of the Commission, immediately upon its
request.
(ii) In order to carry out its duties under this paragraph, the
Office is authorized to expend reasonable and neccessary /8/ funds as
mutually agreed upon by the Office and the Commission. The Office shall
be reimbursed for such funds by the Commission from the appropriations
made with respect to the Commission.
(H) The Commission shall be subject to periodic audit by the General
Accounting Office.
(I)(i) There are authorized to be appropriated such sums as may be
necessary to carry out the provisions of this paragraph.
(ii) Eighty-five percent of such appropriation shall be payable from
the Federal Hospital Insurance Trust Fund, and 15 percent of such
appropriation shall be payable from the Federal Supplementary Medical
Insurance Trust Fund.
(J) The Commission shall submit requests for appropriations in the
same manner as the Office submits requests for appropriations, but
amounts appropriated for the Commission shall be separate from amounts
appropriated for the Office.
(f) Reporting of costs of hospitals receiving payments on basis of
prospective rates
(1)(A) The Secretary shall maintain a system for the reporting of
costs of hospitals receiving payments computed under subsection (d) of
this section.
(B)(i) Subject to clause (ii), the Secretary shall place into effect
a standardized electronic cost reporting format for hospitals under this
subchapter.
(ii) The Secretary may delay or waive the implementation of such
format in particular instances where such implementation would result in
financial hardship (in particular with respect to hospitals with a small
percentage of inpatients entitled to benefits under this subchapter).
(2) If the Secretary determines, based upon information supplied by a
utilization and quality control peer review organization under part B of
subchapter XI of this chapter, that a hospital, in order to circumvent
the payment method established under subsection (b) or (d) of this
section, has taken an action that results in the admission of
individuals entitled to benefits under part A unnecessarily, unnecessary
multiple admissions of the same such individuals, or other inappropriate
medical or other practices with respect to such individuals, the
Secretary may --
(A) deny payment (in whole or in part) under part A of this
subchapter with respect to inpatient hospital services provided with
respect to such an unnecessary admission (or subsequent admission of the
same individual), or
(B) require the hospital to take other corrective action necessary to
prevent or correct the inappropriate practice.
(3) The provisions of subsections (c) through (g) of section 1320a-7
of this title shall apply to determinations made under paragraph (2) in
the same manner as they apply to exclusions effected under section
1320a-7(b)(13) of this title.
(g) Prospective payment for capital-related costs; return on equity
capital for hospitals
(1)(A) Notwithstanding section 1395x(v) of this title, instead of any
amounts that are otherwise payable under this subchapter with respect to
the reasonable costs of subsection (d) hospitals and subsection (d)
Puerto Rico hospitals for capital-related costs of inpatient hospital
services, the Secretary shall, for hospital cost reporting periods
beginning on or after October 1, 1991, provide for payments for such
costs in accordance with a prospective payment system established by the
Secretary. Aggregate payments made under subsection (d) of this section
and this subsection during fiscal years 1992 through 1995 shall be
reduced in a manner that results in a reduction (as estimated by the
Secretary) in the amount of such payments equal to a 10 percent
reduction in the amount of payments attributable to capital-related
costs that would otherwise have been made during such fiscal year had
the amount of such payments been based on reasonable costs (as defined
in section 1395x(v) of this title).
(B) Such system --
(i) shall provide for (I) a payment on a per discharge basis, and
(II) an appropriate weighting of such payment amount as relates to the
classification of the discharge;
(ii) may provide for an adjustment to take into account variations in
the relative costs of capital and construction for the different types
of facilities or areas in which they are located;
(iii) may provide for such exceptions (including appropriate
exceptions to reflect capital obligations) as the Secretary determines
to be appropriate, and
(iv) may provide for suitable adjustment to reflect hospital
occupancy rate.
(C) In this paragraph, the term ''capital-related costs'' has the
meaning given such term by the Secretary under subsection (a)(4) of this
section as of September 30, 1987, and does not include a return on
equity capital.
(2)(A) The Secretary shall provide that the amount which is
allowable, with respect to reasonable costs of inpatient hospital
services for which payment may be made under this subchapter, for a
return on equity capital for hospitals shall, for cost reporting periods
beginning on or after April 20, 1983, be equal to amounts otherwise
allowable under regulations in effect on March 1, 1983, except that the
rate of return to be recognized shall be equal to the applicable
percentage (described in subparagraph (B)) of the average of the rates
of interest, for each of the months any part of which is included in the
reporting period, on obligations issued for purchase by the Federal
Hospital Insurance Trust Fund.
(B) In this paragraph, the ''applicable percentage'' is --
(i) 75 percent, for cost reporting periods beginning during fiscal
year 1987,
(ii) 50 percent, for cost reporting periods beginning during fiscal
year 1988,
(iii) 25 percent, for cost reporting periods beginning during fiscal
year 1989, and
(iv) 0 percent, for cost reporting periods beginning on or after
October 1, 1989.
(3)(A) Except as provided in subparagraph (B), in determining the
amount of the payments that may be made under this subchapter with
respect to all the capital-related costs of inpatient hospital services
of a subsection (d) hospital and a subsection (d) Puerto Rico hospital,
the Secretary shall reduce the amounts of such payments otherwise
established under this subchapter by --
(i) 3.5 percent for payments attributable to portions of cost
reporting periods occurring during fiscal year 1987,
(ii) 7 percent for payments attributable to portions of cost
reporting periods or discharges (as the case may be) occurring during
fiscal year 1988 on or after October 1, 1987, and before January 1,
1988,
(iii) 12 percent for payments attributable to portions of cost
reporting periods or discharges (as the case may be) in fiscal year
1988, occurring on or after January 1, 1988,
(iv) 15 percent for payments attributable to portions of cost
reporting periods or discharges (as the case may be) occurring during
fiscal year 1989, and
(v) 15 percent for payments attributable to portions of cost
reporting periods or discharges (as the case may be) occurring during
the period beginning January 1, 1990, and ending September 30, 1991.
(B) Subparagraph (A) shall not apply to payments with respect to the
capital-related costs of any hospital that is a sole community hospital
(as defined in subsection (d)(5)(D)(iii) of this section /9/
or a rural primary care hospital (as defined in section 1395x(mm)(1)
of this title).
(h) Payments for direct graduate medical education costs
(1) Substitution of special payment rules
Notwithstanding section 1395x(v) of this title, instead of any
amounts that are otherwise payable under this subchapter with respect to
the reasonable costs of hospitals for direct graduate medical education
costs, the Secretary shall provide for payments for such costs in
accordance with paragraph (3) of this subsection. In providing for such
payments, the Secretary shall provide for an allocation of such payments
between part A and part B of this subchapter (and the trust funds
established under the respective parts) as reasonably reflects the
proportion of direct graduate medical education costs of hospitals
associated with the provision of services under each respective part.
(2) Determination of hospital-specific approved FTE resident amounts
The Secretary shall determine, for each hospital with an approved
medical residency training program, an approved FTE resident amount for
each cost reporting period beginning on or after July 1, 1985, as
follows:
(A) Determining allowable average cost per FTE resident in a
hospital's base period
The Secretary shall determine, for the hospital's cost reporting
period that began during fiscal year 1984, the average amount recognized
as reasonable under this subchapter for direct graduate medical
education costs of the hospital for each full-time-equivalent resident.
(B) Updating to the first cost reporting period
(i) In general
The Secretary shall update each average amount determined under
subparagraph (A) by the percentage increase in the consumer price index
during the 12-month cost reporting period described in such
subparagraph.
(ii) Exception
The Secretary shall not perform an update under clause (i) in the
case of a hospital if the hospital's reporting period, described in
subparagraph (A), began on or after July 1, 1984, and before October 1,
1984.
(C) Amount for first cost reporting period
For the first cost reporting period of the hospital beginning on or
after July 1, 1985, the approved FTE resident amount for the hospital is
equal to the amount determined under subparagraph (B) increased by 1
percent.
(D) Amount for subsequent cost reporting periods
For each subsequent cost reporting period, the approved FTE resident
amount for the hospital is equal to the amount determined under this
paragraph for the previous cost reporting period updated, through the
midpoint of the period, by projecting the estimated percentage change in
the consumer price index during the 12-month period ending at that
midpoint, with appropriate adjustments to reflect previous under- or
over-estimations under this subparagraph in the projected percentage
change in the consumer price index.
(E) Treatment of certain hospitals
In the case of a hospital that did not have an approved medical
residency training program or was not participating in the program under
this subchapter for a cost reporting period beginning during fiscal year
1984, the Secretary shall, for the first such period for which it has
such a residency training program and is participating under this
subchapter, provide for such approved FTE resident amount as the
Secretary determines to be appropriate, based on approved FTE resident
amounts for comparable programs.
(3) Hospital payment amount per resident
(A) In general
The payment amount, for a hospital cost reporting period beginning on
or after July 1, 1985, is equal to the product of --
(i) the aggregate approved amount (as defined in subparagraph (B))
for that period, and
(ii) the hospital's medicare patient load (as defined in subparagraph
(C)) for that period.
(B) Aggregate approved amount
As used in subparagraph (A), the term ''aggregate approved amount''
means, for a hospital cost reporting period, the product of --
(i) the hospital's approved FTE resident amount (determined under
paragraph (2)) for that period, and
(ii) the weighted average number of full-time-equivalent residents
(as determined under paragraph (4)) in the hospital's approved medical
residency training programs in that period.
(C) Medicare patient load
As used in subparagraph (A), the term ''medicare patient load''
means, with respect to a hospital's cost reporting period, the fraction
of the total number of inpatient-bed-days (as established by the
Secretary) during the period which are attributable to patients with
respect to whom payment may be made under part A of this subchapter.
(4) Determination of full-time-equivalent residents
(A) Rules
The Secretary shall establish rules consistent with this paragraph
for the computation of the number of full-time-equivalent residents in
an approved medical residency training program.
(B) Adjustment for part-year or part-time residents
Such rules shall take into account individuals who serve as residents
for only a portion of a period with a hospital or simultaneously with
more than one hospital.
(C) Weighting factors for certain residents
Subject to subparagraph (D), such rules shall provide, in calculating
the number of full-time-equivalent residents in an approved residency
program --
(i) before July 1, 1986, for each resident the weighting factor is
1.00,
(ii) on or after July 1, 1986, for a resident who is in the
resident's initial residency period (as defined in paragraph (5)(F)),
the weighting factor is 1.00,
(iii) on or after July 1, 1986, and before July 1, 1987, for a
resident who is not in the resident's initial residency period (as
defined in paragraph (5)(F)), the weighting factor is .75, and
(iv) on or after July 1, 1987, for a resident who is not in the
resident's initial residency period (as defined in paragraph (5)(F)),
the weighting factor is .50.
(D) Foreign medical graduates required to pass FMGEMS examination
(i) In general
Except as provided in clause (ii), such rules shall provide that, in
the case of an individual who is a foreign medical graduate (as defined
in paragraph (5)(D)), the individual shall not be counted as a resident
on or after July 1, 1986, unless --
(I) the individual has passed the FMGEMS examination (as defined in
paragraph (5)(E)), or
(II) the individual has previously received certification from, or
has previously passed the examination of, the Educational Commission for
Foreign Medical Graduates.
(ii) Transition for current FMGS
On or after July 1, 1986, but before July 1, 1987, in the case of a
foreign medical graduate who --
(I) has served as a resident before July 1, 1986, and is serving as a
resident after that date, but
(II) has not passed the FMGEMS examination or a previous examination
of the Educational Commission for Foreign Medical Graduates before July
1, 1986,
the individual shall be counted as a resident at a rate equal to
one-half of the rate at which the individual would otherwise be counted.
(E) Counting time spent in outpatient settings
Such rules shall provide that only time spent in activities relating
to patient care shall be counted and that all the time so spent by a
resident under an approved medical residency training program shall be
counted towards the determination of full-time equivalency, without
regard to the setting in which the activities are performed, if the
hospital incurs all, or substantially all, of the costs for the training
program in that setting.
(5) Definitions and special rules
As used in this subsection:
(A) Approved medical residency training program
The term ''approved medical residency training program'' means a
residency or other postgraduate medical training program participation
in which may be counted toward certification in a specialty or
subspecialty and includes formal postgraduate training programs in
geriatric medicine approved by the Secretary.
(B) Consumer price index
The term ''consumer price index'' refers to the Consumer Price Index
for All Urban Consumers (United States city average), as published by
the Secretary of Commerce.
(C) Direct graduate medical education costs
The term ''direct graduate medical education costs'' means direct
costs of approved educational activities for approved medical residency
training programs.
(D) Foreign medical graduate
The term ''foreign medical graduate'' means a resident who is not a
graduate of --
(i) a school of medicine accredited by the Liaison Committee on
Medical Education of the American Medical Association and the
Association of American Medical Colleges (or approved by such Committee
as meeting the standards necessary for such accreditation),
(ii) a school of osteopathy accredited by the American Osteopathic
Association, or approved by such Association as meeting the standards
necessary for such accreditation, or
(iii) a school of dentistry or podiatry which is accredited (or meets
the standards for accreditation) by an organization recognized by the
Secretary for such purpose.
(E) FMGEMS examination
The term ''FMGEMS examination'' means parts I and II of the Foreign
Medical Graduate Examination in the Medical Sciences recognized by the
Secretary for this purpose.
(F) Initial residency period
The term ''initial residency period'' means the period of board
eligibility plus one year, except that --
(i) except as provided in clause (ii), in no case shall the initial
period of residency exceed an aggregate period of formal training of
more than five years for any individual, and
(ii) a period, of not more than two years, during which an individual
is in a geriatric residency or fellowship program which meets such
criteria as the Secretary may establish, shall be treated as part of the
initial residency period, but shall not be counted against any
limitation on the initial residency period.
The initial residency period shall be determined, with respect to a
resident, as of the time the resident enters the residency training
program.
(G) Period of board eligibility
(i) General rule
Subject to clauses (ii) and (iii), the term ''period of board
eligibility'' means, for a resident, the minimum number of years of
formal training necessary to satisfy the requirements for initial board
eligibility in the particular specialty for which the resident is
training.
(ii) Application of 1985-1986 directory
Except as provided in clause (iii), the period of board eligibility
shall be such period specified in the 1985-1986 Directory of Residency
Training Programs published by the Accreditation Council on Graduate
Medical Education.
(iii) Changes in period of board eligibility
On or after July 1, 1989, if the Accreditation Council on Graduate
Medical Education, in its Directory of Residency Training Programs --
(I) increases the minimum number of years of formal training
necessary to satisfy the requirements for a specialty, above the period
specified in its 1985-1986 Directory, the Secretary may increase the
period of board eligibility for that specialty, but not to exceed the
period of board eligibility specified in that later Directory, or
(II) decreases the minimum number of years of formal training
necessary to satisfy the requirements for a specialty, below the period
specified in its 1985-1986 Directory, the Secretary may decrease the
period of board eligibility for that specialty, but not below the period
of board eligibility specified in that later Directory.
(H) Resident
The term ''resident'' includes an intern or other participant in an
approved medical residency training program.
(i) Avoiding duplicative payments to hospitals participating in rural
demonstration programs
The Secretary shall reduce any payment amounts otherwise determined
under this section to the extent necessary to avoid duplication of any
payment made under section 4005(e) of the Omnibus Budget Reconciliation
Act of 1987.
(Aug. 14, 1935, ch. 531, title XVIII, 1886, as added and amended
Sept. 3, 1982, Pub. L. 97-248, title I, 101(a)(1), 110, 96 Stat. 331,
339; Jan. 12, 1983, Pub. L. 97-448, title III, 309(b)(13)-(15), 96
Stat. 2409; Apr. 20, 1983, Pub. L. 98-21, title VI, 601(a)(1), (2),
(b), (c), (d)(2), (e), 97 Stat. 149, 150, 152; July 18, 1984, Pub. L.
98-369, div. B, title III, 2307(b)(1), 2310(a), 2311(a)-(c), 2312(a),
(b), 2313(a), (b), (d), 2315(a)-(c), 2354(b)(42)-(44), 98 Stat. 1073,
1075-1080, 1102; Nov. 8, 1984, Pub. L. 98-617, 3(b)(9), 98 Stat. 3296;
Apr. 7, 1986, Pub. L. 99-272, title IX, 9101(b), (c), 9102(a)-(c),
9104(a), (b), 9105(a)-(c), 9106(a), 9107(a), 9109(a), 9111(a), 9127(a),
9202(a), 100 Stat. 153-155, 157-162, 170, 171; July 2, 1986, Pub. L.
99-349, title II, 206, 100 Stat. 749; Oct. 21, 1986, Pub. L. 99-509,
title IX, 9302(a)(1), (2), (b)(1), (c), (d)(1)(A), (e), 9303,
9304(a)-(c), 9306(a)-(c), 9307(c)(1), 9314(a), 9320(g), 9321(e)(2), 100
Stat. 1982-1985, 1988, 1995, 2005, 2015, 2018; Oct. 22, 1986, Pub. L.
99-514, 2, title XVIII, 1895(b)(1)(A)-(C), (2)(A)-(C), (3), (9), 100
Stat. 2095, 2931-2933; Aug. 18, 1987, Pub. L. 100-93, 8(c)(4), 101
Stat. 693; Dec. 22, 1987, Pub. L. 100-203, title IV, 4002(a)-(f)(1),
4003(a)-(c), 4004(a), 4005(a)(1), (c)(1), (d)(1)(A), 4006(a)-(b)(2),
4007(b)(1), 4009(d)(1), (j)(1)-(6)(B), 4083(b)(1), 101 Stat. 1330-42 to
1330-44, 1330-46, 1330-47, 1330-49, 1330-52, 1330-53, 1330-57 to
1330-59, 1330-129, as amended July 1, 1988, Pub. L. 100-360, title IV,
411(b)(1)(E), (3), (4)(C)(i), (5)(B), (6)(B), (8)(B), 102 Stat. 769,
770, 772; July 1, 1988, Pub. L. 100-360, title IV, 411(b)(1)(A)-(D),
(F)-(H)(i), (4)(A), (B), (5)(A), 102 Stat. 768-770; Oct. 13, 1988, Pub.
L. 100-485, title VI, 608(d)(18)(A), (B), 102 Stat. 2418; Nov. 10,
1988, Pub. L. 100-647, title I, 1018(r)(1), title VIII, 8401,
8403(a), 102 Stat. 3586, 3798; Dec. 13, 1989, Pub. L. 101-234, title
III, 301(b)(3), (c)(3), 103 Stat. 1985, 1986; Dec. 19, 1989, Pub. L.
101-239, title VI, 6002, 6003(a)(1), (b)-(c)(3), (e)(1), (2)(B)-(E),
(f), (g)(2), (4)-(h)(4), (6), 6004(a)(1), (2), (b)(1), 6011(a), 6015(a),
6022, 103 Stat. 2140-2144, 2151, 2154-2157, 2159-2161, 2164, 2167; Oct.
1, 1990, Pub. L. 101-403, title I, 115(b)(1), 104 Stat. 870; Nov. 5,
1990, Pub. L. 101-508, title IV, 4001, 4002(a)(1), (b)(1)-(4), (c)(1),
(2), (e)(1), (g)(1), (2), (h)(1)(A), (2)(B), 4003(a), 4005(a)(1),
(c)(1)(B), (2), 4008(f)(1), (m)(2)(A), 104 Stat. 1388-31 to 1388-38,
1388-40, 1388-42, 1388-45, 1388-53.)
Pub. L. 101-508, title IV, 4002(c)(2)(B), (3), Nov. 5, 1990, 104
Stat. 1388-34, 1388-35, provided that, effective Oct. 1, 1994,
subsection (d) of this section is amended --
(1) in paragraph (1)(A)(iii), by striking ''rural, large urban, or
other urban area'' and inserting ''large urban or other area'';
(2) in paragraph (3)(A) --
(A) in clause (ii), by striking ''the Secretary'' and inserting ''and
ending on or before September 30, 1994, the Secretary'',
(B) by redesignating clause (iii) as clause (v), and
(C) by inserting after clause (ii) the following new clauses:
(iii) For discharges occurring in the fiscal year beginning on
October 1, 1994, the average standardized amount for hospitals located
in a rural area shall be equal to the average standardized amount for
hospitals located in an other urban area.
(iv) For discharges occurring in a fiscal year beginning on or after
October 1, 1995, the Secretary shall compute an average standardized
amount for hospitals located in a large urban area and for hospitals
located in other areas within the United States and within each region
equal to the respective average standardized amount computed for the
previous fiscal year under this subparagraph increased by the applicable
percentage increase under subsection (b)(3)(B)(i) of this section with
respect to hospitals located in the respective areas for the fiscal year
involved.
(3) in paragraph (3)(B), by striking ''for hospitals located in an
urban area'' and all that follows and inserting the following: ''by a
factor equal to the proportion of payments under this subsection (as
estimated by the Secretary) based on DRG prospective payment amounts
which are additional payments described in paragraph (5)(A) (relating to
outlier payments).'';
(4) in paragraph (3)(D)(i) --
(A) in the matter preceding subclause (I), by striking ''an urban
area (or,'' and all that follows through ''area),'' and inserting ''a
large urban area'', and
(B) in subclause (I), by striking ''an urban area'' and inserting ''a
large urban area'';
(5) in paragraph (3)(D)(ii), by striking ''a rural area'' each place
it appears and inserting ''other areas''; and
(6) in paragraph (8)(D) --
(A) in the first sentence, by striking ''for hospitals located in an
urban area'', and
(B) by striking the second sentence.
Parts A and B of this subchapter, referred to in text, are classified
to sections 1395c et seq. and 1395j et seq., respectively, of this
title.
The Internal Revenue Code of 1986, referred to in subsec. (b)(6), is
classified generally to Title 26, Internal Revenue Code.
Section 222(a) of the Social Security Amendments of 1972, referred to
in subsec. (c)(4)(B), is section 222(a) of Pub. L. 92-603, Oct. 30,
1972, 86 Stat. 1329, which is set out as a note under section 1395b-1
of this title.
Section 9104(a) of the Medicare and Medicaid Budget Reconciliation
Amendments of 1985, referred to in subsec. (d)(2)(C)(i), is section
9104(a) of Pub. L. 99-272, which amended subsec. (d)(5)(B) of this
section.
Section 6003(c) of the Omnibus Budget Reconciliation Act of 1989,
referred to in subsec. (d)(2)(C)(iv), is section 6003(c) of Pub. L.
101-239, which amended this section and enacted provisions set out
below.
Section 4002(b) of the Omnibus Budget Reconciliation Act of 1990,
referred to in subsec. (d)(2)(C)(iv), is section 4002(b) of Pub. L.
101-508, which amended this section and enacted provisions set out
below.
Section 9104 of the Medicare and Medicaid Budget Reconciliation
Amendments of 1985, referred to in subsec. (d)(3)(C)(ii), is section
9104 of Pub. L. 99-272, which amended subsec. (d)(2)(C)(i), (3)(C),
(D)(i)(I), (ii)(I), and (5)(B) of this section.
Section 4003(a)(1) of the Omnibus Budget Reconciliation Act of 1987,
referred to in subsec. (d)(3)(C)(ii), is section 4003(a)(1) of Pub. L.
100-203, which amended subsec. (d)(5)(B)(ii) of this section.
The Omnibus Budget Reconciliation Act of 1990, referred to in subsec.
(d)(3)(C)(ii), is Pub. L. 101-508, Nov. 5, 1990, 104 Stat. 1388. For
complete classification of this Act to the Code, see Tables.
The provisions of title 5 governing appointments in the competitive
service, referred to in subsecs. (d)(10)(B)(i) and (e)(2)(A),
(6)(C)(i), are classified generally to section 3301 et seq. of Title 5,
Government Organization and Employees.
Section 9304 of the Omnibus Budget Reconciliation Act of 1986,
referred to in subsec. (e)(1)(C)(ii), is section 9304 of Pub. L.
99-509, which enacted subsecs. (d)(9) and (e)(1)(C) of this section and
amended subsec. (d)(5)(C)(i)(I), (ii) of this section.
Section 10(a)(1) of the Federal Advisory Committee Act, referred to
in subsec. (e)(6)(C), is section 10(a)(1) of Pub. L. 92-463, Oct. 6,
1972, 86 Stat. 770, as amended, which is set out in the Appendix to
Title 5.
Section 5948 of title 5, referred to in subsec. (e)(6)(D), was
repealed effective Sept. 30, 1989, by Pub. L. 95-603, 3, Nov. 6,
1978, 92 Stat. 3020, as amended.
Part B of subchapter XI of this chapter, referred to in subsec.
(f)(2), is classified to section 1320c et seq. of this title.
Section 4005(e) of the Omnibus Budget Reconciliation Act of 1987,
referred to in subsec. (i), is section 4005(e) of Pub. L. 100-203,
which is set out below.
1990 -- Subsec. (a)(4). Pub. L. 101-508, 4003(a), struck out period
at end of first sentence and inserted '', and includes the costs of all
services for which payment may be made under this subchapter that are
provided by the hospital (or by an entity wholly owned or operated by
the hospital) to the patient during the 3 days immediately preceding the
date of the patient's admission if such services are diagnostic services
(including clinical diagnostic laboratory tests) or are other services
related to the admission (as defined by the Secretary).''
Subsec. (b)(1)(B)(ii). Pub. L. 101-508, 4005(a)(1), added cl. (ii)
and struck out former cl. (ii) which read as follows: ''in the case of
cost reporting periods beginning on or after October 1, 1982, and before
October 1, 1984, 25 percent of the amount by which the amount of the
operating costs exceeds the target amount;''.
Subsec. (b)(3)(B)(i)(V). Pub. L. 101-508, 4002(a)(1)(A), struck out
''and'' after semicolon at end.
Subsec. (b)(3)(B)(i)(VI). Pub. L. 101-508, 4002(c)(1)(A),
substituted ''in a large urban or other urban area, and the market
basket percentage increase minus 0.7 percentage point for hospitals
located in a rural area'' for ''in all areas''.
Pub. L. 101-508, 4002(a)(1)(C), added subcl. (VI). Former subcl.
(VI) redesignated (IX).
Pub. L. 101-508, 4002(a)(1)(B)(i), substituted ''1994'' for
''1991''.
Subsec. (b)(3)(B)(i)(VII). Pub. L. 101-508, 4002(c)(1)(B),
substituted ''in a large urban or other urban area, and the market
basket percentage increase minus 0.6 percentage point for hospitals
located in a rural area'' for ''in all areas''.
Pub. L. 101-508, 4002(a)(1)(C), added subcl. (VII).
Subsec. (b)(3)(B)(i)(VIII). Pub. L. 101-508, 4002(c)(1)(C),
substituted ''in a large urban or other urban area, and the market
basket percentage increase minus 0.55 for hospitals located in a rural
area,'' for ''in all areas, and''.
Pub. L. 101-508, 4002(a)(1)(C), added subcl. (VIII).
Subsec. (b)(3)(B)(i)(IX). Pub. L. 101-508, 4002(c)(1)(E), added
subcl. (IX). Former subcl. (IX) redesignated (XI).
Pub. L. 101-508, 4002(c)(1)(D)(i), substituted ''1996'' for
''1994''.
Pub. L. 101-508, 4002(a)(1)(B)(ii), redesignated subcl. (VI) as
(IX).
Subsec. (b)(3)(B)(i)(X). Pub. L. 101-508, 4002(c)(1)(E), added
subcl. (X).
Subsec. (b)(3)(B)(i)(XI). Pub. L. 101-508, 4002(c)(1)(D)(ii),
redesignated subcl. (IX) as (XI).
Subsec. (b)(3)(B)(ii). Pub. L. 101-508, 4002(c)(2)(A)(i),
substituted ''(A), (C), (D), and (E),'' for ''(A) and (E),'' in
introductory provisions.
Subsec. (b)(3)(C)(ii), (D)(ii). Pub. L. 101-508, 4002(c)(2)(A)(ii),
substituted ''subparagraph (B)(ii)'' for ''subparagraph (B)(i)''.
Subsec. (b)(4)(A). Pub. L. 101-508, 4005(c)(1)(B), inserted at end
''The Secretary shall announce a decision on any request for an
exemption, exception, or adjustment under this paragraph not later than
180 days after receiving a completed application from the intermediary
for such exemption, exception, or adjustment, and shall include in such
decision a detailed explanation of the grounds on which such request was
approved or denied.''
Subsec. (b)(4)(B), (C). Pub. L. 101-508, 4005(c)(2), added subpar.
(B) and redesignated former subpar. (B) as (C).
Subsec. (c)(4). Pub. L. 101-508, 4008(f)(1), substituted ''payments
under the State system as compared to aggregate payments which would
have been made under the national system since'' for ''rate of increase
from'' in last sentence.
Subsec. (d)(1)(A)(iii). Pub. L. 101-508, 4002(e)(1), substituted
''beginning on or after April 1, 1988, and ending on September 30,
1993,'' for ''beginning on or after October 1, 1987, is equal to the
national adjusted DRG prospective payment rate determined under
paragraph (3) for such discharges, or, if the average standardized
amount (described in clause (i)(I) or clause (ii)(I) of paragraph
(3)(D)) for hospitals within the region of, and in the same rural, large
urban, or other urban area as, the hospital is greater than the average
standardized amount (described in the respective clause) for hospitals
within the United States in that type of area for discharges occurring
during the period beginning on April 1, 1988, and ending on October 20,
1990''.
Pub. L. 101-403 substituted ''October 20, 1990'' for ''September 30,
1990''.
Subsec. (d)(2)(C)(iv). Pub. L. 101-508, 4002(b)(4)(B), substituted
''1989 or the enactment of section 4002(b) of the Omnibus Budget
Reconciliation Act of 1990.'' for ''1989.''
Pub. L. 101-508, 4002(b)(4)(A), struck out period at end and
inserted '', except that the Secretary shall not exclude additional
payments under such paragraph made as a result of the enactment of
section 6003(c) of the Omnibus Budget Reconciliation Act of 1989.''
Pub. L. 101-508, 4002(b)(3)(A), struck out ''and before October 1,
1995,'' after ''October 1, 1986,''.
Subsec. (d)(3)(C)(ii). Pub. L. 101-508, 4002(b)(3)(B)(B),
substituted ''occurring on or after October 1, 1986,'' through the end
of cl. (ii) for ''occurring -- '' and subcls. (I) and (II) which read
as follows:
''(I) on or after October 1, 1986, and before October 1, 1995, of an
amount equal to the estimated reduction in the payment amounts under
paragraph (5)(B) that would have resulted from the enactment of the
amendments made by section 9104 of the Medicare and Medicaid Budget
Reconciliation Amendments of 1985 and by section 4003(a)(1) of the
Omnibus Budget Reconciliation Act of 1987 if the factor described in
clause (ii)(II) of paragraph (5)(B) were applied for discharges
occurring during such period instead of the factor described in clause
(ii)(I) of that paragraph, and
''(II) on or after October 1, 1995, of an amount equal to the
estimated reduction in the payment amounts under paragraph (5)(B) for
those discharges that has resulted from the enactment of the amendments
made by section 9104 of the Medicare and Medicaid Budget Reconciliation
Amendments of 1985 and by section 4003(a)(1) of the Omnibus Budget
Reconciliation Act of 1987.''
Subsec. (d)(4)(D). Pub. L. 101-508, 4002(g)(2)(A), struck out
subpar. (D) which read as follows: ''The Commission (established under
subsection (e)(2) of this section) shall consult with and make
recommendations to the Secretary with respect to the need for
adjustments under subparagraph (C), based upon its evaluation of
scientific evidence with respect to new practices, including the use of
new technologies and treatment modalities. The Commission shall report
to the Congress with respect to its evaluation of any adjustments made
by the Secretary under subparagraph (C).''
Subsec. (d)(5)(B)(ii). Pub. L. 101-508, 4002(b)(3)(B)(A), amended
cl. (ii) generally. Prior to amendment, cl. (ii) read as follows:
''For purposes of clause (i)(II), the indirect teaching adjustment
factor for discharges occurring --
''(I) on or after May 1, 1986, and before October 1, 1995, is equal
to 1.89 ((1+r).405^1), or
''(II) on or after October 1, 1995, is equal to 1.43 ((1+r).5795^1),
where 'r' is the ratio of the hospital's full-time equivalent interns
and residents to beds.''
Subsec. (d)(5)(D)(iii). Pub. L. 101-508, 4008(m)(2)(A), substituted
''For purposes of this subchapter, the term'' for ''The term'' at
beginning.
Subsec. (d)(5)(F)(i). Pub. L. 101-508, 4002(b)(3)(A), struck out
''and before October 1, 1995,'' after ''May 1, 1986,''.
Subsec. (d)(5)(F)(iii). Pub. L. 101-508, 4002(b)(2), substituted
''35 percent'' for ''30 percent''.
Subsec. (d)(5)(F)(vii)(I). Pub. L. 101-508, 4002(b)(1)(A),
substituted ''greater than 20.2 -- '' and subdivs. (a) to (d) for
''greater than 20.2, (P^20.2)(.65)+5.62, or''.
Subsec. (d)(5)(F)(vii)(II). Pub. L. 101-508, 4002(b)(1)(B),
substituted ''hospital -- '' and subdivs. (a) to (c) for ''hospital,
(P^15)(.6)+2.5,''.
Subsec. (d)(8)(C)(i). Pub. L. 101-508, 4002(h)(1)(A)(i), substituted
''area, or by treating hospitals located in one urban area as being
located in another urban area -- '' for ''area -- ''.
Subsec. (d)(8)(C)(i)(II). Pub. L. 101-508, 4002(h)(1)(A)(ii),
amended subcl. (II) generally. Prior to amendment, subcl. (II) read
as follows: ''reduces the wage index for that urban area by more than 1
percentage point (as applied under this subsection), the Secretary shall
calculate and apply such wage index under this subsection separately to
hospitals located in such urban area (excluding all the hospitals so
treated) and to the hospitals so treated (as if each affected rural
county were a separate urban area).''
Subsec. (d)(8)(C)(ii) to (iv). Pub. L. 101-508, 4002(h)(1)(A)(iii),
(iv), redesignated cls. (iii) and (iv) as (ii) and (iii), respectively,
and struck out former cl. (ii) which read as follows: ''If the
application of subparagraph (B) or a decision of the Medicare Geographic
Classification Review Board or the Secretary under paragraph (10), by
reclassifying a county from a rural to an urban area or by reclassifying
an urban county from one urban area to another urban area --
''(I) reduces the wage index for the urban area within which the
county or counties is reclassified by 1 percentage point or less (as
applied under this subsection), the Secretary, in calculating such wage
index under this subsection, shall exclude those counties so
reclassified, or
''(II) reduces the wage index for the urban area within which the
county or counties is reclassified by more than 1 percentage point (as
applied under this subsection), the Secretary shall calculate and apply
such wage index under this subsection separately to hospitals located in
such urban area (excluding all the hospitals so reclassified) and to
hospitals located in the counties so reclassified (as if each affected
county were a separate area).''
Subsec. (d)(10)(A). Pub. L. 101-508, 4002(h)(2)(B)(i), substituted
''Geographic'' for ''Geographical''.
Subsec. (d)(10)(B)(i). Pub. L. 101-508, 4002(h)(2)(B)(ii),
substituted ''representative'' for ''representatives'' and struck out
''1 member shall be a member of the Prospective Payment Assessment
Commission, and at least'' after ''At least''.
Subsec. (d)(10)(B)(ii). Pub. L. 101-508, 4002(h)(2)(B)(iii),
substituted ''initial'' for ''all''.
Subsec. (d)(10)(C)(iii)(II). Pub. L. 101-508, 4002(h)(2)(B)(iv),
substituted ''Appeal of decisions of the Board shall be subject to the
provisions of section 557b of title 5'' for ''A decision of the Board
shall be final unless the unsuccessful applicant appeals such decision
to the Secretary by not later than 15 days after the Board renders its
decision. The Secretary in considering the appeal of an applicant shall
receive no new evidence but shall consider the record as a whole as such
record appeared before the Board'' and substituted ''after the date on
which'' for ''after''.
Subsec. (e)(2). Pub. L. 101-508, 4002(g)(1), designated existing
provisions as subpar. (A) and added subpars. (B) and (C).
Subsec. (e)(2)(A). Pub. L. 101-508, 4002(g)(2)(B), substituted ''The
Commission'' for ''In addition to carrying out its functions under
subsection (d)(4)(D) of this section, the Commission''.
Subsec. (e)(3)(A). Pub. L. 101-508, 4002(g)(2)(C), substituted
''Congress'' for ''the Secretary'' and inserted before period at end '',
together with its general recommendations under paragraph (2)(B)
regarding the effectiveness and quality of health care delivery systems
in the United States''.
Subsec. (e)(4). Pub. L. 101-508, 4002(g)(2)(D), designated existing
provisions as subpar. (A) and added subpar. (B).
Subsec. (e)(5). Pub. L. 101-508, 4002(g)(2)(E), substituted
''recommendations'' for ''recommendation'' in subpars. (A) and (B) and
inserted at end ''To the extent that the Secretary's recommendations
under paragraph (4) differ from the Commission's recommendations for
that fiscal year, the Secretary shall include in the publication
referred to in subparagraph (A) an explanation of the Secretary's
grounds for not following the Commission's recommendations.''
Subsec. (e)(6)(G). Pub. L. 101-508, 4002(g)(2)(F), redesignated cls.
(ii) and (iii) as (i) and (ii), respectively, and struck out former cl.
(i) which read as follows: ''The Office shall report annually to the
Congress on the functioning and progress of the Commission and on the
status of the assessment of medical procedures and services by the
Commission.''
Subsec. (g)(1)(A). Pub. L. 101-508, 4001(b), inserted at end
''Aggregate payments made under subsection (d) of this section and this
subsection during fiscal years 1992 through 1995 shall be reduced in a
manner that results in a reduction (as estimated by the Secretary) in
the amount of such payments equal to a 10 percent reduction in the
amount of payments attributable to capital-related costs that would
otherwise have been made during such fiscal year had the amount of such
payments been based on reasonable costs (as defined in section 1395x(v)
of this title).''
Subsec. (g)(3)(A)(v). Pub. L. 101-508, 4001(a), substituted
''September 30, 1991'' for ''September 30, 1990''.
Subsec. (g)(3)(B). Pub. L. 101-508, 4001(c), substituted
''subsection (d)(5)(D)(iii) of this section or a rural primary care
hospital (as defined in section 1395x(mm)(1) of this title)'' for
''subsection (d)(5)(D)(iii) of this section)''.
1989 -- Subsec. (a)(4). Pub. L. 101-239, 6011(a), (d), temporarily
struck out ''or,'' after ''equity capital,'' and substituted ''October
1, 1987), or costs with respect to administering blood clotting factors
to individuals with hemophilia'' for ''October 1, 1987)''. See Effective
and Termination Dates of 1989 Amendment note below.
Subsec. (b)(3)(A). Pub. L. 101-239, 6004(b)(1)(A), substituted
''(C), (D), and (E)'' for ''(C) and (D)'' in introductory provisions.
Pub. L. 101-239, 6003(f)(2)(i), substituted ''subparagraphs (C) and
(D)'' for ''subparagraph (C)'' in introductory provisions.
Pub. L. 101-239, 6003(e)(1)(B)(i), substituted ''(A) Except as
provided in subparagraph (C), for purposes of this subsection'' for
''(A) For purposes of this subsection'' in introductory provisions.
Subsec. (b)(3)(B)(i)(V), (VI). Pub. L. 101-239, 6003(a)(1), added
subcl. (V), redesignated former subcl. (V) as (VI), and substituted
''fiscal year 1991'' for ''fiscal year 1990'' in subcl. (VI).
Subsec. (b)(3)(B)(ii). Pub. L. 101-239, 6004(b)(1)(B), substituted
''For purposes of subparagraphs (A) and (E)'' for ''For purposes of
subparagraph (A)'' in introductory provisions.
Subsec. (b)(3)(C). Pub. L. 101-239, 6003(e)(1)(B)(ii), added subpar.
(C).
Subsec. (b)(3)(D). Pub. L. 101-239, 6003(f)(2)(ii), added subpar.
(D).
Subsec. (b)(3)(E). Pub. L. 101-239, 6004(b)(1)(C), added subpar.
(E).
Subsec. (b)(4)(A). Pub. L. 101-239, 6015(a), substituted ''deems
appropriate, including the assignment of a new base period which is more
representative, as determined by the Secretary, of the reasonable and
necessary cost of inpatient services and'' for ''deems appropriate,''.
Subsec. (c)(4). Pub. L. 101-239, 6022, substituted ''the aggregate
rate of increase from October 1, 1984, to the most recent date for which
annual data are available'' for ''the aggregate payment or payments per
inpatient admission or discharge during the three cost reporting periods
beginning on or after October 1, 1983, after which such test, at the
option of the Secretary, shall no longer apply, and such State systems
shall be treated in the same manner as under other waivers'' in second
sentence.
Subsec. (d)(1)(B)(v). Pub. L. 101-239, 6004(a)(1), added cl. (v).
Subsec. (d)(3)(E). Pub. L. 101-239, 6003(h)(6), substituted
''October 1, 1990, and October 1, 1993 (and at least every 12 months
thereafter)'' for ''October 1, 1990 (and at least every 36 months
thereafter)'' and inserted at end ''Any adjustments or updates made
under this subparagraph for a fiscal year (beginning with fiscal year
1991) shall be made in a manner that assures that the aggregate payments
under this subsection in the fiscal year are not greater or less than
those that would have been made in the year without such adjustment.''
Subsec. (d)(4)(C). Pub. L. 101-239, 6003(b), designated existing
provisions as cl. (i) and added cls. (ii) to (iv).
Subsec. (d)(5)(C). Pub. L. 101-239, 6003(e)(1)(A)(i), (ii), (iv),
(2)(B), redesignated former cl. (i)(I) as cl. (i), redesignated former
cl. (i)(II) as cl. (ii) and substituted ''clause (i)'' for ''subclause
(I)'' in three places, and redesignated former cls. (ii), (iii), and
(iv) as subpars. (D), (I), and (H), respectively.
Subsec. (d)(5)(D). Pub. L. 101-239, 6003(e)(1)(A)(iv), amended
former subpar. (C)(ii) generally, redesignating it as subpar. (D) and
substituting cls. (i) to (iv) relating to payments to sole community
hospitals for cost reporting periods beginning on or after Apr. 1,
1990, for former single paragraph relating to payments to such hospitals
for cost reporting periods beginning on or after Oct. 1, 1984.
Subsec. (d)(5)(D)(iii)(III). Pub. L. 101-239, 6003(g)(2)(A), added
subcl. (III).
Subsec. (d)(5)(D)(v). Pub. L. 101-239, 6003(g)(2)(B), added cl.
(v).
Subsec. (d)(5)(E). Pub. L. 101-239, 6003(e)(1)(A)(iii), redesignated
subpar. (D) as (E).
Subsec. (d)(5)(F)(iii). Pub. L. 101-239, 6003(c)(3), substituted
''30 percent'' for ''25 percent''.
Subsec. (d)(5)(F)(iv)(I). Pub. L. 101-239, 6003(c)(1)(A),
substituted ''the applicable formula described in clause (vii)'' for
''the following formula: (P^15)(.5)+2.5, where 'P' is the hospital's
disproportionate patient percentage (as defined in clause (vi))''.
Subsec. (d)(5)(F)(iv)(III). Pub. L. 101-239, 6003(c)(2)(A)(ii),
inserted ''in subclause (IV) or (V) or'' after ''described''.
Subsec. (d)(5)(F)(iv)(IV) to (VI). Pub. L. 101-239,
6003(c)(2)(A)(i), (iii), (iv), added subcls. (IV) to (VI).
Subsec. (d)(5)(F)(v)(II) to (IV). Pub. L. 101-239, 6003(c)(2)(B),
added subcl. (II), redesignated former subcls. (II) and (III) as (III)
and (IV), respectively, and substituted ''area and is not described in
subclause (II)'' for ''area'' in subcl. (IV).
Subsec. (d)(5)(F)(vii). Pub. L. 101-239, 6003(c)(1)(B), added cl.
(vii).
Subsec. (d)(5)(F)(viii). Pub. L. 101-239, 6003(c)(2)(C), added cl.
(viii).
Subsec. (d)(5)(G). Pub. L. 101-239, 6003(f)(1), added subpar. (G).
Subsec. (d)(5)(H). Pub. L. 101-239, 6003(e)(1)(A)(i), redesignated
subpar. (C)(iv) as subpar. (H).
Subsec. (d)(5)(I). Pub. L. 101-239, 6004(a)(2), struck out
''(including exceptions and adjustments that may be appropriate with
respect to hospitals involved extensively in treatment for and research
on cancer)'' after ''deems appropriate''.
Pub. L. 101-239, 6003(e)(1)(A)(ii), redesignated subpar. (C)(iii)
as subpar. (I).
Subsec. (d)(8)(C). Pub. L. 101-239, 6003(h)(3), amended subpar. (C)
generally. Prior to amendment, subpar. (C) read as follows:
''(i) If the application of subparagraph (B) or a decision of the
Medicare Geographic Classification Review Board or the Secretary under
paragraph (10),, (sic) by treating hospitals located in a rural county
or counties as being located in an urban area, reduces the wage index
for that urban area (as applied under this subsection), the Secretary
shall calculate and apply such wage index under this subsection
separately to hospitals located in such urban area (excluding all the
hospitals so treated) and to the hospitals so treated (as if each
affected rural county were a separate urban area). If the application
of subparagraph (B) or a decision of the Medicare Geographic
Classification Review Board or the Secretary under paragraph (10),,
(sic) by treating the hospitals located in a rural county or counties as
not being located in the rural area in a State, reduces the wage index
for that rural area (as applied under this subsection), the Secretary
shall calculate and apply such wage index under this subsection as if
the hospitals so treated had not been excluded from calculation of the
wage index for that rural area.
''(ii) Clause (i) shall only apply to discharges occurring on or
after October 1, 1989, and before October 1, 1991.''
Subsec. (d)(8)(C)(i). Pub. L. 101-239, 6003(h)(2), substituted
''subparagraph (B) or a decision of the Medicare Geographic
Classification Review Board or the Secretary under paragraph (10),'' for
''subparagraph (B)'' in two places.
Subsec. (d)(8)(C)(iv). Pub. L. 101-239, 6003(h)(4), added cl. (iv).
Subsec. (d)(8)(D). Pub. L. 101-239, 6003(h)(2)(B), substituted ''(B)
and (C) or a decision of the Medicare Geographic Classification Review
Board or the Secretary under paragraph (10)'' for ''(B) and (C)'' in
three places.
Subsec. (d)(9)(B)(ii)(IV). Pub. L. 101-239, 6003(e)(2)(C),
substituted ''subparagraph (D)(iii)'' for ''subparagraph (D)(v)''.
Subsec. (d)(9)(D)(iii). Pub. L. 101-239, 6003(e)(2)(D)(ii),
redesignated cl. (v) as (iii). Former cl. (iii) redesignated (iv).
Subsec. (d)(9)(D)(iv). Pub. L. 101-239, 6003(e)(2)(D)(i), (ii),
redesignated former cl. (iii) as (iv), substituted ''Subparagraph (H)''
for ''Subparagraph (C)(iii)'', and struck out former cl. (iv) which
read as follows: ''Subparagraph (E) (relating to payments for costs of
certified registered nurse anesthetists).''
Subsec. (d)(9)(D)(v). Pub. L. 101-239, 6003(e)(2)(D)(iii),
redesignated cl. (v) as (iii).
Subsec. (d)(10). Pub. L. 101-239, 6003(h)(1), added par. (10).
Subsec. (g)(3)(A)(iv). Pub. L. 101-234, 301(b)(3), (c)(3), amended
cl. (iv) identically, substituting ''(as the case may be)'' for ''(as
the case may) be''.
Subsec. (g)(3)(A)(v). Pub. L. 101-239, 6002, added cl. (v).
Subsec. (g)(3)(B). Pub. L. 101-239, 6003(e)(2)(E), substituted
''subsection (d)(5)(D)(iii)'' for ''subsection (d)(5)(C)(ii)''.
Subsec. (i). Pub. L. 101-239, 6003(g)(4), added subsec. (i).
1988 -- Subsec. (b)(3)(B)(i)(III). Pub. L. 100-485, 608(d)(18)(A),
substituted ''for hospitals'' for ''for for hospitals'' before ''located
in other urban areas''.
Pub. L. 100-360, 411(b)(1)(A), substituted ''for hospitals located
in other urban areas'' for ''other hospitals''.
Subsec. (b)(3)(B)(i)(IV). Pub. L. 100-485, 608(d)(18)(A),
substituted ''for hospitals'' for ''for for hospitals'' before ''located
in other urban areas''.
Pub. L. 100-360, 411(b)(1)(A), (B), substituted ''percentage
points'' for ''percent'' in three places and ''for hospitals located in
other urban areas'' for ''other hospitals''.
Subsec. (b)(3)(B)(i)(V). Pub. L. 100-360, 411(b)(1)(C), inserted
''increase'' after ''market basket percentage''.
Subsec. (d)(1)(A)(iii). Pub. L. 100-360, 411(b)(1)(G), substituted
''if the average standardized amount (described in clause (i)(I) or
clause (ii)(I) of paragraph (3)(D)) for hospitals within the region of,
and in the same rural, large urban, or other urban area as, the hospital
is greater than the average standardized amount (described in the
respective clause) for hospitals within the United States in that type
of area'' for ''if greater''.
Subsec. (d)(2)(C)(i). Pub. L. 100-647, 1018(r)(1), struck out Pub.
L. 99-514, 1895(b)(1), (2). Previously, Pub. L. 99-509,
9307(c)(1)(A), struck out Pub. L. 99-514, 1895(b)(1)(A). See 1986
Amendment note below.
Subsec. (d)(2)(C)(iv). Pub. L. 100-647, 8401, substituted ''1995''
for ''1990''.
Pub. L. 100-647, 1018(r)(1), struck out Pub. L. 99-514,
1895(b)(1), (2). Previously, Pub. L. 99-509, 9307(c)(1)(B)(i), as
amended by Pub. L. 100-203, 4009(j)(6)(A), struck out Pub. L.
99-514, 1895(b)(2)(A). See 1986 Amendment note below.
Subsec. (d)(2)(D). Pub. L. 100-360, 411(b)(1)(D), substituted ''the
publications described in subsection (e)(5) of this section'' for ''the
publication described in subsection (e)(5)(B) of this section'' in
second sentence.
Pub. L. 100-360, 411(b)(1)(H)(i), struck out at end ''For purposes
of payment under this subsection, a hospital is considered to be located
in an urban area or large urban area, respectively, if the hospital is
paid under this subsection at the rate for hospitals located in such an
area.''
Subsec. (d)(3)(A). Pub. L. 100-647, 1018(r)(1), struck out Pub. L.
99-514, 1895(b)(1), (2). Previously, Pub. L. 99-509, 9307(c)(1)(A),
struck out Pub. L. 99-514, 1895(b)(1)(B). See 1986 Amendment note
below.
Subsec. (d)(3)(A)(i). Pub. L. 100-360, 411(b)(1)(E)(i), as added by
Pub. L. 100-485, 608(d)(18)(B), substituted ''occurring'' for
''occuring'' in first sentence.
Pub. L. 100-360, 411(b)(1)(E)(ii), formerly 411(b)(1)(E), as
redesignated by Pub. L. 100-485, 608(d)(18)(B), made technical
correction to Pub. L. 100-203, 4002(c)(1)(B)(iii), see 1987 Amendment
note below.
Subsec. (d)(3)(A)(ii). Pub. L. 100-360, 411(b)(1)(F), substituted
''in other urban areas'' for ''in urban areas''.
Subsec. (d)(3)(C)(ii). Pub. L. 100-647, 1018(r)(1), struck out Pub.
L. 99-514, 1895(b)(1), (2). Previously, Pub. L. 99-509,
9307(c)(1)(A), struck out Pub. L. 99-514, 1895(b)(1)(C). See 1986
Amendment note below.
Subsec. (d)(3)(C)(ii)(I), (II). Pub. L. 100-647, 8401, substituted
''1995'' for ''1990''.
Subsec. (d)(3)(C)(iii). Pub. L. 100-647, 1018(r)(1), struck out Pub.
L. 99-514, 1895(b)(1), (2). Previously, Pub. L. 99-509,
9307(c)(1)(B)(i), as amended by Pub. L. 100-203, 4009(j)(6)(A), struck
out Pub. L. 99-514, 1895(b)(2)(B). See 1986 Amendment note below.
Subsec. (d)(5)(B)(ii)(I), (II). Pub. L. 100-647, 8401, substituted
''1995'' for ''1990''.
Subsec. (d)(5)(F)(i). Pub. L. 100-647, 8401, substituted ''1995''
for ''1990''.
Subsec. (d)(5)(F)(vi)(I). Pub. L. 100-647, 1018(r)(1), struck out
Pub. L. 99-514, 1895(b)(1), (2). See 1986 Amendment note below.
Subsec. (d)(8). Pub. L. 100-360, 411(b)(4)(C)(i), made technical
correction to directory language of Pub. L. 100-203, 4005(a)(1)(D),
see 1987 Amendment note below.
Subsec. (d)(8)(B). Pub. L. 100-360, 411(b)(4)(A)(i), substituted
''For purposes of this subsection, the Secretary'' for ''The
Secretary''.
Pub. L. 100-360, 411(b)(4)(A)(ii), substituted ''the rural county
would otherwise be considered part of an urban area, under the standards
for designating Metropolitan Statistical Areas (and for designating New
England County Metropolitan Areas) published in the Federal Register on
January 3, 1980, if the commuting rates used in determining outlying
counties (or, for New England, similar recognized areas) were determined
on the basis of the aggregate number of resident workers who commute to
(and, if applicable under the standards, from) the central county or
counties of all contiguous Metropolitan Statistical Areas (or New
England County Metropolitan Areas).'' for '' --
''(i) the rural county would otherwise be considered part of an urban
area but for the fact that the rural county does not meet the standard
relating to the rate of commutation between the rural county and the
central county or counties of any adjacent urban area; and
''(ii) either (I) the number of residents of the rural county who
commute for employment to the central county or counties of any adjacent
urban area is equal to at least 15 percent of the number of residents of
the rural county who are employed, or (II) the sum of the number of
residents of the rural county who commute for employment to the central
county or counties of any adjacent urban area and the number of
residents of any adjacent urban area who commute for employment to the
rural county is at least equal to 20 percent of the number of residents
of the rural county who are employed.''
Subsec. (d)(8)(C). Pub. L. 100-647, 8403(a)(2), added subpar. (C).
Former subpar. (C) redesignated (D).
Pub. L. 100-360, 411(b)(4)(B), substituted ''standardized amounts''
for ''standardized amount''.
Subsec. (d)(8)(D). Pub. L. 100-647, 8403(a)(1), redesignated former
subpar. (C) as (D) and substituted ''subparagraphs (B) and (C)'' for
''subparagraph (B)'' wherever appearing.
Subsec. (d)(9)(C)(iv). Pub. L. 100-360, 411(b)(3), added Pub. L.
100-203, 4004(a)(2), see 1987 Amendment note below.
Subsec. (e)(6)(B). Pub. L. 100-360, 411(b)(8)(B), amended Pub. L.
100-203, 4009(d)(1), see 1987 Amendment note below.
Subsec. (f)(1)(A). Pub. L. 100-360, 411(b)(6)(B), added Pub. L.
100-203, 4007(b)(1)(A), (B), see 1987 Amendment note below.
Subsec. (f)(1)(B). Pub. L. 100-360, 411(b)(6)(B), added Pub. L.
100-203, 4007(b)(1)(C), see 1987 Amendment note below.
Subsec. (g)(3)(A)(ii) to (iv). Pub. L. 100-360, 411(b)(5)(B), made
technical amendment to Pub. L. 100-203, 4006(a), see 1987 Amendment
note below.
Subsec. (g)(3)(A)(iv). Pub. L. 100-360, 411(b)(5)(A), inserted ''for
payments attributable'' after ''15 percent''.
1987 -- Subsec. (a)(4). Pub. L. 100-203, 4009(j)(1), inserted a
comma after ''educational activities''.
Pub. L. 100-203, 4006(b)(2)(A), substituted ''other capital-related
costs (as defined by the Secretary for periods before October 1, 1987)''
for ''with respect to costs incurred in cost reporting periods beginning
prior to October 1 of 1987 (or of such later year as the Secretary may,
in his discretion, select), other capital-related costs, as defined by
the Secretary''.
Subsec. (b)(3)(B)(i). Pub. L. 100-203, 4002(e)(1), struck out
''subparagraph (A) for 12-month cost reporting periods beginning during
a fiscal year and for purposes of'' after ''For purposes of''.
Subsec. (b)(3)(B)(i)(II). Pub. L. 100-203, 4002(a), struck out ''and
for fiscal year 1988, the market basket percentage increase (as defined
in clause (ii)) minus 2.0 percentage points, and'' after ''1.15
percent,''.
Subsec. (b)(3)(B)(i)(III) to (V). Pub. L. 100-203, 4002(a), added
subcls. (III) to (V) and struck out former subcl. (III) which read
''for fiscal year 1989 and subsequent fiscal years, the percentage
determined by the Secretary pursuant to subsection (e)(4) of this
section.''
Subsec. (b)(3)(B)(ii), (iii). Pub. L. 100-203, 4002(e)(2), (3),
added cl. (ii), redesignated former cl. (ii) as (iii), and substituted
''For purposes of this subparagraph'' for ''For purposes of clause
(i)''.
Subsec. (d)(1)(A)(iii). Pub. L. 100-203, 4002(d), inserted before
period at end '', or, if greater for discharges occurring during the
period beginning on April 1, 1988, and ending on September 30, 1990, the
sum of (I) 85 percent of the national adjusted DRG prospective payment
rate determined under paragraph (3) for such discharges, and (II) 15
percent of the regional adjusted DRG prospective payment rate determined
under such paragraph''.
Subsec. (d)(2)(C)(iv). Pub. L. 100-203, 4009(j)(6)(A), made
technical amendment to Pub. L. 99-509, 9307(c)(1)(B). See 1986
Amendment note below.
Pub. L. 100-203, 4003(c), substituted ''1990'' for ''1989''.
Subsec. (d)(2)(D). Pub. L. 100-203, 4002(f)(1)(A), inserted sentence
at end providing that hospital is considered located in urban area or
large urban area, respectively, if it is paid under this subsection at
rate for hospitals located in such area.
Pub. L. 100-203, 4002(b), in second sentence inserted definition of
''large urban area''.
Subsec. (d)(3). Pub. L. 100-203, 4002(c)(1)(A), substituted ''large
urban, other urban, or rural areas'' for ''urban or rural areas'' in
second sentence.
Subsec. (d)(3)(A)(i). Pub. L. 100-203, 4002(c)(1)(B), (C), as
amended by Pub. L. 100-360, 411(b)(1)(E)(ii), designated existing
provisions as cl. (i), substituted ''For discharges occuring in a
fiscal year beginning before October 1, 1987, the Secretary'' for ''The
Secretary'' and ''the fiscal year involved'' for ''each of fiscal years
1985, 1986, 1987, and 1988'', struck out '', and adjusted for subsequent
fiscal years in accordance with the final determination of the Secretary
under subsection (e)(4) of this section, and adjusted to reflect the
most recent case-mix data available'', and added cls. (ii) and (iii).
Subsec. (d)(3)(C)(ii). Pub. L. 100-203, 4003(c), substituted
''1990'' for ''1989'' in subcls. (I) and (II).
Pub. L. 100-203, 4003(a)(2), inserted ''and by section 4003(a)(1) of
the Omnibus Budget Reconciliation Act of 1987'' after ''Amendments of
1985'' in subcls. (I) and (II).
Subsec. (d)(3)(C)(iii). Pub. L. 100-203, 4009(j)(6)(A), made
technical amendment to Pub. L. 99-509, 9307(c)(1)(B). See 1986
Amendment note below.
Subsec. (d)(3)(D)(i). Pub. L. 100-203, 4002(c)(1)(D), inserted
''(or, for discharges occurring on or after April 1, 1988, in a large
urban area or other urban area)'' after first reference to ''urban
area'', and in subcl. (I) inserted ''such'' before ''an urban area''.
Subsec. (d)(3)(E). Pub. L. 100-203, 4004(a)(1), formerly 4004(a),
as redesignated by Pub. L. 100-360, 411(b)(3), inserted at end ''Not
later than October 1, 1990 (and at least every 36 months thereafter),
the Secretary shall update the factor under the preceding sentence on
the basis of a survey conducted by the Secretary (and updated as
appropriate) of the wages and wage-related costs of subsection (d)
hospitals in the United States. To the extent determined feasible by
the Secretary, such survey shall measure the earnings and paid hours of
employment by occupational category and shall exclude data with respect
to the wages and wage-related costs incurred in furnishing skilled
nursing facility services.''
Subsec. (d)(5)(B)(ii). Pub. L. 100-203, 4003(c), substituted
''1990'' for ''1989'' in subcls. (I) and (II).
Pub. L. 100-203, 4003(a)(1), substituted ''1.89'' for ''2'' in
subcl. (I) and ''1.43'' for ''1.5'' in subcl. (II).
Subsec. (d)(5)(C)(i)(I). Pub. L. 100-203, 4005(d)(1)(A), substituted
''275'' for ''500''.
Subsec. (d)(5)(C)(i)(II). Pub. L. 100-203, 4009(j)(2), inserted
''index'' after ''case mix'' in two places.
Subsec. (d)(5)(C)(ii). Pub. L. 100-203, 4005(c)(1), substituted
''1990'' for ''1988'' in second sentence and inserted after second
sentence ''A subsection (d) hospital that meets the criteria for
classification as a sole community hospital and otherwise qualifies for
the adjustment authorized by the preceding sentence may qualify for such
an adjustment without regard to the formula by which payments are
determined for the hospital under paragraph (1)(A).''
Subsec. (d)(5)(F)(i). Pub. L. 100-203, 4003(c), substituted ''1990''
for ''1989''.
Subsec. (d)(5)(F)(i)(II). Pub. L. 100-203, 4009(j)(3)(A),
substituted ''such net inpatient care revenues'' for second reference to
''such revenues''.
Subsec. (d)(5)(F)(iii). Pub. L. 100-203, 4003(b)(1), substituted
''25 percent'' for ''15 percent''.
Subsec. (d)(5)(F)(iv)(I). Pub. L. 100-203, 4009(j)(3)(B),
substituted ''clause (v)'' for ''subclause (III)''.
Pub. L. 100-203, 4003(b)(2), struck out ''the lesser of 15 percent,
or'' after ''is equal to''.
Subsec. (d)(5)(F)(vi)(I). Pub. L. 100-203, 4009(j)(6)(A), made
technical amendment to Pub. L. 99-509, 9307(c)(1)(B)(ii). See 1986
Amendment note below.
Subsec. (d)(8). Pub. L. 100-203, 4005(a)(1), as amended by Pub. L.
100-360, 411(b)(4)(C)(i), designated existing provisions as subpar.
(A), redesignated former subpar. (A) and cls. (i) and (ii) as cl. (i)
and subcls. (I) and (II), respectively, redesignated former subpar.
(B) and cls. (i) and (ii) as cl. (ii) and subcl. (I) and (II),
respectively, and added subpars. (B) and (C).
Subsec. (d)(9)(A)(ii). Pub. L. 100-203, 4002(c)(2), substituted ''a
large urban area,'' for ''an urban area, and'' in subcl. (I), added
subcl. (II), and redesignated former subcl. (II) as (III).
Subsec. (d)(9)(B). Pub. L. 100-203, 4009(j)(4), realigned margin of
introductory provisions.
Subsec. (d)(9)(C)(iv). Pub. L. 100-203, 4004(a)(2), as added by Pub.
L. 100-360, 411(b)(3), inserted at end ''The second and third
sentences of paragraph (3)(E) shall apply to subsection (d) Puerto Rico
hospitals under this clause in the same manner as they apply to
subsection (d) hospitals under such paragraph and, for purposes of this
clause, any reference in such paragraph to a subsection (d) hospital is
deemed a reference to a subsection (d) Puerto Rico hospital.''
Subsec. (e)(3)(B). Pub. L. 100-203, 4002(f)(1)(B), struck out ''or
determine'' after ''recommend''.
Subsec. (e)(4). Pub. L. 100-203, 4002(f)(1)(C), substituted ''for
each fiscal year (beginning with fiscal year 1988)'' for ''for fiscal
year 1988'', struck out ''and shall determine for each subsequent fiscal
year the percentage change which will apply for purposes of this section
as the applicable percentage increase (otherwise described in subsection
(b)(3)(B) of this section) for discharges in that fiscal year, and''
after ''in that fiscal year'', and amended last sentence generally.
Prior to amendment, last sentence read as follows: ''The percentage
change shall be the same for all subsection (d) hospitals and subsection
(d) Puerto Rico hospitals, but may be different from that for other
hospitals (and units not included as such hospitals) and may vary among
such other hospitals and units.''
Subsec. (e)(5). Pub. L. 100-203, 4009(j)(6)(B), amended Pub. L.
99-509, 9302(a)(2)(C). See 1986 Amendment note below.
Pub. L. 100-203, 4002(f)(1)(D), struck out ''or determination''
after ''recommendation'' in subpars. (A) and (B).
Subsec. (e)(6)(B). Pub. L. 100-203, 4009(d)(1), as amended by Pub.
L. 100-360, 411(b)(8)(B), substituted ''include individuals with
national recognition for their expertise in health economics, hospital
reimbursement, hospital financial management, and other related fields,
who provide a mix of different professionals, broad geographic
representation, and a balance between urban and rural representatives''
for ''provide expertise and experience in the provision and financing of
health care'', and struck out last sentence which required Director to
seek nominations from wide range of groups, including specified types of
national organizations.
Subsec. (e)(6)(D). Pub. L. 100-203, 4083(b)(1), inserted at end
''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.''
Subsec. (f)(1)(A). Pub. L. 100-203, 4007(b)(1)(A), (B), as added by
Pub. L. 100-360, 411(b)(6)(B), inserted subpar. (A) designation and
struck out '', for a period ending not earlier than September 30,
1988,'' after ''shall maintain''.
Subsec. (f)(1)(B). Pub. L. 100-203, 4007(b)(1)(C), as added by Pub.
L. 100-360, 411(b)(6)(B), added subpar. (B).
Subsec. (f)(3). Pub. L. 100-93 amended par. (3) generally. Prior to
amendment, par. (3) read as follows: ''The provisions of paragraphs
(2), (3), and (4) of section 1395y(d) of this title shall apply to
determinations under paragraph (2) of this subsection in the same manner
as they apply to determinations made under section 1395y(d)(1) of this
title.''
Subsec. (g)(1). Pub. L. 100-203, 4006(b)(1), amended par. (1)
generally. Prior to amendment, par. (1) read as follows: ''If the
Congress does not enact legislation, after April 20, 1983, and before
October 1, 1987, respecting the payment under this subchapter for
capital-related costs for inpatient hospital services, no payment may be
made under this subchapter for capital-related costs of capital
expenditures (as defined in section 1320a-1(g) of this title and except
as provided in section 1320a-1(j) of this title) for inpatient hospital
services in a State, which expenditures are obligated after September
30, 1987, unless the State has an agreement with the Secretary under
section 1320a-1(b) of this title and under the agreement the State has
recommended approval of the capital expenditures.''
Subsec. (g)(3)(A)(ii) to (iv). Pub. L. 100-203, 4006(a), as amended
by Pub. L. 100-360, 411(b)(5)(B), substituted ''on or after October 1,
1987, and before January 1, 1988,'' for '', and'', at end of cl. (ii),
added cls. (iii) and (iv), and struck out former cl. (iii) which read
as follows: ''10 percent for payments attributable to portions of cost
reporting periods or discharges (as the case may be) occurring during
fiscal year 1989.''
Subsec. (g)(3)(C). Pub. L. 100-203, 4006(b)(2)(B), struck out
subpar. (C) which read as follows: ''If the Secretary provides, under
subsection (a)(4) of this section, for the inclusion of other
capital-related costs in operating costs of inpatient hospital services,
the Secretary shall provide --
''(i) notwithstanding any other provision of this subchapter, for the
continuation of payment under the reasonable cost methodology described
in section 1395x(v)(1) of this title with respect to capital-related
costs of any hospital that is such a sole community hospital for cost
reporting periods beginning before October 1, 1990, and
''(ii) in the design of such payment system that the aggregate
payment amounts under this subchapter for such other capital-related
costs for payments attributable to portions of cost reporting periods
occurring during fiscal year 1988 and fiscal year 1989 shall approximate
the aggregate payment amount under this subchapter that would have been
made (taking into account the provisions of subparagraphs (A) and (B))
during that fiscal year but for the inclusion of such costs by the
Secretary.''
Subsec. (h)(4)(C). Pub. L. 100-203, 4009(j)(5), substituted
''subparagraph (D)'' for ''subparagraph (E)''.
1986 -- Subsec. (a)(4). Pub. L. 99-509, 9320(g)(1), struck out '',
costs of anesthesia services provided by a certified registered nurse
anesthetist,'' after ''approved educational activities''.
Pub. L. 99-509, 9303(c), substituted ''October 1 of 1987 (or of such
later year as the Secretary may, in his discretion, select)'' for
''October 1, 1987''.
Pub. L. 99-349 substituted ''1987'' for ''1986''.
Pub. L. 99-272, 9107(a)(2), inserted ''a return on equity capital,''
after ''anesthetist,'' and ''other'' before ''capital-related costs''.
Subsec. (b)(3)(B). Pub. L. 99-272, 9101(b), amended subpar. (B)
generally. Prior to amendment, subpar. (B) read as follows: ''For
purposes of subparagraph (A) and subsection (d) of this section and
except as provided in subsection (e) of this section, the 'applicable
percentage increase' for any 12-month cost reporting period or fiscal
year shall be equal to one-quarter of 1 percentage point plus the
percentage, estimated by the Secretary before the beginning of the
period or year, by which the cost of the mix of goods and services
(including personnel costs but excluding non-operating costs) comprising
routine, ancillary, and special care unit inpatient hospital services,
based on an index of appropriately weighted indicators of changes in
wages and prices which are representative of the mix of goods and
services included in such inpatient hospital services, for such cost
reporting period or fiscal year will exceed the cost of such mix of
goods and services for the preceding 12-month cost reporting period or
fiscal year. In determining a percentage change under subsection (e)(4)
of this section with respect to discharges occurring in any cost
reporting period or fiscal year beginning on or after October 1, 1985,
and before October 1, 1986, the Secretary may not establish a percentage
increase which exceeds the applicable percentage increase otherwise
determined for that period or fiscal year under the preceding
sentence.''
Subsec. (b)(3)(B)(i)(II). Pub. L. 99-509, 9302(a)(1), amended subcl.
(II) generally. Prior to amendment, subcl. (II) read as follows:
''for fiscal years 1987 and 1988, a percentage determined by the
Secretary pursuant to subsection (e)(4) of this section, but not to
exceed the market basket percentage increase (as defined in clause
(ii)), and''.
Subsec. (b)(6). Pub. L. 99-514, 2, substituted ''Internal Revenue
Code of 1986'' for ''Internal Revenue Code of 1954''.
Subsec. (c)(7). Pub. L. 99-272, 9109(a), added par. (7).
Subsec. (d)(1)(A). Pub. L. 99-272, 9102(a), substituted ''1987'' for
''1986'' in cls. (ii) and (iii).
Subsec. (d)(1)(C). Pub. L. 99-272, 9102(b), struck out '', or
discharges occurring'' after ''periods beginning'' in introductory
provision, and ''and'' after ''percent;'' in cl. (ii), added cl.
(iii), redesignated former cl. (iii) as (iv), and in cl. (iv)
substituted ''on or after October 1, 1986, and before October 1, 1987''
for ''on or after October 1, 1985, and before October 1, 1986''.
Subsec. (d)(1)(D). Pub. L. 99-272, 9102(c), struck out ''cost
reporting periods beginning, or'' before ''discharges occurring'' in
introductory provision, in cl. (i) substituted ''1986'' for ''1985'',
and in cl. (ii) substituted ''1986'' and ''1987'' for ''1985'' and
''1986'', respectively.
Subsec. (d)(2)(C)(i). Pub. L. 99-509, 9307(c)(1)(A), struck out Pub.
L. 99-514, 1895(b)(1)(A), which had directed the striking out of
''(taking into account, for discharges occurring after September 30,
1986, the amendments made by section 9104(a) of the Medicare and
Medicaid Budget Reconciliation Amendments of 1985)'' after ''medical
education costs''.
Pub. L. 99-272, 9104(b)(1), inserted ''(taking into account, for
discharges occurring after September 30, 1986, the amendments made by
section 9104(a) of the Medicare and Medicaid Budget Reconciliation
Amendments of 1985)'' after ''medical education costs''.
Subsec. (d)(2)(C)(iv). Pub. L. 99-509, 9306(c), substituted ''1989''
for ''1988''.
Pub. L. 99-509, 9307(c)(1)(B)(i), as amended by Pub. L. 100-203,
4009(j)(6)(A), struck out Pub. L. 99-514, 1895(b)(2)(A), which had
directed that cl. (iv) was to be struck out.
Pub. L. 99-272, 9105(b), added cl. (iv).
Subsec. (d)(3)(A). Pub. L. 99-509, 9302(a)(2)(A), (c), substituted
''1986, 1987, and 1988'' for ''and 1986'' and inserted provisions
relating to the computation of urban and rural averages with respect to
discharges occurring on or after October 1, 1987.
Pub. L. 99-509, 9307(c)(1)(A), struck out Pub. L. 99-514,
1895(b)(1)(B), which had directed insertion of ''If the formula under
paragraph (5)(B) for determining payments for the indirect costs of
medical education is changed for any fiscal year, the Secretary shall
readjust the standardized amounts previously determined for each
hospital to take into account the changes in that formula.''
Pub. L. 99-272, 9101(c)(1), substituted ''for each of fiscal years
1985 and 1986'' for ''for fiscal year 1985''.
Subsec. (d)(3)(B). Pub. L. 99-509, 9302(b)(1), inserted ''for
hospitals located in an urban area and for hospitals located in a rural
area'' after ''subparagraph (A)'', and inserted before the period ''for
hospitals located in such respective area''.
Subsec. (d)(3)(C). Pub. L. 99-272, 9104(b)(2), designated existing
provision as cl. (i), substituted ''For discharges occurring in fiscal
year 1985, the Secretary'' for ''The Secretary'', and added cl. (ii).
Subsec. (d)(3)(C)(ii). Pub. L. 99-509, 9306(c), substituted ''1989''
for ''1988'' in subcls. (I) and (II).
Pub. L. 99-509, 9307(c)(1)(A), struck out Pub. L. 99-514,
1895(b)(1)(C), which had directed a general amendment of cl. (ii) to
read as follows: ''The Secretary shall further reduce each of the
average standardized amounts by a proportion equal to the proportion
(estimated by the Secretary) of the amount of payments under this
subsection based on DRG prospective payment amounts which is the
difference between --
''(I) the sum of the additional payment amounts under paragraph
(5)(B) (relating to indirect costs of medical education) if the indirect
teaching adjustment factor were equal to 1.159r (as 'r' is defined in
paragraph (5)(B)(ii)), and
''(II) that sum using the factor specified in paragraph
(5)(B)(ii)(II).''
Subsec. (d)(3)(C)(iii). Pub. L. 99-509, 9307(c)(1)(B)(i), as amended
by Pub. L. 100-203, 4009(j)(6)(A), struck out Pub. L. 99-514,
1895(b)(2)(B), which had added cl. (iii) reading as follows: ''The
Secretary shall further reduce each of the average standardized amounts
by reducing the standardized amount for each hospital (as previously
determined without regard to this clause) by a proportion equal to the
proportion (established by the Secretary) of the amount of payments
under this subsection based on DRG prospective payment amounts which are
additional payments described in paragraph (5)(F) (relating to
disproportionate share payments) for subsection (d) hospitals.''
Subsec. (d)(3)(D)(i)(I), (ii)(I). Pub. L. 99-272, 9104(b)(3),
inserted ''or reduced'' after ''(B), and adjusted''.
Subsec. (d)(4)(C). Pub. L. 99-509, 9302(e)(1), substituted ''in
fiscal year 1988 and at least annually'' for ''in fiscal year 1986 and
at least every four fiscal years''.
Subsec. (d)(5)(B). Pub. L. 99-272, 9104(a), amended subpar. (B)
generally. Prior to amendment, subpar. (B) read as follows: ''The
Secretary shall provide for an additional payment amount for subsection
(d) hospitals with indirect costs of medical education, in an amount
computed in the same manner as the adjustment for such costs under
regulations (in effect as of January 1, 1983) under subsection (a)(2) of
this section, except that in the computation under this subparagraph the
Secretary shall use an educational adjustment factor equal to twice the
factor provided under such regulations. In determining such adjustment
the Secretary shall not distinguish between those interns and residents
who are employees of a hospital and those interns and residents who
furnish services to a hospital but are not employees of such hospital.''
Subsec. (d)(5)(B)(ii). Pub. L. 99-509, 9306(c), substituted ''1989''
for ''1988'' in subcls. (I) and (II).
Subsec. (d)(5)(C)(i). Pub. L. 99-509, 9302(d)(1)(A), designated
existing provisions as subcl. (I) and added subcl. (II).
Pub. L. 99-272, 9106(a), inserted ''and which shall not require a
rural osteopathic hospital to have more than 3,000 discharges in a year
in order to be classified as a rural referral center'' before the period
in second sentence.
Pub. L. 99-272, 9105(c) struck out '', and of public or other
hospitals that serve a significantly disproportionate number of patients
who have low income or are entitled to benefits under part A of this
subchapter'' after ''in rural areas)''.
Subsec. (d)(5)(C)(i)(I). Pub. L. 99-509, 9304(b)(1), inserted
''(other than under paragraph (9))'' after ''established under this
subsection'' in first sentence.
Subsec. (d)(5)(C)(ii). Pub. L. 99-509, 9304(b)(2), inserted ''(other
than under paragraph (9))'' after ''this subsection'' in second and
third sentences.
Pub. L. 99-509, 9302(e)(4), substituted ''1988'' for ''1986''.
Pub. L. 99-272, 9111(a), inserted provision authorizing the
Secretary to adjust amount of payments to sole community hospitals that
realize a significant increase in operating costs in a cost reporting
period attributable to addition of new inpatient facilities or services.
Subsec. (d)(5)(E). Pub. L. 99-509, 9320(g)(2), struck out subpar.
(E) which read as follows: ''The Secretary shall provide for an
additional payment amount for any subsection (d) hospital equal to the
reasonable costs incurred by such hospital for anesthesia services
provided by a certified registered nurse anesthetist. Payment under
this subparagraph shall be the only payment made to such hospital with
respect to such services.''
Subsec. (d)(5)(F). Pub. L. 99-272, 9105(a), added subpar. (F).
Subsec. (d)(5)(F)(i). Pub. L. 99-509, 9306(c), substituted ''1989''
for ''1988''.
Subsec. (d)(5)(F)(iv)(I). Pub. L. 99-509, 9306(b)(1), inserted ''or
is described in the second sentence of subclause (III)'' after ''100 or
more beds''.
Subsec. (d)(5)(F)(iv)(III). Pub. L. 99-509, 9306(b)(2), inserted
''and is not described in the second sentence of clause (v)'' after
''rural area''.
Subsec. (d)(5)(F)(v). Pub. L. 99-509, 9306(a), inserted at end ''A
hospital located in a rural area and with 500 or more beds also 'serves
a significantly disproportionate number of low income patients' for a
cost reporting period if the hospital has a disproportionate patient
percentage (as defined in clause (vi)) for that period which equals or
exceeds a percentage specified by the Secretary.''
Subsec. (d)(5)(F)(vi)(I). Pub. L. 99-514, 1895(b)(2)(A), formerly
1895(b)(2)(C), as amended by Pub. L. 99-509, 9307(c)(1)(B)(ii), as
amended by Pub. L. 100-203, 4009(j)(6)(A), which directed the
substitution of ''supplemental'' for ''supplementary'' and ''period''
for ''fiscal year'', was repealed by Pub. L. 100-647, 1018(r)(1).
Subsec. (d)(9). Pub. L. 99-509, 9304(a), added par. (9).
Subsec. (e)(1)(C). Pub. L. 99-509, 9304(c), added subpar. (C).
Subsec. (e)(3). Pub. L. 99-509, 9302(e)(3), designated existing
provisions as subpar. (A) and added subpar. (B).
Pub. L. 99-272, 9101(c)(2), struck out ''(instead of the applicable
percentage increase described in subsection (b)(3)(B) of this section)''
after ''should be used''.
Subsec. (e)(3)(A). Pub. L. 99-509, 9321(e)(2)(A), substituted
''March'' for ''April''.
Subsec. (e)(4). Pub. L. 99-509, 9302(a)(2)(B), (e)(2), substituted
''recommend for fiscal year 1988 an appropriate change factor for
inpatient hospital services for discharges in that fiscal year and shall
determine for each subsequent fiscal year'' for ''determine for each
fiscal year (beginning with fiscal year 1987) and inserted at end ''The
percentage change shall be the same for all subsection (d) hospitals and
subsection (d) Puerto Rico hospitals, but may be different from that for
other hospitals (and units not included as such hospitals) and may vary
among such other hospitals and units.''
Pub. L. 99-272, 9101(c)(3), substituted ''fiscal year 1987'' for
''fiscal year 1986''.
Subsec. (e)(5). Pub. L. 99-509, 9302(a)(2)(C), as amended by Pub.
L. 100-203, 4009(j)(6)(B), inserted ''recommendation or'' before
''determination'' in subpars. (A) and (B).
Subsec. (e)(5)(A). Pub. L. 99-509, 9321(e)(2)(B), substituted
''May'' for ''June''.
Subsec. (e)(6)(A). Pub. L. 99-272, 9127(a), substituted ''17
individuals'' for ''15 individuals''.
Subsec. (g)(1). Pub. L. 99-349 substituted ''1987'' for ''1986'' in
two places.
Subsec. (g)(2). Pub. L. 99-272, 9107(a)(1), designated existing
provision as subpar. (A), inserted ''the applicable percentage
(described in subparagraph (B)) of'', and added subpar. (B).
Subsec. (g)(2)(B). Pub. L. 99-514, 1895(b)(3), realigned margins of
subpar. (B).
Subsec. (g)(3). Pub. L. 99-509, 9303(a), added par. (3).
Subsec. (g)(3)(A). Pub. L. 99-509, 9303(b), inserted ''and a
subsection (d) Puerto Rico hospital'' after ''subsection (d) hospital''.
Subsec. (h). Pub. L. 99-272, 9202(a), added subsec. (h).
Subsec. (h)(2)(C). Pub. L. 99-514, 1895(b)(9)(A), substituted
''subparagraph (B)'' for ''paragraph (B)''.
Subsec. (h)(4)(D). Pub. L. 99-514, 1895(b)(9)(B), (C), redesignated
subpar. (E) as (D) and in cl. (ii) inserted ''but before July 1,
1987,''.
Subsec. (h)(4)(E). Pub. L. 99-509, 9314(a), added subpar. (E).
Pub. L. 99-514, 1895(b)(9)(C), redesignated former subpar. (E) as
(D).
Subsec. (h)(5)(B). Pub. L. 99-514, 1895(b)(9)(D), substituted
''The'' for ''As used in this paragraph, the''.
1984 -- Subsec. (a)(2)(B). Pub. L. 98-369, 2354(b)(42), substituted
''disproportionate'' for ''disportionate''.
Subsec. (a)(4). Pub. L. 98-369, 2312(b), temporarily inserted '',
costs of anesthesia services provided by a certified registered nurse
anesthetist'' after ''approved educational activities''. See Effective
and Termination Dates of 1984 Amendments note below.
Subsec. (b)(3)(A)(ii). Pub. L. 98-369, 2354(b)(43), inserted ''of''
after ''in the case''.
Subsec. (b)(3)(B). Pub. L. 8-369, 2310(a), substituted ''one-quarter
of 1 percentage point'' for ''1 percentage point'' and inserted
provision that in determining the percentage change under subsec. (e)
of this section with respect to discharges occurring in any cost
reporting period or fiscal year beginning on or after Oct. 1, 1985, and
before Oct. 1, 1986, the Secretary may not establish a percentage
increase which exceeds the applicable percentage increase otherwise
determined for that period or fiscal year under the preceding sentence.
Subsec. (c)(4)(A). Pub. L. 98-369, 2315(a), substituted ''(D), and
(E)'' for ''and (D)''.
Subsec. (d)(2)(D). Pub. L. 98-369, 2315(b), struck out ''Standard''
before ''Metropolitan'' in provision following cl. (ii).
Pub. L. 98-369, 2311(b), inserted provision for determining the
region a hospital located in a Metropolitan Statistical Area would be
deemed to be located.
Subsec. (d)(3)(D)(i)(I). Pub. L. 8-369, 2354(b)(44), substituted
''(C))'' for ''(C),''.
Subsec. (d)(5)(B). Pub. L. 98-369, 2307(b)(1), inserted provision
that in determining such adjustment the Secretary not distinguish
between those interns and residents who are employees of a hospital and
those who furnish services to a hospital but are not employees of such
hospital.
Subsec. (d)(5)(C)(i). Pub. L. 98-617 substituted ''August 17, 1984''
for ''30 days after July 18, 1984'' before ''for implementation by''.
Pub. L. 98-369, 2311(a), inserted provisions permitting a hospital
classified as a rural hospital to appeal to the Secretary for
reclassification as a rural referral center on the basis of criteria
established and published by the Secretary and requiring the Secretary
to make a final determination with respect to such appeal within 60 days
after the date the appeal was submitted.
Subsec. (d)(5)(E). Pub. L. 98-369, 2312(a), temporarily added
subpar. (E). See Effective and Termination Dates of 1984 Amendments
note below.
Subsec. (d)(8). Pub. L. 8-369, 2311(c), added par. (8).
Subsec. (e)(2). Pub. L. 98-369, 2313(a), inserted ''(without regard
to the provisions of title 5 governing appointments in the competitive
service)'' after ''appointed by the Director''.
Subsec. (e)(5). Pub. L. 98-369, 2315(c)(1), struck out ''for public
comment'' after ''have published'' in provisions preceding subpar. (A).
Subsec. (e)(5)(A). Pub. L. 98-369, 2315(c)(2), inserted ''for public
comment'' after ''that fiscal year''.
Subsec. (e)(6)(C). Pub. L. 98-369, 2313(b)(3), inserted provision
that section 10(a)(1) of the Federal Advisory Committee Act not apply to
any portion of a Commission meeting if the Commission, by majority vote,
determines such portion of such meeting should be closed.
Subsec. (e)(6)(C)(i). Pub. L. 98-369, 2313(b)(1), amended cl. (i)
generally, substituting provision authorizing the Commission to employ
and fix the compensation of an Executive Director, subject to the
approval of the Director of the Office, and such other personnel, not to
exceed 25, as necessary, without regard to the provisions of title 5
governing appointment in the competitive service, for provision
authorizing the Commission to employ and fix the compensation of such
personnel, not to exceed 25, as may be necessary to carry out its
duties.
Subsec. (e)(6)(C)(iii). Pub. L. 98-369, 2313(b)(2), inserted
''(without regard to section 5 of title 41)'' after ''Commission''.
Subsec. (e)(6)(D). Pub. L. 98-369, 2313(b)(4), inserted provision
relating to payment of physician comparability allowance in the same
manner as provided under section 5948 of title 5 and providing that for
such purpose subsec. (i) of such section apply to the Commission in the
same manner as it applies to the Tennessee Valley Authority.
Subsec. (e)(6)(J). Pub. L. 98-369, 2313(d), added subpar. (J).
1983 -- Subsec. (a)(1)(D). Pub. L. 98-21, 601(a)(1), added subpar.
(D).
Subsec. (a)(4). Pub. L. 98-21, 601(a)(2), inserted provision that
term ''operating costs of inpatient hospital services'' does not include
costs of approved educational activities, or, with respect to costs
incurred in cost reporting periods beginning prior to Oct. 1, 1986,
capital-related costs, as defined by the Secretary.
Pub. L. 97-448, 309(b)(13), substituted ''as such costs are
determined'' for ''and such costs are determined''.
Subsec. (b)(1). Pub. L. 98-21, 601(b)(1), (2), in provisions
preceding subpar. (A), substituted ''Notwithstanding section 1395f(b)
of this title but subject to the provisions of section 1395e of this
title'' for ''Notwithstanding sections 1395f(b) of this title, but
subject to the provisions of sections 1395e of this title'' and inserted
''(other than a subsection (d) hospital, as defined in subsection
(d)(1)(B) of this section)''.
Pub. L. 98-21, 601(b)(3), inserted ''(other than on the basis of a
DRG prospective payment rate determined under subsection (d) of this
section)'' in provisions following subpar. (B).
Pub. L. 97-448, 309(b)(14), substituted ''section 1395f(b)'' for
''sections 1395f(b)'' in provisions preceding subpar. (A).
Subsec. (b)(2). Pub. L. 98-21, 601(b)(4), struck out par. (2) which
provided that par. (1) would not apply to cost reporting periods of
hospitals beginning on or after Oct. 1, 1985.
Subsec. (b)(3)(B). Pub. L. 98-21, 601(b)(5)-(8), inserted ''and
subsection (d) of this section and except as provided in subsection (e)
of this section'' after ''subparagraph (A)'', inserted ''or fiscal
year'' after ''cost reporting period'' each place it appears, inserted
''before the beginning of the period or year'' after ''estimated by the
Secretary'', and substituted ''will exceed'' for ''exceeds''.
Subsec. (b)(6). Pub. L. 98-21, 601(b)(9), added par. (6) and
repealed a prior par. (6) which directed the Secretary to provide for
an adjustment under this paragraph in the amount of payment otherwise
provided a hospital under this subsection in the case of a hospital
which, as of Aug. 15, 1982, was subject to FICA taxes and which was not
subject to such taxes for part or all of a cost reporting period
beginning on or after Oct. 1, 1982, that in making such adjustment for
a cost reporting period the Secretary was to estimate the amount of the
operating costs of inpatient hospital services that would have resulted
if the hospital was subject to the FICA taxes during that period, that
in making such estimate the Secretary was to reduce the amount of such
FICA taxes that would have been paid (but not below zero) by the amount
of costs which the hospital demonstrated to the satisfaction of the
Secretary were incurred in the period for pensions, health, and other
fringe benefits for employees (and former employees and family members)
comparable to, and in lieu of, the benefits provided under subchapter II
of this chapter and this subchapter, that if a hospital's operating
costs of inpatient hospital services estimated under subparagraph (B)
was greater than the hospital's operating costs of inpatient hospital
services determined without regard to this paragraph for a cost
reporting period, then the Secretary was to reduce the amount otherwise
paid the hospital (respecting operating costs of inpatient hospital
services) under this title (taking into account any limitation under
subsection (a) of this section) for the period by the amount by which
(i) the amount that would have been paid the hospital if (I) the amount
of the operating costs of inpatient hospital services estimated under
subparagraph (B) were treated as the amount of the operating costs of
inpatient hospital services and (II) subsection (a) of this section did
not apply to the determination, exceeded (ii) the amount that would
otherwise have been paid the hospital if subsection (a) of this section
(and this paragraph) did not apply, except that, in making such
determination for cost reporting periods beginning on or after Oct. 1,
1984, clause (ii) of paragraph (1)(B) was to continue to apply.
Subsec. (b)(6)(C). Pub. L. 97-448, 309(b)(15), substituted ''under
this subchapter (taking into account any limitation under subsection (a)
of this section)'' for ''under this subsection'' in provisions preceding
cl. (i).
Subsec. (c)(1). Pub. L. 98-21, 601(c)(1), added subpars. (D) and
(E) and provisions following subpar. (E).
Subsec. (c)(3)(A). Pub. L. 98-21, 601(c)(2)(A), substituted ''meets
the requirements of subparagraphs (A), (D), and (E) of paragraph (1)
and, if applicable, the requirements of paragraph (5),'' for ''meets the
requirement of paragraph (1)(A)''.
Subsec. (c)(3)(B). Pub. L. 98-21, 601(c)(2)(B), inserted ''(or, if
applicable, in paragraph (5))''.
Subsec. (c)(4) to (6). Pub. L. 98-21, 601(c)(3), added pars. (4)
to (6).
Subsec. (d). Pub. L. 98-21, 601(d)(2), (e), added subsec. (d) and
redesignated former subsec. (d), relating to the elimination of
lesser-of-cost-or-charges provisions, as subsec. (j) of section 1814 of
act Aug. 14, 1935, which is classified to subsec. (j) of section 1395f
of this title.
Subsecs. (e) to (g). Pub. L. 98-21, 601(e), added subsecs. (e) to
(g).
1982 -- Subsec. (d). Pub. L. 97-248, 110, added subsec. (d).
Section 4002(a)(2) of Pub. L. 101-508 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
payments for discharges occurring on or after January 1, 1991.''
Section 4002(b)(5) of Pub. L. 101-508 provided that: ''The
amendments made by paragraphs (1), (3), and (4)(B) (amending this
section) shall apply to discharges occurring on or after January 1,
1991, the amendment made by paragraph (2) (amending this section) shall
apply to discharges occurring on or after October 1, 1991, and the
amendment made by paragraph (4)(A) (amending this section) shall take
effect as if included in the enactment of the Omnibus Budget
Reconciliation Act of 1989 (Pub. L. 101-239).''
Section 4002(c)(3) of Pub. L. 101-508 provided that: ''The
amendments made by paragraph (1) and paragraph (2)(A) (amending this
section) shall apply to payments for discharges occurring on or after
January 1, 1991, and the amendments made by paragraph (2)(B) (amending
this section) shall take effect October 1, 1994.''
Section 4002(e)(4)((3)) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply to
discharges occurring on or after October 1, 1990.''
Section 4002(g)(5) of Pub. L. 101-508 provided that: ''The
amendments made by this subsection (amending this section and section
1395w-1 of this title) shall take effect on the date of the enactment of
this Act (Nov. 5, 1990).''
Section 4002(h)(1)(B) of Pub. L. 101-508 provided that: ''The
amendments made by subparagraph (A) (amending this section) shall apply
to discharges occurring on or after January 1, 1991.''
Section 4003(b) of Pub. L. 101-508 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply --
''(1) in the case of any services provided during the day immediately
preceding the date of a patient's admission (without regard to whether
the services are related to the admission), to services furnished on or
after the date of the enactment of this Act (Nov. 5, 1990) and before
October 1, 1991;
''(2) in the case of diagnostic services (including clinical
diagnostic laboratory tests), to services furnished on or after January
1, 1991; and
''(3) in the case of any other services, to services furnished on or
after October 1, 1991.''
Section 4005(a)(2) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply to
cost reporting periods beginning on or after October 1, 1991.''
Section 4005(c)(4) of Pub. L. 101-508 provided that: ''The
amendments made by paragraph (1) (amending this section and section
1395h of this title) shall take effect on the date of the enactment of
this Act (Nov. 5, 1990), and the amendments made by paragraph (2)
(amending this section) shall take effect as if included in the
enactment of the Omnibus Budget Reconciliation Act of 1989 (Pub. L.
101-239).''
Section 4008(f)(2) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall take
effect as if included in the enactment of the Omnibus Budget
Reconciliation Act of 1989 (Pub. L. 101-239).''
Section 6003(a)(2) of Pub. L. 101-239 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
payments for discharges occurring on or after January 1, 1990.''
Section 6003(c)(4) of Pub. L. 101-239 provided that: ''The
amendments made by this subsection (amending this section) shall apply
with respect to discharges occurring on or after April 1, 1990.''
Section 6003(h)(7) of Pub. L. 101-239 provided that: ''The
amendments made by paragraphs (3) and (4) (amending this section) shall
apply to discharges occurring on or after April 1, 1990.''
Section 6004(a)(3) of Pub. L. 101-239 provided that: ''The
amendments made by this subsection (amending this section) shall apply
with respect to cost reporting periods beginning on or after October 1,
1989, except that --
''(A) in the case of a hospital classified by the Secretary of Health
and Human Services as a hospital involved extensively in treatment for
or research on cancer under section 1886(d)(5)(I) of the Social Security
Act (subsec. (d)(5)(I) of this section) (as redesignated by section
6003(e)(1)(A)) after the date of the enactment of this Act (Dec. 19,
1989), such amendments shall apply with respect to cost reporting
periods beginning on or after the date of such classification,
''(B) in the case of a hospital that is not described in subparagraph
(A), such amendments shall apply with respect to portions of cost
reporting periods or discharges occurring during and after fiscal year
1987 for purposes of section 1886(g) of the Social Security Act (subsec.
(g) of this section), and
''(C) such amendments shall take effect 30 days after the date of the
enactment of this Act for purposes of determining the eligibility of a
hospital to receive periodic interim payments under section 1815(e)(2)
of the Social Security Act (section 1395g(e)(2) of this title).''
Section 6004(b)(2) of Pub. L. 101-239 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply
with respect to cost reporting periods beginning on or after April 1,
1989.''
Section 6011(d) of Pub. L. 101-239 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply with respect
to items furnished 6 months after the date of enactment of this Act
(Dec. 19, 1989) and shall expire 2 years after the date of enactment of
this Act.''
Section 6015(c) of Pub. L. 101-239 provided that: ''The amendment
made by subsection (a) (amending this section) shall become effective
with respect to cost reporting periods beginning on or after April 1,
1990.''
Amendment by section 1018(r)(1) of Pub. L. 100-647 effective, except
as otherwise provided, as if included in the provision of the Tax Reform
Act of 1986, Pub. L. 99-514, to which such amendment relates, see
section 1019(a) of Pub. L. 100-647, set out as a note under section 1
of Title 26, Internal Revenue Code.
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
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.
Section 4002(g) of Pub. L. 100-203, as amended by Pub. L. 100-360,
title IV, 411(b)(1)(I), July 1, 1988, 102 Stat. 769, provided that:
''(1) PPS hospitals, drg portion of payment. -- In the case of a
subsection (d) hospital (as defined in paragraph (6)) --
''(A) the amendments made by subsections (a) and (c) (amending this
section) shall apply to payments made under section 1886(d)(1)(A)(iii)
of the Social Security Act (subsec. (d)(1)(A)(iii) of this section) on
the basis of discharges occurring on or after April 1, 1988, and
''(B) for discharges occurring on or after October 1, 1988, the
applicable percentage increase (described in section 1886(b)(3)(B) of
such Act (subsec. (b)(3)(B) of this section)) for discharges occurring
during fiscal year 1987 is deemed to have been such percentage increase
as amended by subsection (a).
''(2) PPS sole community hospitals, hospital specific portion of
payment. -- In the case of a subsection (d) hospital which receives
payments made under section 1886(d)(1)(A) of the Social Security Act
(subsec. (d)(1)(A) of this section) because it is a sole community
hospital --
''(A) the amendment made by subsections (a) and (c) (amending this
section) shall apply to payments under section 1886(d)(1)(A)(ii)(I) of
the Social Security Act made on the basis of discharges occurring during
a cost reporting period of a hospital, for the hospital's cost reporting
period beginning on or after October 1, 1987;
''(B) notwithstanding subparagraph (A), for cost reporting period
beginning during fiscal year 1988, the applicable percentage increase
(as defined in section 1886(b)(3)(B) of such Act (subsec. (b)(3)(B) of
this section)) for the --
''(i) first 51 days of the cost reporting period shall be 0 percent,
''(ii) next 132 days of such period shall be 2.7 percent, and
''(iii) remainder of such period of the cost reporting period shall
be the applicable percentage increase (as so defined, as amended by
subsection (a)); and
''(C) for cost reporting periods beginning on or after October 1,
1988, the applicable percentage increase (as so defined) with respect to
the previous cost reporting period shall be deemed to have been the
applicable percentage increase (as so defined, as amended by subsection
(a)).
''(3) PPS-exempt hospitals. -- In the case of a hospital that is not
a subsection (d) hospital --
''(A) the amendments made by subsection (e) (amending this section)
shall apply to cost reporting periods beginning on or after October 1,
1987;
''(B) notwithstanding subparagraph (A), for the hospital's cost
reporting period beginning during fiscal year 1988, payment under title
XVIII of the Social Security Act (this subchapter) shall be made as
though the applicable percentage increase described in section
1886(b)(3)(B) of such Act (subsec. (b)(3)(B) of this section) were equal
to the product of 2.7 percent and the ratio of 315 to 366; and
''(C) for cost reporting periods beginning on or after October 1,
1988, the applicable percentage increase (as so defined) with respect to
the cost reporting period beginning during fiscal year 1988 shall be
deemed to have been 2.7 percent.
''(4) Definition, regional floor, and technical and conforming
amendments. -- The amendments made by subsections (b) and (d) and
paragraphs (1) and (2) of subsection (f) (amending this section and
provisions set out as a note below) shall take effect on the date of the
enactment of this Act (Dec. 22, 1987).
''(5) Transition for large urban area rates. -- In computing the
average standardized amount for hospitals located in a large urban area
or other urban area under section 1886(d)(3)(A)(ii) of the Social
Security Act (subsec. (d)(3)(A)(ii) of this section) (as amended by
subsection (c)) for fiscal year 1988, the reference to 'the respective
average standardized amount computed for the previous fiscal year under
this subparagraph' is deemed a reference to the average standardized
amount computed for hospitals located in an urban area for the 51-day
period beginning on October 1, 1987.
''(6) Definition. -- In this subsection, the term 'subsection (d)
hospital' has the meaning given such term in section 1886(d)(1)(B) of
the Social Security Act (subsec. (d)(1)(B) of this section).''
Section 4003(e) of Pub. L. 100-203 provided that: ''The amendments
made by this section (amending this section) shall apply to payments for
discharges occurring on or after October 1, 1988.''
Section 4005(a)(3) of Pub. L. 100-203, as amended by Pub. L.
100-360, title IV, 411(b)(4)(C)(ii), July 1, 1988, 102 Stat. 770,
provided that: ''This subsection (amending this section) shall apply to
discharges occurring on or after October 1, 1988.''
Section 4005(c)(2)(A) of Pub. L. 100-203 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
cost reporting periods beginning on or after October 1, 1987(.)''
Section 4005(d)(1)(B) of Pub. L. 100-203 provided that: ''The
amendment made by subparagraph (A) (amending this section) shall apply
to discharges occurring on or after April 1, 1988.''
Section 4006(b)(3) of Pub. L. 100-203 provided that: ''The
amendment made by paragraph (1) (amending this section) shall take
effect on October 1, 1987. The amendments made by paragraph (2)
(amending this section) shall apply to cost reporting periods beginning
on or after October 1, 1987.''
Section 4007(b)(2) of Pub. L. 100-203, as amended by Pub. L.
100-360, title IV, 411(b)(6)(B), July 1, 1988, 102 Stat. 770, provided
that: ''The amendment made by paragraph (1)(C) (amending this section)
shall apply to hospital cost reporting periods beginning on or after
October 1, 1989.''
Section 4009(d)(2) of Pub. L. 100-203 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
appointments made after the date of the enactment of this Act (Dec. 22,
1987).''
Section 4009(j)(6) of Pub. L. 100-203 provided that the amendment
made by that section is effective as if included in the enactment of
Pub. L. 99-509.
Section 4083(b)(2) of Pub. L. 100-203 provided that: ''The
amendments made by paragraph (1) (amending this section) shall take
effect on the date of the enactment of this Act (Dec. 22, 1987).''
Amendment by Pub. L. 100-93 effective at end of fourteen-day period
beginning Aug. 18, 1987, and inapplicable to administrative proceedings
commenced before end of such period, see section 15(a) of Pub. L.
100-93, set out as a note under section 1320a-7 of this title.
Section 1895(b)(1)(D) of Pub. L. 99-514, which provided for
applicability of amendments to this section by section 1895(b)(1) of
Pub. L. 99-514 to discharges occurring on or after Oct. 1, 1986, with
certain exceptions, was repealed by Pub. L. 99-509, title IX,
9307(c)(1)(A), Oct. 21, 1986, 100 Stat. 1995, and by Pub. L.
100-647, title I, 1018(r)(1), Nov. 10, 1988, 102 Stat. 3586.
Section 1895(b)(2)(B), formerly 1895(b)(2)(D), of Pub. L. 99-514,
as amended by Pub. L. 99-509, title IX, 9307(c)(1)(B)(iii), as amended
by Pub. L. 100-203, title IV, 4009(j)(6)(A), Dec. 22, 1987, 101 Stat.
1330-59, which provided for applicability of amendments to this section
by section 1895(b)(2)(A) of Pub. L. 99-514 to discharges occurring on
or after May 1, 1986, was repealed by Pub. L. 100-647, title I,
1018(r)(1), Nov. 10, 1988, 102 Stat. 3586.
Amendment by section 1895(b)(3), (9) of Pub. L. 99-514 effective,
except as otherwise provided, as if included in enactment of the
Consolidated Omnibus Budget Reconciliation Act of 1985, Pub. L.
99-272, see section 1895(e) of Pub. L. 99-514, set out as a note under
section 162 of Title 26, Internal Revenue Code.
Section 9302(a)(3) of Pub. L. 99-509 provided that: ''The amendment
made by paragraph (1) (amending this section) shall apply to cost
reporting periods beginning on or after October 1, 1986 and, for
purposes of section 1886(d) of the Social Security Act (subsec. (d) of
this section), for cost reporting periods beginning and discharges
occurring on or after October 1, 1986.''
Section 9302(b)(2) of Pub. L. 99-509 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
discharges occurring on or after October 1, 1986.''
Section 9302(d)(1)(B) of Pub. L. 99-509 provided that:
''(i) Subject to clause (ii), the amendments made by subparagraph (A)
(amending this section) shall apply to payments for discharges occurring
on or after October 1, 1986.
''(ii) An appeal for classification of a rural hospital as a regional
referral center, pursuant to the amendments made by subparagraph (A),
which is filed before January 1, 1987, and which is approved shall be
effective with respect to discharges occurring on or after October 1,
1986.''
Section 9303(b) of Pub. L. 99-509 provided that the amendment made
by such section 9303(b) is effective for cost reporting periods
beginning and discharges occurring (as the case may be) on or after Oct.
1, 1987.
Section 9304(d) of Pub. L. 99-509 provided that: ''The amendments
made by this section (amending this section) shall apply to discharges
occurring on or after October 1, 1987.''
Section 9306(d) of Pub. L. 99-509 provided that: ''The amendments
made by subsections (a) and (b) (amending this section) shall apply to
discharges occurring on or after October 1, 1986.''
Section 9307(c)(1) of Pub. L. 99-509 provided that the amendment
made by such section 9307(c)(1) is effective as if included in the
enactment of the Tax Reform Act of 1986 (Pub. L. 99-514), if H.Con.Res.
395, 99th Congress, 2d Session, is not adopted. H.Con.Res. 395 was not
adopted.
Section 9314(b) of Pub. L. 99-509 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply to payments
for approved residency training programs as of July 1, 1987.''
Amendment by section 9320(g) of Pub. L. 99-509 applicable to
services furnished on or after Jan. 1, 1989, with exceptions for
hospitals located in rural areas which meet certain requirements related
to certified registered nurse anesthetists, see section 9320(i), (k) of
Pub. L. 99-509, as amended, set out as notes under section 1395k of
this title.
Section 9321(e)(3)(B) of Pub. L. 99-509 provided that: ''The
amendments made by paragraph (2) (amending this section) shall take
effect beginning with fiscal year 1989.''
Section 9101(d) of Pub. L. 99-272 provided that: ''The amendment
made by subsection (a) (amending section 5(c) of Pub. L. 99-107, set out
below) shall take effect on March 15, 1986, and the amendments made by
subsection (c) (amending this section) shall take effect on the date of
the enactment of this Act (Apr. 7, 1986).''
Section 9101(e) of Pub. L. 99-272 provided that:
''(1) PPS hospitals, drg portion of payment. -- In the case of a
subsection (d) hospital (as defined in paragraph (4)) --
''(A) the amendment made by subsection (b) (amending this section)
shall apply to payments made under section 1886(d)(1)(A) of such Act
(subsec. (d)(1)(A) of this section) made on the basis of discharges
occurring on or after May 1, 1986; and
''(B) for discharges occurring on or after October 1, 1986, the
applicable percentage increase (described in section 1886(b)(3)(B)
(subsec. (b)(3)(B) of this section)) for discharges occurring during
fiscal year 1986 shall be deemed to have been 1/2 percent.
''(2) PPS hospitals, hospital specific portion of payment. -- In the
case of a subsection (d) hospital --
''(A) the amendment made by subsection (b) (amending this section)
shall apply to payments under section 1886(d)(1)(A) of the Social
Security Act (subsec. (d)(1)(A) of this section) made on the basis of
discharges occurring during a cost reporting period of a hospital, for
the hospital's cost reporting periods beginning on or after October 1,
1985;
''(B) notwithstanding subparagraph (A), for the cost reporting period
beginning during fiscal year 1986, the applicable percentage increase
(as defined in section 1886(b)(3)(B) of such Act (subsec. (b)(3)(B) of
this section)) for the --
''(i) first 7 months of the cost reporting period shall be 0 percent,
and
''(ii) for the remaining 5 months of the cost reporting period shall
be 1/2 percent; and
''(C) for cost reporting periods beginning on or after October 1,
1986, the applicable percentage increase (as so defined) with respect to
the previous cost reporting period shall be deemed to have been 1/2
percent.
''(3) PPS-exempt hospitals. -- In the case of a hospital that is not
a subsection (d) hospital --
''(A) the amendment made by subsection (b) (amending this section)
shall apply to cost reporting periods beginning on or after October 1,
1985;
''(B) notwithstanding subparagraph (A), for the hospital's cost
reporting period beginning during fiscal year 1986, payment under title
XVIII of the Social Security Act (this subchapter) shall be made as
though the applicable percentage increase described in section
1886(b)(3)(B) (subsec. (b)(3)(B) of this section) were equal to 5/24 of
1 percent; and
''(C) for cost reporting periods beginning on or after October 1,
1986, the applicable percentage increase (as so defined) with respect to
the cost reporting period beginning during fiscal year 1986 shall be
deemed to have been 1/2 percent.
''(4) Definition. -- In this subsection, the term 'subsection (d)
hospital' has the meaning given such term in section 1886(d)(1)(B) of
the Social Security Act (subsec. (d)(1)(B) of this section).''
Section 9102(d) of Pub. L. 99-272 provided that:
''(1) Delay in final transition. -- The amendment made by subsection
(a) (amending this section) shall take effect on the date of the
enactment of this Act (Apr. 7, 1986).''
''(2) Change in hospital specific percentage. -- The amendments made
by subsection (b) (amending this section) shall apply --
''(A) to cost reporting periods beginning on or after October 1,
1985, but
''(B) notwithstanding subparagraph (A), for a hospital's cost
reporting period beginning during fiscal year 1986, for purposes of
section 1886(d)(1)(A) of the Social Security Act (subsec. (d)(1)(A) of
this section) --
''(i) during the first 7 months of the period the 'target percentage'
is 50 percent and the 'DRG percentage' is 50 percent, and
''(ii) during the remaining 5 months of the period the 'target
percentage' is 45 percent and the 'DRG percentage' is 55 percent.
''(3) Change in blended rate. -- The amendments made by subsection
(c) (amending this section) shall apply to discharges occurring on or
after May 1, 1986.
''(4) Exception. --
''(A) Notwithstanding any other provision of this subsection, the
amendments made by this section (amending this section) shall not apply
to payments with respect to the operating costs of inpatient hospital
services (as defined in section 1886(a)(4) of the Social Security Act
(subsec. (a)(4) of this section)) of a subsection (d) hospital (as
defined in section 1886(d)(1)(B) of such Act (subsec. (d)(1)(B) of this
section)) located in the State of Oregon.
''(B) Notwithstanding any other provision of law, for a cost
reporting period beginning during fiscal year 1986 of a subsection (d)
hospital to which the amendments made by this section (amending this
section) do not apply, for purposes of section 1886(d)(1)(A) of of (sic)
Social Security Act (subsec. (d)(1)(A) of this section) --
''(i) during the first 7 months of the period the 'target percentage'
is 50 percent and the 'DRG percentage' is 50 percent, and
''(ii) during the remaining 5 months of the period the 'target
percentage' is 25 percent and the 'DRG percentage' is 75 percent.
''(C) Notwithstanding any other provision of law, for purposes of
section 1886(d)(1)(D) of such Act (subsec. (d)(1)(D) of this section),
the applicable combined adjusted DRG prospective payment rate for a
subsection (d) hospital to which the amendments made by this section
(amending this section) do not apply is, for discharges occurring on or
after October 1, 1985, and before May 1, 1986, a combined rate
consisting of 25 percent of the national adjusted DRG prospective
payment rate and 75 percent of the regional adjusted DRG prospective
payment rate for such discharges.''
Section 9104(c) of Pub. L. 99-272 provided that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (amending this section) shall apply to discharges occurring
on or after May 1, 1986.
''(2) The amendments made by this section shall not first be applied
to discharges occurring as of a date unless, for discharges occurring on
that date, the amendments made by section 9105 (amending this section)
are also being applied.''
Section 9105(e) of Pub. L. 99-272 provided that: ''The amendments
made by this section (amending this section) shall apply to discharges
occurring on or after May 1, 1986.''
Section 9106(b) of Pub. L. 99-272 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply to cost
reporting periods beginning on or after January 1, 1986.''
Section 9107(c)(1) of Pub. L. 99-272 provided that: ''The
amendments made by subsection (a) (amending this section) shall apply to
hospital cost reporting periods beginning on or after October 1, 1986.''
Section 9109(b) of Pub. L. 99-272 provided that: ''The amendment
made by subsection (a) (amending this section) shall take effect on the
date of the enactment of this Act (Apr. 7, 1986).''
Section 9111(b) of Pub. L. 99-272 provided that: ''The amendment
made by this section (amending this section) shall apply to payments for
cost reporting periods beginning on or after October 1, 1983, and before
October 1, 1989.''
Section 9202(b) of Pub. L. 99-272 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply to hospital
cost reporting periods beginning on or after July 1, 1985.''
Amendment by Pub. L. 98-617 effective as if originally included in
the Deficit Reduction Act of 1984, Pub. L. 98-369, see section 3(c) of
Pub. L. 98-617, set out as a note under section 1395f of this title.
Section 2307(b)(2) of Pub. L. 98-369 provided that: ''The amendment
made by paragraph (1) (amending this section) shall apply to cost
reporting periods beginning on or after October 1, 1984.''
Section 2310(b) of Pub. L. 98-369 provided that: ''The amendments
made by this section (amending this section) shall apply to cost
reporting periods beginning in, and discharges occurring in, fiscal year
1985 and thereafter.''
Section 2311(d) of Pub. L. 98-369 provided that:
''(1) Except as provided in paragraph (2), the amendments made by
subsections (b) and (c) (amending this section) shall be effective with
respect to cost reporting periods beginning on or after October 1, 1983,
and the amendment made by subsection (a) (amending this section) shall
be effective with respect to cost reporting periods beginning on or
after October 1, 1984.
''(2) The amendment made by subsection (b) (amending this section)
shall not apply so as to reduce any payment under section 1886(d) of the
Social Security Act (subsec. (d) of this section) to a hospital the
region of which is deemed to be changed pursuant to such amendment for
discharges occurring in any cost reporting period beginning before
October 1, 1984.''
Section 2312(c) of Pub. L. 98-369, as amended by Pub. L. 99-509,
title IX, 9320(a), Oct. 21, 1986, 100 Stat. 2013; Pub. L. 100-360,
title IV, 411(p), July 1, 1988, as added by Pub. L. 100-485, title VI,
608(d)(29), Oct. 13, 1988, 102 Stat. 2424, provided that: ''The
amendments made by subsections (a) and (b) (amending this section) shall
apply to cost reporting periods beginning on or after October 1, 1984,
and before January 1, 1989. In the case of a cost reporting period that
begins before January 1, 1989, but ends after such date, additional
payments under the amendment made by subsection (a) shall be
proportionately reduced to reflect the portion of the period occurring
after such date.''
Amendment by section 2313(a), (b), (d) of Pub. L. 98-369 effective
July 18, 1984, see section 2313(e) of Pub. L. 98-369, set out as an
Effective Date of 1984 Amendment note under section 1395y of this title.
Section 2315(g) of Pub. L. 98-369 provided that: ''The amendments
made by this section (amending this section and sections 1395i-2 and
1395cc of this title and enacting and amending provisions set out as
notes under this section) shall be effective as though they had been
included in the enactment of the Social Security Amendments of 1983
(Public Law 98-21).''
Amendment by section 2354(b)(42)-(44) 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 an Effective Date of 1984 Amendment note
under section 1320a-1 of this title.
Section 601(b)(9) of Pub. L. 98-21 provided that the repeal of
subsec. (b)(6) of this section is effective with respect to cost
reporting periods beginning on or after October 1, 1982, and that the
enactment of a new subsec. (b)(6) of this section is effective with
respect to cost reporting periods beginning on or after October 1, 1983.
Section 604 of title VI of Pub. L. 98-21, as amended by Pub. L.
98-369, div. B, title III, 2315(f)(1), July 18, 1984, 98 Stat. 1080,
provided that:
''(a)(1) Except as provided in section 602(l) (amending section
1395cc of this title) and in paragraph (2), the amendments made by the
preceding provisions of this title (amending this section and sections
1320c-2, 1395f, 1395n, 1395x, 1395y, 1395cc, 1395mm, 1395oo, 1395rr, and
1395xx of this title) apply to items and services furnished by or under
arrangements with a hospital beginning with its first cost reporting
period that begins on or after October 1, 1983. A change in a
hospital's cost reporting period that has been made after November 1982
shall be recognized for purposes of this section only if the Secretary
finds good cause for that change.
''(2) Section 1866(a)(1)(F) of the Social Security Act (section
1395cc(a)(1)(F) of this title) (as added by section 602(f)(1)(C) of this
title), section 1862(a)(14) (section 1395y(a)(14) of this title) (as
added by section 602(e)(3) of this title) and sections 1886(a)(1)(G) and
(H) of such Act (probably should be section 1866(a)(1)(G) and (H) which
is classified to section 1395cc(a)(1)(G) and (H) of this title) (as
added by section 602(f)(1)(C) of this title) take effect on October 1,
1983.
''(b) The Secretary shall make an appropriate reduction in the
payment amount under section 1886(d) of the Social Security Act (subsec.
(d) of this section) (as amended by this title) for any discharge, if
the admission has occurred before a hospital's first cost reporting
period that begins after September 1983, to take into account amounts
payable under title XVIII of that Act (this subchapter) (as in effect
before the date of the enactment of this Act (Apr. 20, 1983)) for items
and services furnished before that period.
''(c)(1) The Secretary shall cause to be published in the Federal
Register a notice of the interim final DRG prospective payment rates
established under subsection (d) of section 1886 of the Social Security
Act (subsec. (d) of this section) (as amended by this title) no later
than September 1, 1983, and allow for a period of public comment
thereon. Payment on the basis of prospective rates shall become
effective on October 1, 1983, without the necessity for consideration of
comments received, but the Secretary shall, by notice published in the
Federal Register, affirm or modify the amounts by December 31, 1983,
after considering those comments.
''(2) A modification under paragraph (1) that reduces a prospective
payment rate shall apply only to discharges occurring after 30 days
after the date the notice of the modification is published in the
Federal Register.
''(3) Rules to implement the amendments made by this title (amending
this section and sections 1320a-1, 1320c-2, 1395f, 1395i-2, 1395n,
1395r, 1395v, 1395w, 1395x, 1395y, 1395cc, 1395mm, 1395oo, 1395rr, and
1395xx of this title, enacting provisions set out as notes under
sections 1395r and 1395x of this title, and amending provisions set out
as a note under section 1395x of this title) shall be established in
accordance with the procedure described in this subsection.''
Amendment by Pub. L. 97-448 effective as if originally included as a
part of this section as this section was added 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.
Section 101(b)(1) of Pub. L. 97-248 provided that: ''The amendments
made by subsection (a) (enacting this section and amending section 1395x
of this title) shall apply to cost reporting periods beginning on or
after October 1, 1982.''
Section 4003(c) of Pub. L. 101-508 provided that: ''The Secretary
of Health and Human Services shall issue such regulations (on an interim
or other basis) as may be necessary to implement this section (amending
this section and enacting provisions set out as a note above).''
Section 2315(f)(2) of Pub. L. 98-369 provided that:
''Notwithstanding section 604(c) of the Social Security Amendments of
1983 (section 604(c) of Pub. L. 98-21, set out above), the Secretary of
Health and Human Services shall cause to be published in the Federal
Register proposed regulations to carry out subsection (c) of section
1886 of the Social Security Act (subsec. (c) of this section) not later
than July 1, 1984, and allow for a period of 45 days for public comment
thereon. After consideration of the comments received, the Secretary
shall cause to be published in the Federal Register final regulations to
carry out such subsection not later than October 1, 1984.''
Section 101(b)(2)(A) of Pub. L. 97-248 provided that: ''The
Secretary of Health and Human Services shall first issue such final
regulations (whether on an interim or other basis) before October 1,
1982, as may be necessary to implement such amendments (amendments by
section 101(a) of Pub. L. 97-248, enacting this section and amending
section 1395x of this title) on a timely basis. If such regulations are
promulgated on an interim final basis, the Secretary shall take such
steps as may be necessary to provide opportunity for public comment, and
appropriate revision based thereon, so as to provide that such
regulations are not on an interim basis later than March 31, 1983.''
Section 4002(d)(1) of Pub. L. 101-508 provided that:
''(A) For purposes of section 1886(d)(3)(E) of the Social Security
Act (subsec. (d)(3)(E) of this section) for discharges occurring on or
after January 1, 1991, and before October 1, 1993, the Secretary of
Health and Human Services shall apply an area wage index determined
using the survey of the 1988 wages and wage-related costs of hospitals
in the United States conducted under such section.
''(B) The Secretary shall apply the wage index described in
subparagraph (A) without regard to a previous survey of wages and
wage-related costs.''
Section 4002(e)(2) of Pub. L. 101-508 provided that:
''(A) The Secretary of Health and Human Services shall collect
sufficient data on the input prices associated with the non-wage-related
portion of the adjusted average standardized amounts established under
section 1886(d)(3) of the Social Security Act (subsec. (d)(3) of this
section) to identify the extent to which variations in such amounts
among hospitals located in different geographic areas are attributable
to differences in such prices.
''(B) Not later than June 1, 1993, the Secretary shall submit a
report to Congress analyzing such data, and shall include in such report
recommendations regarding a methodology for adjusting such average
standardized amounts to reflect such variations.
''(C) The provisions of chapter 35 of title 44, United States Code,
shall not apply to data collected by the Secretary under subparagraph
(A).''
Section 4002(h)(2)(A) of Pub. L. 101-508 provided that: ''For
purposes of determining whether a hospital requesting a change in
geographic classification for fiscal year 1992 under section 1886(d)(10)
of the Social Security Act (subsec. (d)(10) of this section) has met the
deadline described in subparagraph (C)(ii) of such section, an
application submitted under such subparagraph shall be considered to
have been submitted by the first day of the preceding fiscal year if it
is submitted within 60 days of the date of publication of the guidelines
described in subparagraph (D)(i) of such section.''
Section 4004 of Pub. L. 101-508 provided that:
''(a) Hospital Graduate Medical Education Recoupment. --
''(1) In general. -- The Secretary of Health and Human Services may
not, before October 1, 1991, recoup payments from a hospital because of
alleged overpayments to such hospital under part A of title XVIII of the
Social Security Act (part A of this subchapter) due to a determination
that the amount of payments made for graduate medical education programs
exceeds the amount allowable under section 1886(h) (subsec. (h) of this
section).
''(2) Cap on annual amount of recoupment. -- With respect to
overpayments to a hospital described in paragraph (1), the Secretary may
not recoup more than 25 percent of the amount of such overpayments from
the hospital during a fiscal year.
''(3) Effective date. -- Paragraphs (1) and (2) shall take effect
October 1, 1990.
''(b) University Hospital Nursing Education. --
''(1) In general. -- The reasonable costs incurred by a hospital (or
by an educational institution related to the hospital by common
ownership or control) during a cost reporting period for clinical
training (as defined by the Secretary) conducted on the premises of the
hospital under approved nursing and allied health education programs
that are not operated by the hospital shall be allowable as reasonable
costs under part A of title XVIII of the Social Security Act and
reimbursed under such part on a pass-through basis.
''(2) Conditions for reimbursement. -- The reasonable costs incurred
by a hospital during a cost reporting period shall be reimbursable
pursuant to paragraph (1) only if --
''(A) the hospital claimed and was reimbursed for such costs during
the most recent cost reporting period that ended on or before October 1,
1989;
''(B) the proportion of the hospital's total allowable costs that is
attributable to the clinical training costs of the approved program, and
allowable under (b)(1) during the cost reporting period does not exceed
the proportion of total allowable costs that were attributable to the
clinical training costs during the cost reporting period described in
subparagraph (A);
''(C) the hospital receives a benefit for the support it furnishes to
such program through the provision of clinical services by nursing or
allied health students participating in such program; and
''(D) the costs incurred by the hospital for such program do not
exceed the costs that would be incurred by the hospital if it operated
the program itself.
''(3) Prohibition against recoupment of costs by secretary. --
''(A) In general. -- The Secretary of Health and Human Services may
not recoup payments from (or otherwise reduce or adjust payments under
part A of title XVIII of the Social Security Act to) a hospital because
of alleged overpayments to such hospital under such title due to a
determination that costs which were reported by the hospital on its
medicare cost reports for cost reporting periods beginning on or after
October 1, 1983, and before October 1, 1990, relating to approved
nursing and allied health education programs did not meet the
requirements for allowable nursing and allied health education costs (as
developed by the Secretary pursuant to section 1861(v) of such Act
(section 1395x(v) of this title)).
''(B) Refund of amounts recouped. -- If, prior to the date of the
enactment of this Act (Nov. 5, 1990), the Secretary has recouped
payments from (or otherwise reduced or adjusted payments under part A of
title XVIII of the Social Security Act to) a hospital because of
overpayments described in subparagraph (A), the Secretary shall refund
the amount recouped, reduced, or adjusted from the hospital.
''(4) Special audit to determine costs. -- In determining the amount
of costs incurred by, claimed by, and reimbursed to, a hospital for
purposes of this subsection, the Secretary shall conduct a special audit
(or use such other appropriate mechanism) to ensure the accuracy of such
past claims and payments.
''(5) Effective date. -- Except as provided in paragraph (3), the
provisions of this subsection shall apply to cost reporting periods
beginning on or after October 1, 1990.''
Section 4159 of Pub. L. 101-508 provided that:
''(a) Hospital Graduate Medical Education Recoupment. --
''(1) In general. -- The Secretary of Health and Human Services may
not, before October 1, 1991, recoup payments from a hospital because of
alleged overpayments to such hospital under part B of title XVIII of the
Social Security Act (part B of this subchapter) due to a determination
that the amount of payments made for graduate medical education programs
exceeds the amount allowable under section 1886(h) (subsec. (h) of this
section).
''(2) Cap on annual amount of recoupment. -- With respect to
overpayments to a hospital described in paragraph (1), the Secretary may
not recoup more than 25 percent of the amount of such overpayments from
the hospital during a fiscal year.
''(3) Effective date. -- Paragraphs (1) and (2) shall take effect
October 1, 1990.
''(b) University Hospital Nursing Education. --
''(1) In general. -- The reasonable costs incurred by a hospital (or
by an educational institution related to the hospital by common
ownership or control) during a cost reporting period for clinical
training (as defined by the Secretary) conducted on the premises of the
hospital under approved nursing and allied health education programs
that are not operated by the hospital shall be allowable as reasonable
costs under part B of title XVIII of the Social Security Act and
reimbursed under such part on a pass-through basis.
''(2) Conditions for reimbursement. -- The reasonable costs incurred
by a hospital during a cost reporting period shall be reimbursable
pursuant to paragraph (1) only if --
''(A) the hospital claimed and was reimbursed for such costs during
the most recent cost reporting period that ended on or before October 1,
1989;
''(B) the proportion of the hospital's total allowable costs that is
attributable to the clinical training costs of the approved program, and
allowable under (b)(1) during the cost reporting period does not exceed
the proportion of total allowable costs that were attributable to
clinical training costs during the cost reporting period described in
subparagraph (A);
''(C) the hospital receives a benefit for the support it furnishes to
such program through the provision of clinical services by nursing or
allied health students participating in such program; and
''(D) the costs incurred by the hospital for such program do not
exceed the costs that would be incurred by the hospital if it operated
the program itself.
''(3) Prohibition against recoupment of costs by secretary. --
''(A) In general. -- The Secretary of Health and Human Services may
not recoup payments from (or otherwise reduce or adjust payments under
part B of title XVIII of the Social Security Act to) a hospital because
of alleged overpayments to such hospital under such title due to a
determination that costs which were reported by the hospital on its
medicare cost reports for cost reporting periods beginning on or after
October 1, 1983, and before October 1, 1990, relating to approved
nursing and allied health education programs did not meet the
requirements for allowable nursing and allied health education costs (as
developed by the Secretary pursuant to section 1861(v) of such Act
(section 1395x(v) of this title)).
''(B) Refund of amounts recouped. -- If, prior to the date of the
enactment of this Act (Nov. 5, 1990), the Secretary has recouped
payments from (or otherwise reduced or adjusted payments under part B of
title XVIII of the Social Security Act to) a hospital because of
overpayments described in subparagraph (A), the Secretary shall refund
the amount recouped, reduced, or adjusted from the hospital.
''(4) Special audit to determine costs. -- In determining the amount
of costs incurred by, claimed by, and reimbursed to, a hospital for
purposes of this subsection, the Secretary shall conduct a special audit
(or use such other appropriate mechanism) to ensure the accuracy of such
past claims and payments.
''(5) Effective Date. -- Except as provided in paragraph (3), the
provisions of this subsection shall apply to cost reporting periods
beginning on or after October 1, 1990.''
Section 4005(b) of Pub. L. 101-508 provided that:
''(1) Development of proposal. -- The Secretary of Health and Human
Services shall develop a proposal to modify the current system under
which hospitals that are not subsection (d) hospitals (as defined in
section 1886(d)(1)(B) of the Social Security Act (subsec. (d)(1)(B) of
this section)) receive payment for the operating and capital-related
costs of inpatient hospital services under part A (part A of this
subchapter) of the medicare program or a proposal to replace such system
with a system under which such payments would be made on the basis of
nationally-determined average standardized amounts. In developing any
proposal under this paragraph to replace the current system with a
prospective payment system, the Secretary shall --
''(A) take into consideration the need to provide for appropriate
limits on increases in expenditures under the medicare program;
''(B) provide for adjustments to prospectively determined rates to
account for changes in a hospital's case mix, severity of illness of
patients, volume of cases, and the development of new technologies and
standards of medical practice;
''(C) take into consideration the need to increase the payment
otherwise made under such system in the case of services provided to
patients whose length of stay or costs of treatment greatly exceed the
length of stay or cost of treatment provided for under the applicable
prospectively determined payment rate;
''(D) take into consideration the need to adjust payments under the
system to take into account factors such as a disproportionate share of
low-income patients, costs related to graduate medical education
programs, differences in wages and wage-related costs among hospitals
located in various geographic areas, and other factors the Secretary
considers appropriate; and
''(E) provide for the appropriate allocation of operating and
capital-related costs of hospitals not subject to the new prospective
payment system and distinct units of such hospitals that would be paid
under such system.
''(2) Reports. -- (A) By not later than April 1, 1992, the Secretary
shall submit the proposal developed under paragraph (1) to the Committee
on Finance of the Senate and the Committee on Ways and Means of the
House of Representatives.
''(B) By not later than June 1, 1992, the Prospective Payment
Assessment Commission shall submit an analysis of and comments on the
proposal developed under paragraph (1) to the Committee on Finance of
the Senate and the Committee on Ways and Means of the House of
Representatives.''
Section 4005(c)(3) of Pub. L. 101-508 provided that: ''The
Administrator of the Health Care Financing Administration shall provide
guidance to agencies and organizations performing functions pursuant to
section 1816 of the Social Security Act (section 1395h of this title)
and to hospitals that are not subsection (d) hospitals (as defined in
section 1886(d)(1)(B) of such Act (subsec. (d)(1)(B) of this section))
to assist such agencies, organizations, and hospitals in filing complete
applications with the Administrator for exemptions, exceptions, and
adjustments under section 1886(b)(4)(A) of such Act.''
Section 4007 of Pub. L. 101-508 provided that:
''(a) In General. -- Notwithstanding any other provision of law, for
purposes of determining the amount of payment for items or services
under part A of title XVIII of the Social Security Act (part A of this
subchapter) (including payments under section 1886 of such Act (this
section) attributable to or allocated under such part) during the period
described in subsection (b):
''(1) The market basket percentage increase (described in section
1886(b)(3)(B)(iii) of the Social Security Act) shall be deemed to be 0
for discharges occurring during such period.
''(2) The percentage increase or decrease in the medical care
expenditure category of the consumer price index applicable under
section 1814(i)(2)(B) of such Act (section 1395f(i)(2)(B) of this title)
shall be deemed to be 0.
''(3) The area wage index applicable to a subsection (d) hospital
under section 1886(d)(3)(E) of such Act shall be deemed to be the area
wage index applicable to such hospital as of September 30, 1990.
''(4) The percentage change in the consumer price index applicable
under section 1886(h)(2)(D) of such Act shall be deemed to be 0.
''(b) Description of Period. -- The period referred to in subsection
(a) is the period beginning on October 21, 1990, and ending on December
31, 1990.''
Section 4008(l) of Pub. L. 101-508 provided that:
''(1) In general. -- The Secretary of Health and Human Services shall
review the requirements applicable under title XVIII of the Social
Security Act (this subchapter) to determine which requirements could be
made less administratively and economically burdensome (without
diminishing the quality of care) for hospitals defined in section
1886(d)(1)(B) of such Act (subsec. (d)(1)(B) of this section) that are
located in a rural area (as defined in section 1886(d)(2)(D) of such
Act). Such review shall specifically include standards related to
staffing requirements.
''(2) Report. -- The Secretary of Health and Human Services shall
report to Congress by April 1, 1992, on the results of the review
conducted under subsection (a), and include conclusions on which
regulations, if any, should be modified with respect to hospitals
described in subsection (a).''
Section 4027(4207)(b)(1) of Pub. L. 101-508 provided that:
''Notwithstanding any other provision of law, the Secretary of Health
and Human Services may not issue any proposed or final regulation,
instruction, or other policy which is estimated by the Secretary to
result in a net reduction in expenditures under title XVIII of the
Social Security Act (this subchapter) in a fiscal year (beginning with
fiscal year 1991 and ending with fiscal year 1993, or, if later, the
last fiscal year for which there is a maximum deficit amount specified
under section 3(7) of the Congressional Budget and Impoundment Control
Act of 1974 (2 U.S.C. 622(7))) of more than $50,000,000, except as
follows:
''(A) The Secretary may issue such a proposed regulation,
instruction, or other policy with respect to the fiscal year before the
May 15 preceding the beginning of the fiscal year.
''(B) The Secretary may issue such a final regulation, instruction,
or other policy with respect to the fiscal year on or after October 15
of the fiscal year.
''(C) The Secretary may, at any time, issue such a proposed or final
regulation, instruction, or other policy with respect to the fiscal year
if required to implement specific provisions under statute.''
Section 4027(4207)(b)(2) of Pub. L. 101-508 provided that:
''Notwithstanding any other provision of law, the Secretary of Health
and Human Services is not authorized to issue, after the date of the
enactment of this Act (Nov. 5, 1990), any final regulation, instruction,
or other policy change which is primarily intended to have the effect of
slowing down or speeding up claims processing, or delaying payment of
claims, under title XVIII of the Social Security Act (this
subchapter).''
Section 115(a) of Pub. L. 101-403 provided that: ''For purposes of
determining the amount of payment made to a hospital under part A of
title XVIII of the Social Security Act (part A of this subchapter) for
the operating costs of inpatient hospital services for discharges
occurring on or after October 1, 1990, and on or before October 20,
1990, the Secretary of Health and Human Services, in adjusting such
amount under section 1886(d)(3)(E) of such Act (subsec. (d)(3)(E) of
this section) to reflect the relative hospital wage level in the
geographic area of the hospital compared to the national average
hospital wage index, shall apply the area wage index applicable to such
hospital as of September 30, 1990.''
Section 115(b)(2) of Pub. L. 101-403 provided that: ''The Secretary
of Health and Human Services shall make any adjustments resulting from
the amendment made by paragraph (1) (amending this section) in the
amount of the payments made to hospitals under section 1886(d) of the
Social Security Act (subsec. (d) of this section) in a fiscal year for
the operating costs of inpatient hospital services in a manner that
ensures that the aggregate payments under such section are not greater
or less than those that would have been made in the year without such
adjustments.''
Section 6003(a)(3) of Pub. L. 101-239 provided that: ''For
discharges occurring on or after October 1, 1990, the applicable
percentage increase (described in section 1886(b)(3)(B) of the Social
Security Act (subsec. (b)(3)(B) of this section)) for discharges
occurring during fiscal year 1990 is deemed to have been such percentage
increase as amended by paragraph (1).''
Section 6003(e)(3) of Pub. L. 101-239 provided that: ''Any hospital
classified as a sole community hospital under section 1886(d)(5)(C)(ii)
of the Social Security Act (subsec. (d)(5)(C)(ii) of this section) on
the date of the enactment of this Act (Dec. 19, 1989) that will no
longer be classified as a sole community hospital after such date as a
result of the amendments made by paragraph (1) (amending this section)
shall continue to be classified as a sole community hospital for
purposes of section 1886(d)(5)(D) of such Act (subsec. (d)(5)(D) of this
section).''
Section 6003(h)(5) of Pub. L. 101-239 provided that:
''(A) In general. -- If the Secretary of Health and Human Services
(hereinafter referred to as the 'Secretary') discovers an error with
respect to the determination, adjustment, or computation of the area
wage index described in section 1886(d)(3)(E) of the Social Security Act
(subsec. (d)(3)(E) of this section) and subsequently corrects such
error, the Secretary shall make an additional payment under title XVIII
of such Act (this subchapter) to a hospital affected by such error for
inpatient hospital discharges occurring during the period when the
erroneously determined, adjusted, or computed wage index was in effect.
''(B) Conditions for additional payment. -- A hospital is eligible
for an additional payment under subparagraph (A) only if --
''(i) the error resulted from the submission of erroneous data,
except that a hospital is not eligible for such additional payment if it
submitted such erroneous data;
''(ii) the error was made with respect to the survey of the 1984
wages and wage-related costs of hospitals in the United States conducted
under section 1886(d)(3)(E) of the Social Security Act; and
''(iii) the correction of the error resulted in an adjustment to the
area wage index of not less than 3 percentage points.
''(C) Period of applicability. -- A hospital may not receive an
additional payment under subparagraph (A) for discharges occurring after
October 1, 1990.''
Section 6003(i) of Pub. L. 101-239 provided that:
''(1) In general. -- The Secretary of Health and Human Services
(hereinafter referred to as the 'Secretary') shall design a legislative
proposal eliminating the system of determining separate average
standardized amounts for subsection (d) hospitals (as defined in section
1886(d)(1)(B) of the Social Security Act (subsec. (d)(1)(B) of this
section)) classified as being located in large urban, other urban, or
rural areas under section 1886(d)(2)(D) of such Act (subsec. (d)(2)(D)
of this section), and shall include in such proposal the following:
''(A) A transition period beginning in fiscal year 1992 during which
a single rate for determining payment to hospitals in all areas shall be
phased in with such single rate to be completely in effect by fiscal
year 1995.
''(B) Recommendations, where appropriate, for modifying or
maintaining additional payments or adjustments made under title XVIII of
the Social Security Act (this subchapter) for teaching hospitals, rural
referral centers, sole community hospitals, disproportionate share
hospitals, and outlier cases, and for creating additional payments or
adjustments where deemed appropriate by the Secretary.
''(C) Recommendations with respect to recalculating standardized
amounts to reflect information from more recent cost reporting periods.
''(D) Recommendations, where appropriate, for modifying reimbursement
for hospitals that are not subsection (d) hospitals under title XVIII of
such Act.
''(E) A recommendation for a methodology to reflect the severity of
illness of different patients within the same diagnosis-related group
(as determined in section 1886(d)(4)(B) of such Act (subsec. (d)(4)(B)
of this section)).
''(2) Report to congress and propac. -- (A) Not later than October 1,
1990, the Secretary shall submit the proposal described in paragraph (1)
and an accompanying analysis of the impact of the proposed elimination
of separate average standardized amounts on various categories of
hospitals to Congress and the Prospective Payment Assessment Commission.
''(B) Not later than February 1, 1991, the Prospective Payment
Assessment Commission and the Director of the Congressional Budget
Office shall each prepare and submit to Congress a report analyzing the
legislative proposal submitted under subparagraph (A), and shall include
in such report an analysis of the probable impact of such legislation on
hospitals participating in the medicare program.''
Section 6011(b), (c) of Pub. L. 101-239 provided that:
''(b) Determining Payment Amount. -- The Secretary of Health and
Human Services shall determine the amount of payment made to hospitals
under part A of title XVIII of the Social Security Act (part A of this
subchapter) for the costs of administering blood clotting factors to
individuals with hemophilia by multiplying a predetermined price per
unit of blood clotting factor (determined in consultation with the
Prospective Payment Assessment Commission) by the number of units
provided to the individual.
''(c) Recommendations on Payments. -- The Prospective Payment
Assessment Commission and the Health Care Financing Administration shall
develop recommendations with respect to payments to hospitals under part
A of title XVIII of the Social Security Act for the costs of
administering blood clotting factors to individuals with hemophilia, and
shall submit such recommendations to Congress not later than 18 months
after the date of enactment of this Act (Dec. 19, 1989).''
Section 6015(b) of Pub. L. 101-239 provided that: ''By not later
than 180 days after the date of enactment of this Act (Dec. 19, 1989),
the Secretary of Health and Human Services shall publish instructions
specifying the application process to be used in providing exceptions
and adjustments under section 1886(b)(4)(A) of the Social Security Act
(subsec. (b)(4)(A) of this section).''
Section 6205(b) of Pub. L. 101-239 provided that:
''(1) The Secretary of Health and Human Services (in this subsection
referred to as the 'Secretary') shall not, before October 1, 1990,
recoup from, or otherwise reduce or adjust payments under title XVIII of
the Social Security Act (this subchapter) to, hospitals because of
alleged overpayments to such hospitals under such title due to a
determination that costs which were reported by a hospital on its
medicare cost reports relating to approved nursing and allied health
education programs were allowable costs and are included in the
definition of 'operating costs of inpatient hospital services' pursuant
to section 1886(a)(4) of such Act (subsec. (a)(4) of this section), so
that no pass-through of such costs was permitted under that section.
''(2)(A) Before July 1, 1990, the Secretary shall issue regulations
respecting payment of costs described in paragraph (1).
''(B) In issuing such regulations --
''(i) the Secretary shall allow a comment period of not less than 60
days,
''(ii) the Secretary shall consult with the Prospective Payment
Assessment Commission, and
''(iii) any final rule shall not be effective prior to October 1,
1990, or 30 days after publication of the final rule in the Federal
Register, whichever is later.
''(C) Such regulations shall specify --
''(i) the relationship required between an approved nursing or allied
health education program and a hospital for the program's costs to be
attributed to the hospital;
''(ii) the types of costs related to nursing or allied health
education programs that are allowable by medicare;
''(iii) the distinction between costs of approved educational
activities as recognized under section 1886(a)(3) of the Social Security
Act (subsec. (a)(3) of this section) and educational costs treated as
operating costs of inpatient hospital services; and
''(iv) the treatment of other funding sources for the program.''
Section 6217 of Pub. L. 101-239, as amended by Pub. L. 101-508,
title IV, 4027(4207)(k)(5), Nov. 5, 1990, 104 Stat. 1388-125,
provided that:
''(a) Establishment. -- The Secretary of Health and Human Services
shall establish a demonstration project in a public hospital that is
located in a large urban area and that has established a triage system,
under which the Secretary shall make payments out of the Federal
Hospital Insurance Trust Fund and the Federal Supplementary Medical
Insurance Trust Fund (in such proportions as the Secretary determines to
be appropriate in a year) for 3 years to reimburse the hospital for the
reasonable costs of operating the system, including costs --
''(1) to train hospital personnel to operate and participate in the
system; and
''(2) to provide services to patients who might otherwise be denied
appropriate and prompt care.
''(b) Limitations on Payment. -- (1) The Secretary may not make
payment under the demonstration project established under subsection (a)
for costs that the Secretary determines are not reasonable.
''(2) The amount of payment made under the demonstration project
during a single year may not exceed $500,000.''
Section 101(c)(2)(B) of title I of Pub. L. 101-234 provided that:
''The Secretary of Health and Human Services shall make an appropriate
adjustment to the target amount established under section 1886(b)(3)(A)
of the Social Security Act (subsec. (b)(3)(A) of this section) in the
case of inpatient hospital services provided to an inpatient whose stay
began before January 1, 1990, in order to take into account the target
amount that would have applied but for the amendments made by this title
(see Tables for classification).''
Section 8405 of Pub. L. 100-647 provided that: ''With respect to
employees of the Prospective Payment Assessment Commission hired before
December 22, 1987, such employees shall have the option to elect within
60 days of the date of enactment of this Act (Nov. 10, 1988) to be
covered under either the personnel policy in effect with respect to such
employees before December 22, 1987, or under the employees coverage
provided under the last sentence of section 1886(e)(6)(D) of the Social
Security Act (subsec. (e)(6)(D) of this section).''
Section 104(c) of Pub. L. 100-360, as amended by Pub. L. 100-485,
title VI, 608(d)(3)(C)-(E), Oct. 13, 1988, 102 Stat. 2413; Pub. L.
101-234, title I, 101(c)(1), (2)(A), Dec. 13, 1989, 103 Stat. 1980,
provided that:
''(1) PPS hospitals. -- In adjusting DRG prospective payment rates
under section 1886(d) of the Social Security Act (subsec. (d) of this
section), outlier cutoff points under section 1886(d)(5)(A) of such Act,
and weighting factors under section 1886(d)(4) of such Act for
discharges occurring on or after October 1, 1988, and before January 1,
1990, the Secretary of Health and Human Services shall, to the extent
appropriate, take into consideration the reductions in payments to
hospitals by (or on behalf of) medicare beneficiaries resulting from the
elimination of a day limitation on medicare inpatient hospital services
(under the amendments made by section 101 (amending section 1395d of
this title)).
''(2) PPS-exempt hospitals. -- In adjusting target amounts under
section 1886(b)(3) of the Social Security Act (subsec. (b)(3) of this
section) for portions of cost reporting periods occurring on or after
January 1, 1989, and before January 1, 1990, the Secretary shall, on a
hospital-specific basis, take into consideration the reductions in
payments to hospitals by (or on behalf of) medicare beneficiaries
resulting from the elimination of a day limitation on medicare inpatient
hospital services (under the amendments made by section 101 (amending
section 1395d of this title)), without regard to whether such a hospital
is paid on the basis described in subparagraph (A) or (B) of section
1886(b)(1) of such Act, without regard to whether any of such
beneficiaries exhausted medicare inpatient hospital insurance benefits
before January 1, 1989.''
(Amendment of section 104(c) of Pub. L. 100-360, set out above, by
section 101(c)(1), (2)(A) of Pub. L. 101-234 effective as if included in
enactment of Pub. L. 100-360, see section 101(d) of Pub. L. 101-234,
set out as a note under section 1395c of this title).
Section 203(c)(2) of Pub. L. 100-360, which required Prospective
Payment Assessment Commission to conduct a study, and make
recommendations to Congress and Secretary of Health and Human Services
by not later than Mar. 1, 1991, concerning appropriate adjustment to
payment amounts provided under subsec. (d) of this section for
inpatient hospital services to account for reduced costs to hospitals
resulting from amendments made by section 203 of Pub. L. 100-360,
amending sections 1320c-3, 1395h, 1395k to 1395n, 1395w-2, 1395x, 1395z,
and 1395aa of this title, was repealed by Pub. L. 101-234, title II,
201(a), Dec. 13, 1989, 103 Stat. 1981.
Section 4004(b) of Pub. L. 100-203 provided that: ''In calculating
the wage index under section 1886(d) of the Social Security Act (subsec.
(d) of this section) for purposes of making payment adjustments after
September 30, 1988, as required under paragraphs (2)(H) and (3)(E) of
such section, in the case of any institution which received the waiver
specified in section 602(k) of the Social Security Amendments of 1983
(section 602(k) of Pub. L. 98-21, set out as a note under section 1395y
of this title), the Secretary of Health and Human Services shall include
wage costs paid to related organization employees directly involved in
the delivery and administration of care provided by the related
organization to hospital inpatients. For purposes of the preceding
sentence, the term 'wage costs' does not include costs of overhead or
home office administrative salaries or any costs that are not incurred
in the hospital's Metropolitan Statistical Area.''
Section 4005(c)(2)(B) of Pub. L. 100-203 provided that: ''The
Secretary of Health and Human Services shall take appropriate steps to
ensure that the total amount paid in a fiscal year under title XVIII of
the Social Security Act (this subchapter) by reason of the amendment
made by paragraph (1)(B) (amending this section) does not exceed
$5,000,000 in the case of fiscal year 1988 and $10,000,000 for fiscal
year 1989.''
Section 4005(d)(2) of Pub. L. 100-203 provided that:
''(A) In general. -- The Secretary of Health and Human Services shall
provide for a study of the criteria used for the classification of
hospitals as rural referral centers under section 1886(d)(5)(C)(i) of
the Social Security Act (subsec. (d)(5)(C)(i) of this section). The
study shall include an examination of --
''(i) the extent that hospitals classified as rural referral centers
receive more or less than their actual costs of providing inpatient
hospital services, and
''(ii) the appropriateness of providing for payment for such centers
at a rate other than the rate for a hospital located in an other (sic)
urban area.
''(B) Report. -- The Secretary shall report to Congress, by not later
than March 1, 1989, on the study conducted under subparagraph (A) and on
recommendations for the criteria that should be applied under section
1886(d)(5)(C)(i) of the Social Security Act for the classification of
hospitals as rural referral centers for cost reporting periods beginning
on or after October 1, 1989.''
Section 4005(e) of Pub. L. 100-203, as amended by Pub. L. 101-239,
title VI, 6003(g)(1)(B)(i), Dec. 19, 1989, 103 Stat. 2150, provided
that:
''(1) The Administrator of the Health Care Financing Administration,
in consultation with the Assistant Secretary for Health (or a designee),
shall establish a program of grants to assist eligible small rural
hospitals and their communities in the planning and implementation of
projects to modify the type and extent of services such hospitals
provide in order to adjust for one or more of the following factors:
''(A) Changes in clinical practice patterns.
''(B) Changes in service populations.
''(C) Declining demand for acute-care inpatient hospital capacity.
''(D) Declining ability to provide appropriate staffing for inpatient
hospitals.
''(E) Increasing demand for ambulatory and emergency services.
''(F) Increasing demand for appropriate integration of community
health services.
''(G) The need for adequate access (including appropriate
transportation) to emergency care and inpatient care in areas in which a
significant number of underutilized hospital beds are being eliminated.
''(H) The Administrator shall submit a final report on the program to
the Congress not later than 180 days after all projects receiving a
grant under the program are completed.
Each demonstration project under this subsection shall demonstrate
methods of strengthening the financial and managerial capability of the
hospital involved to provide necessary services. Such methods may
include programs of cooperation with other health care providers, of
diversification in services furnished (including the provision of home
health services), of physician recruitment, and of improved management
systems. Grants under this paragraph may be used to provide instruction
and consultation (and such other services as the Administrator
determines appropriate) via telecommunications to physicians in such
rural areas (within the meaning of section 1886(d)(2)(D) of the Social
Security Act (subsec. (d)(2)(D) of this section)) as are designated
either class 1 or class 2 health manpower shortage areas under section
332(a)(1)(A) of the Public Health Service Act (section 254e(a)(1)(A) of
this title).
''(2) For purposes of this subsection, the term 'eligible small rural
hospital' means any non-Federal, short-term general acute care hospital
that --
''(A) is located in a rural area (as determined in accordance with
subsection (d)),
''(B) has less than 100 beds, and
''(C) is not for profit.
''(3)(A) Any eligible small rural hospital that desires to modify the
type or extent of health care services that it provides in order to
adjust for one or more of the factors specified in paragraph (1) may
submit an application to the Administrator and a copy of such
application to the Governor of the State in which it is located. The
application shall specify the nature of the project proposed by the
hospital, the data and information on which the project is based, and a
timetable (of not more than 24 months) for completion of the project.
The application shall be submitted on or before a date specified by the
Administrator and shall be in such form as the Administrator may
require.
''(B) The Governor shall transmit to the Administrator, within a
reasonable time after receiving a copy of an application pursuant to
subparagraph (A), any comments with respect to the application that the
Governor deems appropriate.
''(C) The Governor of a State may designate an appropriate State
agency to receive and comment on applications submitted under
subparagraph (A).
''(4) A hospital shall be considered to be located in a rural area
for purposes of this subsection if it is treated as being located in a
rural area for purposes of section 1886(d)(3)(D) of the Social Security
Act (subsec. (d)(3)(D) of this section).
''(5) In determining which hospitals making application under
paragraph (3) will receive grants under this subsection, the
Administrator shall take into account --
''(A) any comments received under paragraph (3)(B) with respect to a
proposed project;
''(B) the effect that the project will have on --
''(i) reducing expenditures from the Federal Hospital Insurance Trust
Fund,
''(ii) improving the access of medicare beneficiaries to health care
of a reasonable quality;
''(C) the extent to which the proposal of the hospital, using
appropriate data, demonstrates an understanding of --
''(i) the primary market or service area of the hospital, and
''(ii) the health care needs of the elderly and disabled that are not
currently being met by providers in such market or area, and
''(D) the degree of coordination that may be expected between the
proposed project and --
''(i) other local or regional health care providers, and
''(ii) community and government leaders,
as evidenced by the availability of support for the project (in cash
or in kind) and other relevant factors.
''(6) A grant to a hospital under this subsection may not exceed
$50,000 a year and may not exceed a term of 3 years.
''(7)(A) Except as provided in subparagraphs (B) and (C), a hospital
receiving a grant under this subsection may use the grant for any of
expenses incurred in planning and implementing the project with respect
to which the grant is made.
''(B) A hospital receiving a grant under this subsection for a
project may not use the grant to retire debt incurred with respect to
any capital expenditure made prior to the date on which the project is
initiated.
''(C) Not more than one-third of any grant made under this subsection
may be expended for capital-related costs (as defined by the Secretary
for purposes of section 1886(a)(4) of the Social Security Act (subsec.
(a)(4) of this section)) of the project, except that this limitation
shall not apply with respect to a grant used for the purposes described
in subparagraph (D).
''(D) A hospital may use a grant received under this subsection to
develop a plan for converting itself to a rural primary care hospital
(as described in section 1820 of the Social Security Act (section
1395i-4 of this title)) or to develop a rural health network (as defined
in section 1820(g) of such Act) in the State in which it is located if
the State is receiving a grant under section 1820(a)(1).
''(8)(A) A hospital receiving a grant under this section (amending
this section and section 1395tt of this title and enacting provisions
set out as notes under this section and section 1395tt of this title)
shall furnish the Administrator with such information as the
Administrator may require to evaluate the project with respect to which
the grant is made and to ensure that the grant is expended for the
purposes for which it was made.
''(B) The Administrator shall report to the Congress at least once
every 6 months on the program of grants established under this
subsection. The report shall assess the functioning and status of the
program, shall evaluate the progress made toward achieving the purposes
of the program, and shall include any recommendations the Secretary may
deem appropriate with respect to the program. In preparing the report,
the Secretary shall solicit and include the comments and recommendations
of private and public entities with an interest in rural health care.
''(C) The Administrator shall submit a final report on the program to
the Congress not later than 180 days after all projects receiving a
grant under the program are completed.
''(9) For purposes of carrying out the program of grants under this
subsection, there are authorized to be appropriated from the Federal
Hospital Insurance Trust Fund $15,000,000 for fiscal year 1989 and
$25,000,000 for each of the fiscal years 1990, 1991, and 1992.''
(Section 6003(g)(1)(B)(ii) of Pub. L. 101-239 provided that: ''The
amendments made by clause (i) (amending section 4005(e) of Pub. L.
100-203, set out above) shall apply with respect to applications for
grants under the Rural Health Care Transition Grant Program described in
section 4005(e) of the Omnibus Budget Reconciliation Act of 1987 (Pub.
L. 100-203) submitted on or after October 1, 1989, except that the
amendments made by subclauses (V) and (VII) of such clause shall take
effect on the date of the enactment of this Act (Dec. 19, 1989).'')
Section 4007 of Pub. L. 100-203, as amended by Pub. L. 100-360,
title IV, 411(b)(6), July 1, 1988, 102 Stat. 770; Pub. L. 100-485,
title VI, 608(d)(18)(D), Oct. 13, 1988, 102 Stat. 2419, provided
that:
''(a) Development of Data Base. -- The Secretary of Health and Human
Services (in this section referred to as the 'Secretary') shall develop
and place into effect not later than June 1, 1989, a data base of the
operating costs of inpatient hospital services with respect to all
hospitals under title XVIII of the Social Security Act (42 U.S.C. 1395
et seq.), which data base shall be updated at least once every quarter
(and maintained for the 12-month period preceding any such update). The
data base under this subsection may include data from preliminary cost
reports (but the Secretary shall make available an updated analysis of
the differences between preliminary and settled cost reports).
''(b) (Amended subsec. (f) of this section and enacted provisions set
out as an Effective Date of 1987 Amendment note above.)
''(c) Demonstration Project. --
''(1) The Secretary of Health and Human Services shall provide for a
demonstration project to develop, and determine the costs and benefits
of establishing a uniform system for the reporting by medicare
participating hospitals of balance sheet and information described in
paragraph (2). In conducting the project, the Secretary shall require
hospitals in at least 2 States, one of which maintains a uniform
hospital reporting system, to report such information based on standard
information established by the Secretary.
''(2) The information described in this paragraph is as follows:
''(A) Hospital discharges (classified by class of primary payer).
''(B) Patient days (classified by class of primary payer).
''(C) Licensed beds, staffed beds, and occupancy.
''(D) Inpatient charges and revenues (classified by class of primary
payer).
''(E) Outpatient charges and revenues (classified by class of primary
payer).
''(F) Inpatient and outpatient hospital expenses (by cost-center
classified for operating and capital).
''(G) Reasonable costs.
''(H) Other income.
''(I) Bad debt and charity care.
''(J) Capital acquisitions.
''(K) Capital assets.
The Secretary shall develop a definition of 'outpatient visit' for
purposes of reporting hospital information.
''(3) The Secretary shall develop the system under subsection (c) in
a manner so as --
''(A) to facilitate the submittal of the information in the report in
an electronic form, and
''(B) to be compatible with the needs of the medicare prospective
payment system.
''(4) The Secretary shall prepare and submit, to the Prospective
Payment Assessment Commission, the Comptroller General, the Committee on
Ways and Means of the House of Representatives, and the Committee on
Finance of the Senate, by not later than 45 days after the end of each
calendar quarter, data collected under the system.
''(5) In paragraph (2):
''(A) The term 'bad debt and charity care' has such meaning as the
Secretary establishes.
''(B) The term 'class' means, with respect to payers at least, the
programs under this title XVIII of the Social Security Act (this
subchapter), a State plan approved under title XIX of such Act
(subchapter XIX of this chapter), other third party-payers, and other
persons (including self-paying individuals).
''(6) The Secretary shall set aside at least a total of $3,000,000
for fiscal years 1988, 1989, and 1990 from existing research funds or
from operations funds to develop the format, according to paragraph (1)
and for data collection and analysis, but total funds shall not exceed
$15,000,000.
''(7) The Comptroller General shall analyze the adequacy of the
existing system for reporting of hospital information and the costs and
benefits of data reporting under the demonstration system and will
recommend improvements in hospital data collection and in analysis and
display of data in support of policy making.
''(d) Consultation. -- The Secretary shall consult representatives of
the hospital industry in carrying out the provisions of this section.''
Section 4008(d) of Pub. L. 100-203, as amended by Pub. L. 100-360,
title IV, 411(b)(7), July 1, 1988, 102 Stat. 771, provided that:
''(1) Increase in outlier payments for burn center drgs. --
''(A) In general. -- For discharges classified in diagnosis-related
groups relating to burn cases and occurring on or after April 1, 1988,
and before October 1, 1989, the marginal cost of care permitted by the
Secretary of Health and Human Services under section 1886(d)(5)(A)(iii)
of the Social Security Act (subsec. (d)(5)(A)(iii) of this section)
shall be 90 percent of the appropriate per diem cost of care or 90
percent of the cost for cost outliers.
''(B) Budget neutrality. -- Subparagraph (A) shall be implemented in
a manner that ensures that total payments under section 1886(d) of the
Social Security Act are not increased or decreased by reason of the
adjustments required by such subparagraph.
''(2) Limitation on changes in outlier regulations. --
''(A) In general. -- Notwithstanding any other provision of law,
except as required to implement specific provisions required under
statute, the Secretary of Health and Human Services is not authorized to
issue in final form, after the date of the enactment of this Act (Dec.
22, 1987) and before September 1, 1988, any final regulation which
changes the method of payment for outlier cases under section
1886(d)(5)(A) of the Social Security Act (subsec. (d)(5)(A) of this
section).
''(B) Propac report. -- The chairman of the Prospective Payment
Assessment Commission shall report to the Congress and the Secretary of
Health and Human Services, by not later than June 1, 1988, on the method
of payment for outlier cases under such section and providing more
adequate and appropriate payments with respect to burn outlier cases.
''(3) Report on outlier payments. -- The Secretary of Health and
Human Services shall include in the annual report submitted to the
Congress pursuant to section 1875(b) of the Social Security Act (section
1395ll(b) of this title) a comparison with respect to hospitals located
in an urban area and hospitals located in a rural area in the amount of
reductions under section 1886(d)(3)(B) of the Social Security Act
(subsec. (d)(3)(B) of this section) and additional payments under
section 1886(d)(5)(A) of such Act.''
Section 4009(h) of Pub. L. 100-203 provided that:
''(1) Propac reports on study of drg rates for hospitals in rural and
urban areas. -- The Prospective Payment Assessment Commission shall
evaluate the study conducted by the Secretary of Health and Human
Services pursuant to section 603(a)(2)(C)(i) of the Social Security
Amendments of 1983 (section 603(a)(2)(C)(i) of Pub. L. 98-21, set out
below) (relating to the feasibility, impact, and desirability of
eliminating or phasing out separate urban and rural DRG prospective
payment rates) and report its conclusions and recommendations to the
Congress not later than March 1, 1988.
''(2) Propac report on separate urban payment rates. -- The
Prospective Payment Assessment Commission shall evaluate the
desirability of maintaining separate DRG prospective payment rates for
hospitals located in large urban areas (as defined in section
1886(d)(2)(D)) of the Social Security Act (subsec. (d)(2)(D) of this
section)) and in other urban areas, and shall report to Congress on such
evaluation not later than January 1, 1989.
''(3) Report on adjustment for non-labor costs. -- The Prospective
Payment Assessment Commission shall perform an analysis to determine the
feasibility and appropriateness of adjusting the non-wage-related
portion of the adjusted average standardized amounts under section
1886(d)(3) of the Social Security Act (subsec. (d)(3) of this section)
based on area differences in hospitals' costs (other than wage-related
costs) and input prices. The Commission shall report to the Congress on
such analysis by not later than October 1, 1989.''
Section 4009(i) of Pub. L. 100-203, as amended by Pub. L. 100-360,
title IV, 411(b)(8)(C), July 1, 1988, 102 Stat. 772, provided that:
''In the case of urban areas in New England, the Secretary of Health and
Human Services shall apply the second sentence of section 1886(d)(2)(D)
of the Social Security Act (subsec. (d)(2)(D) of this section), as
amended by section 4002(b) of this subtitle, as though 970,000 were
substituted for 1,000,000.''
Section 4038 of Pub. L. 100-203, as amended by Pub. L. 101-239,
title VI, 6216, Dec. 19, 1989, 103 Stat. 2253, provided that:
''(a) In General. -- The Secretary of Health and Human Services (in
this section referred to as the 'Secretary') shall enter into agreements
with 10 sponsoring hospitals submitting applications under this
subsection to conduct demonstration projects to assist resident
physicians in developing field clinical experience in rural areas.
''(b) Nature of Project. -- Under a demonstration project conducted
under subsection (a), a sponsoring hospital entering into an agreement
with the Secretary under such subsection shall enter into arrangements
with a small rural hospital to provide to such rural hospital, for a
period of one to three months of training, physicians (in such number as
the agreement under subsection (a) may provide) who have completed one
year of residency training.
''(c) Selection. -- (1) In selecting from among applications
submitted under subsection (a), the Secretary shall ensure that four
small rural hospitals located in different counties participate in the
demonstration project and that --
''(A) two of such hospitals are located in rural counties of more
than 2,700 square miles (one of which is east of the Mississippi River
and one of which is west of such river); and
''(B) two of such hospitals are located in rural counties with (as
determined by the Secretary) a severe shortage of physicians (one of
which is east of the Mississippi River and one of which is west of such
river).
''(2) The provisions of paragraph (1) shall not apply with respect to
applications submitted as a result of amendments made by section 6216 of
the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239,
amending this note).
''(d) Clarification of Payment. -- For purposes of section 1886 of
the Social Security Act (this section) --
''(1) with respect to subsection (d)(5)(B) of such section, any
resident physician participating in the project under subsection (a) for
any part of a year shall be treated as if he or she were working at the
appropriate sponsoring hospital with an agreement under subsection (a)
on September 1 of such year (and shall not be treated as if working at
the small rural hospital); and
''(2) with respect to subsection (h) of such section, the payment
amount permitted under such subsection for a sponsoring hospital with an
agreement under subsection (a) shall be increased (for the duration of
the project only) by an amount equal to the amount of any direct
graduate medical education costs (as defined in paragraph (5) of such
subsection (h)) incurred by such hospital in supervising the education
and training activities under a project under subsection (a).
''(e) Duration of Project. -- Each demonstration project under
subsection (a) shall be commenced not later than six months after the
date of enactment of this Act (Dec. 22, 1987) (or the date of the
enactment of the Omnibus Budget Reconciliation Act of 1989 (Dec. 19,
1989), in the case of a project conducted as a result of the amendments
made by section 6216 of such Act (Pub. L. 101-239, amending this note))
and shall be conducted for a period of three years.
''(f) Definition. -- In this section, the term 'sponsoring hospital'
means a hospital that receives payments under sections 1886(d)(5)(B) and
1886(h) of the Social Security Act (subsecs. (d)(5)(B) and (h) of this
section).''
Section 4039(d) of Pub. L. 100-203, as amended by Pub. L. 100-360,
title IV, 426(e), July 1, 1988, 102 Stat. 814; Pub. L. 101-239,
title VI, 6207(b), Dec. 19, 1989, 103 Stat. 2245, provided that:
''Notwithstanding any other provision of law, except as required to
implement specific provisions required under statute, the Secretary of
Health and Human Services is not authorized to issue in final form,
after the date of the enactment of this Act (Dec. 22, 1987) and before
October 15, 1990, any regulation, instruction, or other policy which is
estimated by the Secretary to result in a net reduction in expenditures
under title XVIII of the Social Security Act (this subchapter) in fiscal
year 1989 or in fiscal year 1990 or in fiscal year 1991 of more than
$50,000,000.''
Pub. L. 100-119, title I, 107(a)(1), Sept. 29, 1987, 101 Stat.
782, as amended by Pub. L. 100-203, title IV, 4002(f)(2), Dec. 22,
1987, 101 Stat. 1330-45, provided that: ''Notwithstanding any other
provision of law, with respect to payment for inpatient hospital
services under section 1886 of the Social Security Act (this section):
''(A) Temporary freeze in pps hospital rates. -- For purposes of
subsection (d) of such section for discharges occurring during the
period beginning on October 1, 1987, and ending on November 20, 1987 (in
this paragraph referred to as the 'extension period'), the applicable
percentage increase under subsection (b)(3)(B) of such section with
respect to fiscal year 1988 is deemed to be 0 percent.
''(B) Temporary freeze in payment basis. --
''(i) Extension of blended drg rate. -- For purposes of subsection
(d)(1) of such section, the 'applicable combined adjusted DRG
prospective payment rate' for discharges occurring --
''(I) during the extension period is the rate specified in subsection
(d)(1)(D)(ii) of such section, or
''(II) after such period is the national adjusted prospective payment
rate determined under subsection (d)(3) of such section.
''(ii) Extension of hospital-specific payment. -- For the first 51
days of a hospital cost reporting period beginning during fiscal year
1988, payment shall be made under clause (ii) (rather than clause (iii))
of subsection (d)(1)(A) of such section (subject to clause (i) of this
subparagraph), the target percentage and DRG percentage shall be those
specified in subsection (d)(1)(C)(iv) of such section, and the
applicable percentage increase in a hospital's target amount shall be
deemed to be 0 percent.
''(C) Temporary freeze in amounts of payment for capital. -- For
payments attributable to portions of cost reporting periods occurring
during the extension period, the percent specified in subsection
(g)(3)(A)(ii) of such section is deemed to be 3.5 percent.
''(D) Temporary freeze in return on equity reductions. -- For the
first 51 days of a cost reporting period beginning during fiscal year
1988, subsection (g)(2) of such section shall be applied as though the
applicable percentage were 75 percent.
''(E) Temporary freeze in payments rates for pps-exempt hospitals.
-- For purposes of payment under subsection (b) of such section for cost
reporting periods beginning during fiscal year 1988, with respect to the
first 51 days of such a period the applicable percentage increase under
paragraph (3)(B) of such subsection is deemed to be 0 percent.''
(Section 4002(f)(2) of Pub. L. 100-203 provided that the amendment of
section 107(a)(1) of Pub. L. 100-119, set out above, by section
4002(f)(2) of Pub. L. 100-203 is effective as of Sept. 29, 1987.)
Pub. L. 100-119, title I, 107(b), Sept. 29, 1987, 101 Stat. 783,
provided that:
''(1) In general. -- Notwithstanding any other provision of law, the
Secretary of Health and Human Services is not authorized to issue after
September 18, 1987, and before November 21, 1987 --
''(A) any final regulation that changes the policy with respect to
payment under title XVIII of the Social Security Act (this subchapter)
to providers of service for reasonable costs relating to unrecovered
costs associated with unpaid deductible and coinsurance amounts incurred
under such title;
''(B) 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 such title; or
''(C) any final regulation that changes the policy under such title
with respect to payment for a return on equity capital for outpatient
hospital services.
The final regulation of the Health Care Financing Administration
published on September 1, 1987 (52 Federal Register 32920) and relating
to changes to the return on equity capital provisions for outpatient
hospital services is void and of no effect.
''(2) Other cost savings policies. -- Notwithstanding any other
provision of law, except as required to implement specific provisions
required under statute, the Secretary of Health and Human Services is
not authorized to issue in final form, after September 18, 1987, and
before November 21, 1987, any regulation, instruction, or other policy
which is estimated by the Secretary to result in a net reduction in
expenditures under title XVIII of the Social Security Act in fiscal year
1988 of more than $50,000,000. Any regulation, instruction, or policy
which is issued in violation of this paragraph is void and of no effect.
''(3) Exception. -- Paragraphs (1) and (2) shall not be construed to
apply to any regulation, instruction, or policy required to implement
the amendment made by section 9311(a) of the Omnibus Budget
Reconciliation Act of 1986 (section 9311(a) of Pub. L. 99-509, which
amended section 1395g of this title) (relating to periodic interim
payments).''
Section 9302(b)(3) of Pub. L. 99-509 provided that: ''For payments
made under section 1886(d) of the Social Security Act (subsec. (d) of
this section) for discharges occurring in fiscal year 1987 --
''(A) the proportions under paragraph (3)(B) for hospitals located in
urban and rural areas shall be established at such levels as produce the
same total dollar reduction under such paragraph as if this section had
not been enacted; and
''(B) the thresholds and standards used for making additional
payments under paragraph (5) of such section shall be the same as those
in effect as of October 1, 1986.''
Section 6003(d) of Pub. L. 101-239 provided that: ''Any hospital
that is classified as a regional referral center under section
1886(d)(5)(C) of the Social Security Act (subsec. (d)(5)(C) of this
section) as of September 30, 1989, including a hospital so classified as
a result of section 9302(d)(2) of the Omnibus Budget Reconciliation Act
of 1986 (Pub. L. 99-509, set out below), shall continue to be classified
as a regional referral center for cost reporting periods beginning on or
after October 1, 1989, and before October 1, 1992.''
Section 9302(d)(2) of Pub. L. 99-509 provided that: ''Any hospital
that is classified as a regional referral center under section
1886(d)(5)(C)(i) of the Social Security Act (subsec. (d)(5)(C)(i) of
this section) on the date of the enactment of this Act (Oct. 21, 1986)
shall continue to be classified as a regional referral center for cost
reporting periods beginning on or after October 1, 1986, and before
October 1, 1989.''
Section 9302(d)(3) of Pub. L. 99-509 provided that: ''Paragraph (2)
(set out as a note above) and the amendment made by paragraph (1)(A)
(amending this section) shall be implemented in a manner that ensures
that total payments under section 1886 of the Social Security Act (this
section) are not increased or decreased by reason of the classifications
required by such paragraph or amendment.''
Section 9302(f) of Pub. L. 99-509 provided that: ''The Secretary of
Health and Human Services shall provide, within 30 days after the date
of the enactment of this Act (Oct. 21, 1986), for the publication of the
payments rates that will apply under section 1886 of the Social Security
Act (this section), for discharges occurring on or after October 1,
1986, taking into account the amendments made by this section (amending
this section), without regard to the provisions of chapter 5 of title 5,
United States Code.''
Section 9307(d) of Pub. L. 99-509, as amended by Pub. L. 100-203,
title IV, 4008(e), Dec. 22, 1987, 101 Stat. 1330-56, provided that:
''Notwithstanding any other provision of law, for purposes of section
1886(d)(1)(A) of the Social Security Act (subsec. (d)(1)(A) of this
section), in the case of a hospital that --
''(1) had a cost reporting period beginning on September 28, 29, or
30 of 1985,
''(2) is located in a State in which inpatient hospital services were
paid in fiscal year 1985 pursuant to a Statewide demonstration project
under section 402 of the Social Security Amendments of 1967 (section 402
of Pub. L. 90-248, enacting section 1395b-1 of this title 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 sections
1395b-1 and 1395ll of this title and enacting provisions set out as a
note under section 1395b-1 of this title), and
''(3) elects, by notice to the Secretary of Health and Human Services
by not later than April 1, 1988, to have this subsection apply,
during the first 7 months of such cost reporting period the 'target
percentage' shall be 75 percent and the 'DRG percentage' shall be 25
percent, and during the remaining 5 months of such period the 'target
percentage' and the 'DRG percentage' shall each be 50 percent.''
(Section 4008(e) of Pub. L. 100-203 provided that the amendment of
section 9307(d) of Pub. L. 99-509, set out above, by section 4008(e) of
Pub. L. 100-203 is effective as if included in the enactment of Pub. L.
99-509.)
Section 9321(c) of Pub. L. 99-509, as amended by Pub. L. 100-119,
title I, 107(a)(2), Sept. 29, 1987, 101 Stat. 783; Pub. L. 100-203,
title IV, 4009(j)(6)(D), (F), Dec. 22, 1987, 101 Stat. 1330-59,
provided that:
''(1) Prohibition of issuance of final regulations on capital-related
costs as part of payment for operating costs before november 21, 1987.
-- Notwithstanding any other provision of law (except as provided in
paragraph (3)), the Secretary of Health and Human Services may not
issue, in final form, after September 1, 1986, and before November 21,
1987, any regulation that changes the methodology for computing the
amount of payment for capital-related costs (as defined in paragraph
(4)) for inpatient hospital services under part A of title XVIII of the
Social Security Act (part A of this subchapter). Any regulation
published in violation of the previous sentence is void and of no
effect.
''(2) Not including capital-related regulations in budget baseline.
-- Any reference in law to a regulation issued in final form or proposed
by the Health Care Financing Administration pursuant to sections
1886(b)(3)(B), 1886(d)(3)(A), and 1886(e)(4) of the Social Security Act
(subsecs. (b)(3)(B), (d)(3)(A), and (e)(4) of this section) shall not
include any regulation issued or proposed with respect to
capital-related costs (as defined in paragraph (4)).
''(3) Exception. -- Paragraph (1) shall not apply to any regulation
issued for the sole purpose of implementing section 1861(v)(1)(O) and
1886(g)(2) of the Social Security Act (section 1395x(v)(1)(O) of this
title and subsec. (g)(2) of this section) and section 1886(g)(3)(A) and
(B) of the Social Security Act (subsec. (g)(3)(A) and (B) of this
section) (as amended by section 9303(a) of this Act).
''(4) Capital-related costs defined. -- In this subsection, the term
'capital-related costs' means those capital-related costs that are
specifically excluded, under the second sentence of section 1886(a)(4)
of the Social Security Act (subsec. (a)(4) of this section), from the
term 'operating costs of inpatient hospital services' (as defined in
that section) for cost reporting periods beginning prior to October 1,
1987.''
Section 9321(d) of Pub. L. 99-509 provided that: ''Notwithstanding
any other provision of law, except as required to implement specific
provisions required under statute and except as provided under
subsection (c) (set out above) with respect to a regulation described in
that subsection, the Secretary of Health and Human Services is not
authorized to issue in final form after the date of the enactment of
this Act (Oct. 21, 1986) and before September 1, 1987, any regulation,
instruction, or other policy which is estimated by the Secretary to
result in a net reduction in expenditures under title XVIII of the
Social Security Act (this subchapter) in fiscal year 1988 of more than
$50,000,000, and which relates to hospitals or physicians.''
Section 9103(b) of Pub. L. 99-272 provided that:
''(1) The Secretary of Health and Human Services, in consultation
with the Prospective Payment Assessment Commission, shall collect
information and shall develop one or more methodologies to permit the
adjustment of the wage indices used for purposes of sections
1886(d)(2)(C)(ii), 1886(d)(2)(H), and 1886(d)(3)(E) of the Social
Security Act (subsec. (d)(2)(C)(ii), (H), and (3)(E) of this section),
in order to more accurately reflect hospital labor markets, by taking
into account variations in wages and wage-related costs between the
central city portion of urban areas and other parts of urban areas.
''(2) The Secretary shall report to Congress on the information
collected and the methodologies developed under paragraph (1) not later
than May 1, 1987. The report shall include a recommendation as to the
feasibility and desirability of implementing such methodologies.''
Section 9108 of Pub. L. 99-272 provided that:
''(a) Continuation of Waivers. -- A hospital reimbursement control
system which, on January 1, 1985, was carrying out a demonstration under
a contract which had been approved by the Secretary of Health and Human
Services pursuant to section 222(a) of the Social Security Amendments of
1972 (section 222(a) of Pub. L. 92-603, set out as a note under section
1395b-1 of this title), or under section 402 of the Social Security
Amendments of 1967 (as amended by section 222(b) of the Social Security
Amendments of 1972) (section 1395b-1 of this title), shall be deemed to
meet the requirements of section 1886(c)(1)(A) of the Social Security
Act (subsec. (c)(1)(A) of this section) if such system applies --
''(1) to substantially all non-Federal acute care hospitals (as
defined by the Secretary) in the geographic area served by such system
on January 1, 1985, and
''(2) to the review of at least 75 percent of --
''(A) all revenues or expenses in such geographic area for inpatient
hospital services, and
''(B) revenues or expenses in such geographic area for inpatient
hospital services provided under the State's plan approved under title
XIX (subchapter XIX of this chapter).
''(b) Approval. -- In the case of a hospital cost control system
described in subsection (a), the requirements of section 1886(c) of the
Social Security Act (subsec. (c) of this section) which apply to States
shall instead apply to such system and, for such purposes, any reference
to a State is deemed a reference to such system.
''(c) Effective Date. -- This section shall become effective on the
date of the enactment of this Act (Apr. 7, 1986).''
Section 9114 of Pub. L. 99-272 provided that:
''(a) Disclosure of Information. -- The Secretary of Health and Human
Services shall make available to the Prospective Payment Assessment
Commission, the Congressional Budget Office, the Comptroller General,
and the Congressional Research Service the most current information on
the payments being made under section 1886 of the Social Security Act
(this section) to individual hospitals. Such information shall be made
available in a manner that permits examination of the impact of such
section on hospitals.
''(b) Confidentiality. -- Information disclosed under subsection (a)
shall be treated as confidential and shall not be subject to further
disclosure in a manner that permits the identification of individual
hospitals.''
Section 9115 of Pub. L. 99-272 provided that:
''(a) Waiver of Paperwork Reduction. -- Chapter 35 of title 44,
United States Code, shall not apply to information required for purposes
of carrying out this subpart and implementing the amendments made by
this subpart (subpart A ( 9101-9115) of part 1 of subtitle A of title
IX of Pub. L. 99-272, see Tables for classification).
''(b) Use of Interim Final Regulations. -- The Secretary of Health
and Human Services shall issue such regulations (on an interim or other
basis) as may be necessary to implement this subpart and the amendments
made by this subpart.''
Section 9127(b) of Pub. L. 99-272, as amended by Pub. L. 99-514,
title XVIII, 1895(b)(8), Oct. 22, 1986, 100 Stat. 2933, provided
that: ''The Director of the Congressional Office of Technology
Assessment shall appoint the two additional members of the Prospective
Payment Assessment Commission, as required by the amendment made by
subsection (a) (amending this section), no later than 60 days after the
date of the enactment of this Act (Apr. 7, 1986), for terms of three
years, except that the Director may provide initially for such terms as
will insure that (on a continuing basis) the terms of no more than eight
members will expire in any one year.''
of Approved FTE Resident Amounts; Study on Foreign
Medical Graduates; Establishing Physician Identifier
System; Paperwork Reduction
Section 9202(c)-(h) of Pub. L. 99-272, as amended by Pub. L.
100-203, title IV, 4085(f), Dec. 22, 1987, 101 Stat. 1330-131; Pub.
L. 101-508, title IV, 4118(i)(2), Nov. 5, 1990, 104 Stat. 1388-70,
provided that:
''(c) Studies by Secretary. -- (1) The Secretary of Health and Human
Services shall conduct a study with respect to approved educational
activities relating to nursing and other health professions for which
reimbursement is made to hospitals under title XVIII of the Social
Security Act (this subchapter). The study shall address --
''(A) the types and numbers of such programs, and number of students
supported or trained under each program;
''(B) the fiscal and administrative relationships between the
hospitals involved and the schools with which the programs and students
are affiliated; and
''(C) the types and amounts of expenses of such programs for which
reimbursement is made, and the financial and other contributions which
accrue to the hospital as a consequence of having such programs.
The Secretary shall report the results of such study to the Committee
on Finance of the Senate and the Committees on Ways and Means and Energy
and Commerce of the House of Representatives prior to December 31, 1987.
''(2) The Secretary shall conduct a separate study of the
advisability of continuing or terminating the exception under section
1886(h)(5)(F)(ii) of the Social Security Act (subsec. (h)(5)(F)(ii) of
this section) for geriatric residencies and fellowships, and of
expanding such exception to cover other educational activities,
particularly those which are necessary to meet the projected health care
needs of Medicare beneficiaries. Such study shall also examine the
adequacy of the supply of faculty in the field of geriatrics. The
Secretary shall report the results of such study to the committees
described in paragraph (1) prior to July 1, 1990.
''(d) GAO Study. -- (1) The Comptroller General shall conduct a study
of the variation in the amounts of payments made under title XVIII of
the Social Security Act (this subchapter) with respect to patients in
different teaching hospital settings and in the amounts of such payments
which are made with respect to patients who are treated in teaching and
nonteaching hospital settings. Such study shall identify the components
of such payments (including payments with respect to inpatient hospital
services, physicians' services, and capital costs, and, in the case of
teaching hospital patients, payments with respect to direct and indirect
teaching costs) and shall account, to the extent feasible, for any
variations in the amounts of the payment components between teaching and
nonteaching settings and among different teaching settings.
''(2) In carrying out such study, the Comptroller General may utilize
a sample of hospital patients and any other data sources which he deems
appropriate, and shall, to the extent feasible, control for differences
in severity of illness levels, area wage levels, levels of physician
reasonable charges for like services and procedures, and for other
factors which could affect the comparability of patients and of payments
between teaching and nonteaching settings and among teaching settings.
The information obtained in the study shall be coordinated with the
information obtained in conducting the study of teaching physicians'
services under section 2307(c) of the Deficit Reduction Act of 1984
(section 2307(c) of Pub. L. 98-369, set out as a note under section
1395u of this title).
''(3) The Comptroller General shall report the results of the study
to the committees described in subsection (c)(1) prior to December 31,
1987.
''(e) Report on Uniformity of Approved FTE Resident Amounts. -- The
Secretary of Health and Human Services shall report to the committees
described in subsection (c)(1), not later than December 31, 1987, on
whether section 1886(h) of the Social Security Act (subsec. (h) of this
section) should be revised to provide for greater uniformity in the
approved FTE resident amounts established under paragraph (2) of that
section, and, if so, how such revisions should be implemented.
''(f) Study on Foreign Medical Graduates. -- The Secretary of Health
and Human Services shall study, and report to the committees described
in subsection (c)(1), not later than December 31, 1987, respecting the
use of physicians who are foreign medical graduates (within the meaning
of section 1886(h)(5)(D) of the Social Security Act (subsec. (h)(5)(D)
of this section)) in the provision of health care services (particularly
inpatient and outpatient hospital services) to medicare beneficiaries.
Such study shall evaluate --
''(1) the types of services provided;
''(2) the cost of providing such services, relative to the cost of
other physicians providing the services or other approaches to providing
the services;
''(3) any deficiencies in the quality of the services provided, and
methods of assuring the quality of such services; and
''(4) the impact on costs of and access to services if medicare
payment for hospitals' costs of graduate medical education of foreign
medical graduates were phased out.
''((g) Repealed. Pub. L. 101-508, title IV, 4118(i)(2), Nov. 5,
1990, 104 Stat. 1388-70.)
''(h) Paperwork Reduction. -- Chapter 35 of title 44, United States
Code, shall not apply to information required for purposes of carrying
out this section and the amendments made by this section (amending this
section and section 1395x of this title and enacting notes set out under
this section and section 1395x of this title).''
Section 9202(j) of Pub. L. 99-272, as amended by Pub. L. 99-514,
title XVIII, 1895(b)(10), Oct. 22, 1986, 100 Stat. 2933, provided
that: ''In the case of a hospital in a State that has had a waiver
approved under section 1886(c) of the Social Security Act (subsec. (c)
of this section) or section 402 of the Social Security Amendments of
1967 (section 1395b-1 of this title), for cost reporting periods
beginning on or after January 1, 1986, if the waiver is terminated --
''(1) the Secretary of Health and Human Services shall permit the
hospital to change the method by which it allocates administrative and
general costs to the direct medical education cost centers to the method
specified in the medicare cost report;
''(2) the Secretary may make appropriate adjustments in the regional
adjusted DRG prospective payment rate (for the region in which the State
is located), based on the assumption that all teaching hospitals in the
State use the medicare cost report; and
''(3) the Secretary shall adjust the hospital-specific portion of
payment under section 1886(d) of such Act (subsec. (d) of this section)
for any such hospital that actually chooses to use the medicare cost
report.
The Secretary shall implement this subsection based on the best
available data.''
Section 9204 of Pub. L. 99-272, as amended by Pub. L. 99-509, title
IX, 9339(e), Oct. 21, 1986, 100 Stat. 2037; Pub. L. 100-203, title
IV, 4085(c), Dec. 22, 1987, 101 Stat. 1330-130; Pub. L. 100-647,
title VIII, 8426, Nov. 10, 1988, 102 Stat. 3803, provided that:
''(a) Moratorium. -- Prior to January 1, 1990, the Secretary of
Health and Human Services shall not conduct any demonstration projects
relating to competitive bidding as a method of purchasing laboratory
services under title XVIII of the Social Security Act (this subchapter).
The Secretary may contract for the design of, and site selection for,
such demonstration projects.
''(b) Cooperation in Study. -- The Secretary of Health and Human
Services and the Comptroller General shall assist representatives of
clinical laboratories in the industry's conduct of a study to determine
whether methods exist which are better than competitive bidding for
purposes of utilizing competitive market forces in setting payment
levels for laboratory services under title XVIII of the Social Security
Act (this subchapter). If such a study is conducted by the clinical
laboratory industry, the Secretary and the Comptroller General shall
comment on such study and submit such comments and the study to the
Senate Committee on Finance and the House Committees on Ways and Means
and Energy and Commerce.''
Pub. L. 99-107, 5, Sept. 30, 1985, 99 Stat. 479, as amended by
Pub. L. 99-155, 2(d), Nov. 14, 1985, 99 Stat. 814; Pub. L. 99-181,
4, Dec. 13, 1985, 99 Stat. 1172; Pub. L. 99-189, 4, Dec. 18, 1985,
99 Stat. 1184; Pub. L. 99-201, 2, Dec. 23, 1985, 99 Stat. 1665;
Pub. L. 99-272, title IX, 9101(a), 9301(a), Apr. 7, 1986, 100 Stat.
153, 184, provided that:
''(a) Maintaining Existing Hospital Payment Rates. -- Notwithstanding
any other provision of law, the amount of payment under section 1886 of
the Social Security Act (this section) for inpatient hospital services
for discharges occurring (and cost reporting periods beginning) during
the extension period (as defined in subsection (c)) shall be determined
on the same basis as the amount of payment for such services for a
discharge occurring on (or the cost reporting period beginning
immediately on or before) September 30, 1985.
''(b) Maintaining Existing Payment Rates for Physicians' Services.
-- Notwithstanding any other provision of law, the amount of payment
under part B of title XVIII of the Social Security Act (part B of this
subchapter) for physicians' services which are furnished during the
extension period (as defined in subsection (c)) shall be determined on
the same basis as the amount of payment for such services furnished on
September 30, 1985, and the 15-month period, referred to in section
1842(j)(1) of such Act (section 1395u(j)(1) of this title), shall be
deemed to include the extension period.
''(c) Extension Period Defined. --
''(1) Hospital payments. -- For purposes of subsection (a), the term
'extension period' means the period beginning on October 1, 1985, and
ending on April 30, 1986.
''(2) Physician payments. -- For purposes of subsection (b), the term
'extension period' means the period beginning on October 1, 1985, and
ending on April 30, 1986.''
(Amendment of section 5 of Pub. L. 99-107, set out above, by section
9101(a) of Pub. l. 99-272 effective Mar. 15, 1986, see section 9101(d)
of Pub. L. 99-272, set out above.)
Section 2315(h) of Pub. L. 98-369 provided that: ''The Secretary of
Health and Human Services shall, prior to December 31, 1984 --
''(1) develop and publish a definition of 'hospitals that serve a
significantly disproportionate number of patients who have low income or
are entitled to benefits under part A' of title XVIII of the Social
Security Act (part A of this subchapter) for purposes of section
1886(d)(5)(C)(i) of that Act (subsec. (d)(5)(C)(i) of this section), and
''(2) identify those hospitals which meet such definition, and make
such identity available to the Committee on Ways and Means of the House
of Representatives and the Committee on Finance of the Senate.''
Congress
Section 2316 of Pub. L. 98-369, as amended by Pub. L. 99-272, title
IX, 9103(a)(1), Apr. 7, 1986, 100 Stat. 156, provided that:
''(a) The Secretary of Health and Human Services, in consultation
with the Secretary of Labor, shall conduct a study to develop an
appropriate index for purposes of adjusting payment amounts under
section 1886(d) of the Social Security Act (subsec. (d) of this section)
to reflect area differences in average hospital wage levels, as required
under paragraphs (2)(H) and (3)(E) of such section (subsec. (d)(2)(H)
and (3)(E) of this section), taking into account wage differences of
full time and part time workers. The Secretary of Health and Human
Services shall report the results of such study to the Congress not
later than 30 days after the date of the enactment of this Act (July 18,
1984), including any changes which the Secretary determines to be
necessary to provide for an appropriate index.
''(b) The Secretary shall adjust the payment amounts for hospitals
for discharges occurring on or after May 1, 1986, to reflect the changes
the Secretary has promulgated in final regulations (on September 3,
1985) relating to the hospital wage index under section 1886(d)(3)(E) of
the Social Security Act (subsec. (d)(3)(E) of this section). For
discharges occurring after September 30, 1986, the Secretary shall
provide for such periodic adjustments in the appropriate wage index used
under that section as may be necessary, taking into account changes in
the wage levels and relative proportions of full-time and part-time
workers.
''(c) The Secretary shall conduct a study and report to the Congress
on proposed criteria under which, in the case of a hospital that
demonstrates to the Secretary in a current fiscal year that the
adjustment being made under paragraph (2)(H) or (3)(E) of section
1886(d) of the Social Security Act (subsec. (d)(2)(H) or (3)(E) of this
section) for that hospital's discharges in that fiscal year does not
accurately reflect the wage levels in the labor market serving the
hospital, the Secretary, to the extent he deems appropriate, would
modify such adjustment for that hospital for discharges in the
subsequent fiscal year to take into account a difference in payment
amounts in that current fiscal year to the hospital that resulted from
such inaccuracy.''
(Section 9103(a)(2) of Pub. L. 99-272 provided that: ''The amendment
made by paragraph (1) (amending this note) shall be effective as if it
had been included in the Deficit Reduction Act of 1984 (Pub. L.
98-369).'')
Section 601(a)(3) of Pub. L. 98-21 provided that: ''It is the
intent of Congress that, in considering the implementation of a system
for including capital-related costs under a prospectively determined
payment rate for inpatient hospital services, costs related to capital
projects for which expenditures are obligated on or after the effective
date of the implementation of such a system, may or may not be
distinguished and treated differently from costs of projects for which
expenditures were obligated before such date.''
Section 601(g) of Pub. L. 98-21 provided that: ''In determining
whether a hospital is in an urban or rural area for purposes of section
1886(d) of the Social Security Act (subsec. (d) of this section), the
Secretary of Health and Human Services shall classify any hospital
located in New England as being located in an urban area if such
hospital was classified as being located in an urban area under the
Standard Metropolitan Statistical Area system of classification in
effect in 1979.''
Section 603(a) of title VI of Pub. L. 98-21, as amended by Pub. L.
98-369, div. B, title III, 2317, July 18, 1984, 98 Stat. 1081; Pub.
L. 99-509, title IX, 9305(i)(1), Oct. 21, 1986, 100 Stat. 1993,
provided that:
''(1) The Secretary of Health and Human Services (hereinafter in this
title referred to as the 'Secretary') shall study, develop, and report
to the Congress within 18 months after the date of the enactment of this
Act (Apr. 20, 1983) on the method and proposals for legislation by which
capital-related costs, such as return on net equity, associated with
inpatient hospital services can be included within the prospective
payment amounts computed under section 1886(d) of the Social Security
Act (subsec. (d) of this section).
''(2)(A) The Secretary shall study and report annually to the
Congress at the end of each year (beginning with 1984 and ending with
1989) on the impact, of the payment methodology under section 1886(d) of
the Social Security Act (subsec. (d) of this section) during the
previous year, on classes of hospitals, beneficiaries, and other payors
for inpatient hospital services, and other providers, and, in
particular, on the impact of computing DRG prospective payment rates by
census division, rather than exclusively on a national basis. Each such
report shall include such recommendations for such changes in
legislation as the Secretary deems appropriate.
''(B) During fiscal year 1984, the Secretary shall begin the
collection of data necessary to compute the amount of physician charges
attributable, by diagnosis-related groups, to physicians' services
furnished to inpatients of hospitals whose discharges are classified
within those groups. The Secretary shall submit to Congress, not later
than July 1, 1985, a report to Congress which includes recommendations
on the advisability and feasibility of providing for determining the
amount of the payments for physicians' services furnished to hospital
inpatients based on the DRG type classification of the discharges of
those inpatients, and legislative recommendations thereon.
''(C) In the annual report to Congress under subparagraph (A) for
1985, the Secretary shall include the results of studies on --
''(i) the feasibility and impact of eliminating or phasing out
separate urban and rural DRG prospective payment rates under paragraph
(3) of section 1886(d) of the Social Security Act (subsec. (d)(3) of
this section);
''(ii) whether and the method under which hospitals, not paid based
on amounts determined under such section, can be paid for inpatient
hospital services on a prospective basis as under such section;
''(iii) the appropriateness of the factors used under paragraph
(5)(A) of such section to compensate hospitals for the additional
expenses of outlier cases, and the application of severity of illness,
intensity of care, or other modifications to the diagnosis-related
groups, and the advisability and feasibility of providing for such
modifications;
''(iv) the feasibility and desirability of applying the payment
methodology under such section to payment by all payors for inpatient
hospital services; and
''(v) the impact of such section on hospital admissions and the
feasibility of making a volume adjustment in the DRG prospective payment
rates or requiring preadmission certification in order to minimize the
incentive to increase admissions.
Such report shall specifically include, with respect to the item
described in clause (iv), consideration of the extent of cost-shifting
to non-Federal payors and the impact of such cost-shifting on health
insurance costs and premiums borne by employers and employees.
''(D) In the annual report to Congress under subparagraph (A) for
1986, the Secretary shall include the results of a study examining the
overall impact of State systems of hospital payment (either approved
under section 1886(c) of the Social Security Act (subsec. (c) of this
section) or under a waiver approved under section 402(a) of the Social
Security Amendments of 1967 (section 1395b-1(a) of this title) or
section 222(a) of the Social Security Amendments of 1972) (Pub. L.
92-603, set out as a note under 1395b-1 of this title), particularly
assessing such systems' impact not only on the medicare program but also
on the medicaid program, on payments and premiums under private health
insurance plans, and on tax expenditures.
''(E) In each annual report to Congress under subparagraph (A), the
Secretary shall include --
''(i) an evaluation of the adequacy of the procedures for assuring
quality of post-hospital services furnished under title XVIII of the
Social Security Act (this subchapter),
''(ii) an assessment of problems that have prevented groups of
medicare beneficiaries (including those eligible for medical assistance
under title XIX of such Act (subchapter XIX of this chapter)) from
receiving appropriate post-hospital services covered under such title,
and
''(iii) information on reconsiderations and appeals taken under title
XVIII of such Act (this subchapter) with respect to payment for
post-hospital services.
''(3)(A) The Secretary shall complete a study and make legislative
recommendations to the Congress with respect to an equitable method of
reimbursing sole community hospitals which takes into account their
unique vulnerability to substantial variations in occupancy.
''(B) In addition, the Secretary shall examine ways to coordinate an
information transfer between parts A and B of title XVIII of the Social
Security Act (parts A and B of this subchapter), particularly with
respect to those cases where a denial of coverage is made under part A
of such title and no adjustment is made in the reimbursement to the
admitting physician or physicians.
''(C) The Secretary shall also report on the appropriate treatment of
uncompensated care costs, and adjustments that might be appropriate for
large teaching hospitals located in rural areas.
''(D) The Secretary shall also report on the advisability of having
hospitals make available information on the cost of care to patients
financed by both public programs and private payors.
''(E) The studies and reports described in this paragraph shall be
completed and submitted not later than April 1, 1985.
''(4) The Secretary shall complete a study and make recommendations
to the Congress, before April 1, 1984, with respect to a method for
including hospitals located outside of the fifty States and the District
of Columbia under a prospective payment system.''
(Section 9305(i)(2) of Pub. L. 99-509 provided that: ''The amendment
made by paragraph (1)(B) (amending section 603(a) of Pub. L. 98-21, set
out above) shall apply to reports for years beginning with 1986.'')
Section 101(b)(2)(B) of Pub. L. 97-248, as amended by Pub. L.
97-448, title III, 309(a)(1), Jan. 12, 1983, 96 Stat. 2408, provided
that: ''Chapter 35 of title 44, United States Code, shall not apply,
until January 1, 1984, to collection of information and information
collection requests which the Secretary of Health and Human Services
determines to be necessary to carry out the amendments made by this
section (amendments by section 101(a) of Pub. L. 97-248, enacting this
section and amending section 1395x of this title).''
section 8904; title 10 section 1101.
/1/ So in original. The comma probably should not appear.
/2/ So in original. Probably should be followed by ''percentage
point''.
/3/ So in original.
/4/ So in original. The comma probably should not appear.
/5/ So in original. Probably should be followed by ''and''.
/6/ So in original. Probably should be section ''557(b)''.
/7/ See References in Text note below.
/8/ So in original. Probably should be ''necessary''.
/9/ So in original. Probably should be followed by a closing
parenthesis.
42 USC 1395xx. Payment of provider-based physicians and payment under
certain percentage arrangements
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Criteria; amount of payments
(1) The Secretary shall by regulation determine criteria for
distinguishing those services (including inpatient and outpatient
services) rendered in hospitals or skilled nursing facilities --
(A) which constitute professional medical services, which are
personally rendered for an individual patient by a physician and which
contribute to the diagnosis or treatment of an individual patient, and
which may be reimbursed as physicians' services under part B, and
(B) which constitute professional services which are rendered for the
general benefit to patients in a hospital or skilled nursing facility
and which may be reimbursed only on a reasonable cost basis or on the
bases described in section 1395ww of this title.
(2)(A) For purposes of cost reimbursement, the Secretary shall
recognize as a reasonable cost of a hospital or skilled nursing facility
only that portion of the costs attributable to services rendered by a
physician in such hospital or facility which are services described in
paragraph (1)(B), apportioned on the basis of the amount of time
actually spent by such physician rendering such services.
(B) In determining the amount of the payments which may be made with
respect to services described in paragraph (1)(B), after apportioning
costs as required by subparagraph (A), the Secretary may not recognize
as reasonable (in the efficient delivery of health services) such
portion of the provider's costs for such services to the extent that
such costs exceed the reasonable compensation equivalent for such
services. The reasonable compensation equivalent for any service shall
be established by the Secretary in regulations.
(C) The Secretary may, upon a showing by a hospital or facility that
it is unable to recruit or maintain an adequate number of physicians for
the hospital or facility on account of the reimbursement limits
established under this subsection, grant exceptions to such
reimbursement limits as may be necessary to allow such provider to
provide a compensation level sufficient to provide adequate physician
services in such hospital or facility.
(b) Prohibition of recognition of payments under certain percentage
agreements
(1) Except as provided in paragraph (2), in the case of a provider of
services which is paid under this subchapter on a reasonable cost basis,
or other basis related to costs that are reasonable, and which has
entered into a contract for the purpose of having services furnished for
or on behalf of it, the Secretary may not include any cost incurred by
the provider under the contract if the amount payable under the contract
by the provider for that cost is determined on the basis of a percentage
(or other proportion) of the provider's charges, revenues, or claim for
reimbursement.
(2) Paragraph (1) shall not apply --
(A) to services furnished by a physician and described in subsection
(a)(1)(B) of this section and covered by regulations in effect under
subsection (a) of this section, and
(B) under regulations established by the Secretary, where the amount
involved under the percentage contract is reasonable and the contract --
(i) is a customary commercial business practice, or
(ii) provides incentives for the efficient and economical operation
of the provider of services.
(Aug. 14, 1935, ch. 531, title XVIII, 1887, as added and amended
Sept. 3, 1982, Pub. L. 97-248, title I, 108(a)((1)), 109(a), 96 Stat.
337, 338; Apr. 20, 1983, Pub. L. 98-21, title VI, 602(j), 97 Stat.
165.)
1983 -- Subsec. (a)(1)(B). Pub. L. 98-21 inserted ''or on the bases
described in section 1395ww of this title''.
1982 -- Subsec. (b). Pub. L. 97-248, 109(a)(2), added subsec. (b).
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.
Section 109(c)(1), (2) of Pub. L. 97-248 provided that:
''(1) The amendments made by this section (amending this section and
section 1395x of this title) shall become effective on the date of the
enactment of this Act (Sept. 3, 1982), except that section 1887(b)(1) of
the Social Security Act (subsec. (b)(1) of this section) shall not apply
before October 1, 1982, to services furnished by a physician and
described in section 1887(a)(1)(B) of such Act (subsec. (a)(1)(B) of
this section).
''(2) In the case of a contract with a provider of services entered
into prior to the date of the enactment of this Act (Sept. 3, 1982), the
amendment made by subsection (a) (amending this section) shall apply to
payments under such contract (A) 30 days after the first date (after
such date of enactment) the provider of services may unilaterally
terminate the contract, or (B) one year after the date of the enactment
of this Act, whichever is earlier.''
Section 108(b), formerly 108(c), of Pub. L. 97-248, as redesignated
by Pub. L. 97-448, title III, 309(a)(3), Jan. 12, 1983, 96 Stat.
2408, provided that: ''The Secretary of Health and Human Services shall
first promulgate regulations to carry out section 1887(a) of the Social
Security Act (subsec. (a) of this section) not later than October 1,
1982. Such regulations shall become effective on October 1, 1982, and
shall be effective with respect to cost reporting periods ending after
September 30, 1982, but in the case of any cost reporting period
beginning before October 1, 1982, any reduction in payments under title
XVIII of the Social Security Act (this subchapter) to a hospital or
skilled nursing facility resulting from such regulations shall be
imposed only in proportion to the part of the period which occurs after
September 30, 1982.''
42 USC 1395yy. Payment to skilled nursing facilities for routine
service costs
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Per diem limitations
The Secretary, in determining the amount of the payments which may be
made under this subchapter with respect to routine service costs of
extended care services shall not recognize as reasonable (in the
efficient delivery of health services) per diem costs of such services
to the extent that such per diem costs exceed the following per diem
limits, except as otherwise provided in this section:
(1) With respect to freestanding skilled nursing facilities located
in urban areas, the limit shall be equal to 112 percent of the mean per
diem routine service costs for freestanding skilled nursing facilities
located in urban areas.
(2) With respect to freestanding skilled nursing facilities located
in rural areas, the limit shall be equal to 112 percent of the mean per
diem routine service costs for freestanding skilled nursing facilities
located in rural areas.
(3) With respect to hospital-based skilled nursing facilities located
in urban areas, the limit shall be equal to the sum of the limit for
freestanding skilled nursing facilities located in urban areas, plus 50
percent of the amount by which 112 percent of the mean per diem routine
service costs for hospital-based skilled nursing facilities located in
urban areas exceeds the limit for freestanding skilled nursing
facilities located in urban areas.
(4) With respect to hospital-based skilled nursing facilities located
in rural areas, the limit shall be equal to the sum of the limit for
freestanding skilled nursing facilities located in rural areas, plus 50
percent of the amount by which 112 percent of the mean per diem routine
service costs for hospital-based skilled nursing facilities located in
rural areas exceeds the limit for freestanding skilled nursing
facilities located in rural areas.
In applying this subsection the Secretary shall make appropriate
adjustments to the labor related portion of the costs based upon an
appropriate wage index, and shall, for cost reporting periods beginning
on or after October 1, 1992 and every 2 years thereafter, provide for an
update to the per diem cost limits described in this subsection /1/
(b) Exception to limitations for hospital-based skilled nursing
facility
With respect to a hospital-based skilled nursing facility, the
Secretary shall recognize as reasonable the portion of the cost
differences between hospital-based and freestanding skilled nursing
facilities attributable to excess overhead allocations (as determined by
the Secretary) resulting from the reimbursement principles under this
subchapter, notwithstanding the limits set forth in paragraph (3) or (4)
of subsection (a) of this section.
(c) Adjustments in limitations; publication of data
The Secretary may make adjustments in the limits set forth in
subsection (a) of this section with respect to any skilled nursing
facility to the extent the Secretary deems appropriate, based upon case
mix or circumstances beyond the control of the facility. The Secretary
shall publish the data and criteria to be used for purposes of this
subsection on an annual basis.
(d) Access to skilled nursing facilities
(1) Any skilled nursing facility may choose to be paid under this
subsection on the basis of a prospective payment for all routine service
costs (including the costs of services required to attain or maintain
the highest practicable physical, mental, and psychosocial well-being of
each resident eligible for benefits under this subchapter) and
capital-related costs of extended care services provided in a cost
reporting period if such facility had, in the preceding cost reporting
period, fewer than 1,500 patient days with respect to which payments
were made under this subchapter. Such prospective payment shall be in
lieu of payments which would otherwise be made for routine service costs
pursuant to section 1395x(v) of this title and subsections (a) through
(c) of this section and capital-related costs pursuant to section
1395x(v) of this title. This subsection shall not apply to a facility
for any cost reporting period immediately following a cost reporting
period in which such facility had 1,500 or more patient days with
respect to which payments were made under this subchapter, without
regard to whether payments were made under this subsection during such
preceding cost reporting period.
(2)(A) The amount of the payment under this section shall be
determined on a per diem basis.
(B) Subject to the limitations of subparagraph (C), for skilled
nursing facilities located --
(i) in an urban area, the amount shall be equal to 105 percent of the
mean of the per diem reasonable routine service and capital-related
costs of extended care services for skilled nursing facilities in urban
areas within the same region, determined without regard to the
limitations of subsection (a) of this section and adjusted for different
area wage levels, and
(ii) in a rural area the amount shall be equal to 105 percent of the
mean of the per diem reasonable routine service and capital-related
costs of extended care services for skilled nursing facilities in rural
areas within the same region, determined without regard to the
limitations of subsection (a) of this section and adjusted for different
area wage levels.
(C) The per diem amounts determined under subparagraph (B) shall not
exceed the limit on routine service costs determined under subsection
(a) of this section with respect to the facility, adjusted to take into
account average capital-related costs with respect to the type and
location of the facility.
(3) For purposes of this subsection, urban and rural areas shall be
determined in the same manner as for purposes of subsection (a) of this
section, and the term ''region'' shall have the same meaning as under
section 1395ww(d)(2)(D) of this title.
(4) The Secretary shall establish the prospective payment amounts for
cost reporting periods beginning in a fiscal year at least 90 days prior
to the beginning of such fiscal year, on the basis of the most recent
data available for a 12-month period. A skilled nursing facility must
notify the Secretary of its intention to be paid pursuant to this
subsection for a cost reporting period no later than 30 days before the
beginning of that period.
(5) The Secretary shall provide for a simplified cost report to be
filed by facilities being paid pursuant to this subsection, which shall
require only the cost information necessary for determining prospective
payment amounts pursuant to paragraph (2) and reasonable costs of
ancillary services.
(6) In lieu of payment on a cost basis for ancillary services
provided by a facility which is being paid pursuant to this subsection,
the Secretary may pay for such ancillary services on a reasonable charge
basis if the Secretary determines that such payment basis will provide
an equitable level of reimbursement and will ease the reporting burden
of the facility.
(7) In computing the rates of payment to be made under this
subsection, there shall be taken into account the costs described in the
last sentence of section 1395x(v)(1)(E) of this title (relating to
compliance with nursing facility requirements and of conducting nurse
aide training and competency evaluation programs and competency
evaluation programs).
(Aug. 14, 1935, ch. 531, title XVIII, 1888, as added July 18, 1984,
Pub. L. 98-369, div. B, title III, 2319(b), 98 Stat. 1082, and amended
Apr. 7, 1986, Pub. L. 99-272, title IX, 9126(a), (b), 9219(b)(1)(C),
100 Stat. 168, 170, 182; Oct. 22, 1986, Pub. L. 99-514, title XVIII,
1895(b)(7)(A), (B), 100 Stat. 2933; Dec. 22, 1987, Pub. L. 100-203,
title IV, 4201(b)(2), 101 Stat. 1330-174; Nov. 5, 1990, Pub. L.
101-508, title IV, 4008(e)(2), (h)(2)(A)(ii), 104 Stat. 1388-45,
1388-48.)
1990 -- Subsec. (a). Pub. L. 101-508, 4008(e)(2), struck out period
at end and inserted '', and shall, for cost reporting periods beginning
on or after October 1, 1992 and every 2 years thereafter, provide for an
update to the per diem cost limits described in this subsection''.
Subsec. (d)(1). Pub. L. 101-508, 4008(h)(2)(A)(ii), substituted
''(including the costs of services required to attain or maintain the
highest practicable physical, mental, and psychosocial well-being of
each resident eligible for benefits under this subchapter) and
capital-related costs'' for ''(and capital-related costs)''.
1987 -- Subsec. (d)(7). Pub. L. 100-203 added par. (7).
1986 -- Subsec. (b). Pub. L. 99-272, 9219(b)(1)(C), substituted
''notwithstanding'' for ''nothwithstanding''.
Subsec. (c). Pub. L. 99-272, 9126(b), inserted provision requiring
the Secretary to publish data and criteria to be used for purposes of
this subsection on an annual basis.
Subsec. (d). Pub. L. 99-272, 9126(a), added subsec. (d).
Subsec. (d)(1). Pub. L. 99-514, 1895(b)(7)(A), substituted ''cost
reporting period'' for ''fiscal year'' in five places.
Subsec. (d)(4). Pub. L. 99-514, 1895(b)(7)(B), substituted ''cost
reporting periods beginning in a fiscal year'' for ''each fiscal year''
and ''cost reporting period no later than 30 days before the beginning
of that period'' for ''fiscal year within 60 days after the Secretary
establishes the final prospective payment amounts for such fiscal
year''.
Section 4008(e)(3) of Pub. L. 101-508 provided that: ''The
amendments made by paragraphs (1) and (2) (amending this section and
provisions set out as a note below) shall take effect as if included in
the enactment of the Omnibus Budget Reconciliation Act of 1989 (Pub. L.
101-239).''
Amendment by section 4008(h)(2)(A)(ii) of Pub. L. 101-508 effective
as if included in the enactment of the Omnibus Budget Reconciliation Act
of 1987, Pub. L. 100-203, see section 4008(h)(2)(P) of Pub. L.
101-508, set out as a note under section 1395i-3 of this title.
Amendment by Pub. L. 100-203 applicable to services furnished on or
after Oct. 1, 1990, without regard to whether regulations implementing
such amendment are promulgated by such date, except as otherwise
specifically provided in section 1395i-3 of this title, see section
4204(a) of Pub. L. 100-203, as amended, set out as an Effective Date
note under section 1395i-3 of this title.
Section 1895(b)(7)(D) of Pub. L. 99-514 provided that: ''The
amendments made by subparagraphs (A) and (B) (amending this section)
apply to cost reporting periods beginning on or after October 1, 1986.''
Amendment by section 9219(b)(1)(C) of Pub. L. 99-272 effective as if
originally included in the Deficit Reduction Act of 1984, Pub. L.
98-369, see section 9219(b)(1)(D) of Pub. L. 99-272, set out as a note
under section 1395u of this title.
Section 9126(d) of Pub. L. 99-272, as amended by Pub. L. 99-514,
title XVIII, 1895(b)(7)(C), Oct. 22, 1986, 100 Stat. 2933, provided
that:
''(1) The amendment made by subsection (a) (amending this section)
shall apply to cost reporting periods beginning on or after October 1,
1986.
''(2) The amendment made by subsection (b) (amending this section)
shall become effective on the date of the enactment of this Act (Apr.
7, 1986).''
Section 2319(c) of Pub. L. 98-369 provided that: ''The amendments
made by subsections (a) (amending section 1395x of this title) and (b)
(enacting this section) shall apply to cost reporting periods beginning
on or after July 1, 1984.''
Section 4008(k) of Pub. L. 101-508 provided that:
''(1) Development of proposal. -- The Secretary of Health and Human
Services shall develop a proposal to modify the current system under
which skilled nursing facilities receive payment for extended care
services under part A (part A of this subchapter) of the medicare
program or a proposal to replace such system with a system under which
such payments would be made on the basis of prospectively determined
rates. In developing any proposal under this paragraph to replace the
current system with a prospective payment system, the Secretary shall --
''(A) take into consideration the need to provide for appropriate
limits on increases in expenditures under the medicare program without
jeopardizing access to extended care services for individuals unable to
care for themselves;
''(B) provide for adjustments to prospectively determined rates to
account for changes in a facility's case mix, volume of cases, and the
development of new technologies and standards of medical practice;
''(C) take into consideration the need to increase the payment
otherwise made under such system in the case of services provided to
patients whose length of stay or costs of treatment greatly exceed the
length of stay or cost of treatment provided for under the applicable
prospectively determined payment rate;
''(D) take into consideration the need to adjust payments under the
system to take into account factors such as a disproportionate share of
low-income patients, differences in wages and wage-related costs among
facilities located in various geographic areas, and other factors the
Secretary considers appropriate; and
''(E) take into consideration the appropriateness of classifying
patients and payments upon functional disability, cognitive impairment,
and other patient characteristics.
''(2) Reports. -- (A) By not later than April 1, 1991, the Secretary
(acting through the Administrator of the Health Care Financing
Administration) shall submit any research studies to be used in
developing the proposal under paragraph (1) to the Committee on Finance
of the Senate and the Committee on Ways and Means of the House of
Representatives.
''(B) By not later than September 1, 1991, the Secretary shall submit
the proposal developed under paragraph (1) to the Committee on Finance
of the Senate and the Committee on Ways and Means of the House of
Representatives.
''(C) By not later than March 1, 1992, the Prospective Payment
Assessment Commission shall submit an analysis of and comments on the
proposal developed under paragraph (1) to the Committee on Finance of
the Senate and the Committee on Ways and Means of the House of
Representatives.''
Pub. L. 101-239, title VI, 6024, Dec. 19, 1989, 103 Stat. 2167, as
amended by Pub. L. 101-508, title IV, 4008(e)(1), Nov. 5, 1990, 104
Stat. 1388-45, provided that: ''The Secretary of Health and Human
Services shall determine mean per diem routine service costs for
freestanding and hospital based skilled nursing facilities under section
1888(a) of the Social Security Act (subsec. (a) of this section) for
cost reporting periods beginning on or after October 1, 1989, in
accordance with regulations published by the Secretary that require the
use of cost reports submitted by skilled nursing facilities for cost
reporting periods beginning not earlier than October 1, 1985. The
Secretary shall update such costs under such section for cost reporting
periods beginning on or after October 1, 1989, by using cost reports
submitted by skilled nursing facilities for cost reporting periods
ending not earlier than January 31, 1988, and not later than December
31, 1988.''
/1/ So in original. Probably should be followed by a period.
42 USC 1395zz. Medicare and medigap information by telephone
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
The Secretary shall provide information via a toll-free telephone
number on the programs under this subchapter and on medicare
supplemental policies as defined in section 1395ss(g)(1) of this title
(including the relationship of State programs under subchapter XIX of
this chapter to such policies).
(Aug. 14, 1935, ch. 531, title XVIII, 1889, as added Nov. 5, 1990,
Pub. L. 101-508, title IV, 4361(a), 104 Stat. 1388-141.)
A prior section 1395zz, act Aug. 14, 1935, ch. 531, title XVIII,
1889, formerly 1833(f), as added Jan. 2, 1968, Pub. L. 90-248, title
I, 132(b), 81 Stat. 850, and amended Oct. 30, 1972, Pub. L. 92-603,
title II, 245(d), 86 Stat. 1424; Oct. 25, 1977, Pub. L. 95-142,
16(a), 91 Stat. 1200; renumbered 1889 and amended July 18, 1984, Pub.
L. 98-369, div. B, title III, 2321(d), 98 Stat. 1084, which provided
for purchase of durable medical equipment, covering (a) lease-purchase
basis or rental and determination by Secretary, (b) waiver of
coinsurance amount in purchase of used equipment, (c) reimbursement
procedures, and (d) encouragement of lease-purchase basis, was repealed
by Pub. L. 100-203, title IV, 4062(d)(5), (e), Dec. 22, 1987, 101
Stat. 1330-109, applicable to covered items (other than oxygen and
oxygen equipment) furnished on or after Jan. 1, 1989, and to oxygen and
oxygen equipment furnished on or after June 1, 1989.
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.''
42 USC 1395aaa. Transferred
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
Section, act Aug. 14, 1935, ch. 531, title XVIII, 1890, as added
Aug. 18, 1987, Pub. L. 100-93, 10, 101 Stat. 696, which related to
limitation of liability of beneficiaries with respect to services
furnished by excluded individuals and entities, was amended and
transferred to section 1862(e)(2) of act Aug. 14, 1935, by Pub. L.
100-360, title IV, 411(i)(4)(D)(ii), July 1, 1988, 102 Stat. 790, as
amended by Pub. L. 100-485, title VI, 608(d)(24)(C)(ii), Oct. 13,
1988, 102 Stat. 2421, and is classified to section 1395y(e)(2) of this
title.
42 USC 1395bbb. Conditions of participation for home health agencies;
home health quality
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Conditions of participation; protection of individual rights;
notification of State entities; use of home health aides; medical
equipment; individual's plan of care; compliance with Federal, State,
and local laws and regulations
The conditions of participation that a home health agency is required
to meet under this subsection are as follows:
(1) The agency protects and promotes the rights of each individual
under its care, including each of the following rights:
(A) The right to be fully informed in advance about the care and
treatment to be provided by the agency, to be fully informed in advance
of any changes in the care or treatment to be provided by the agency
that may affect the individual's well-being, and (except with respect to
an individual adjudged incompetent) to participate in planning care and
treatment or changes in care or treatment.
(B) The right to voice grievances with respect to treatment or care
that is (or fails to be) furnished without discrimination or reprisal
for voicing grievances.
(C) The right to confidentiality of the clinical records described in
section 1395x(o)(3) of this title.
(D) The right to have one's property treated with respect.
(E) The right to be fully informed orally and in writing (in advance
of coming under the care of the agency) of --
(i) all items and services furnished by (or under arrangements with)
the agency for which payment may be made under this subchapter,
(ii) the coverage available for such items and services under this
subchapter, subchapter XIX of this chapter, and any other Federal
program of which the agency is reasonably aware,
(iii) any charges for items and services not covered under this
subchapter and any charges the individual may have to pay with respect
to items and services furnished by (or under arrangements with) the
agency, and
(iv) any changes in the charges or items and services described in
clause (i), (ii), or (iii).
(F) The right to be fully informed in writing (in advance of coming
under the care of the agency) of the individual's rights and obligations
under this subchapter.
(G) The right to be informed of the availability of the State home
health agency hot-line established under section 1395aa(a) of this
title.
(2) The agency notifies the State entity responsible for the
licensing or certification of the agency of a change in --
(A) the persons with an ownership or control interest (as defined in
section 1320a-3(a)(3) of this title) in the agency,
(B) the persons who are officers, directors, agents, or managing
employees (as defined in section 1320a-5(b) of this title) of the
agency, and
(C) the corporation, association, or other company responsible for
the management of the agency.
Such notice shall be given at the time of the change and shall
include the identity of each new person or company described in the
previous sentence.
(3)(A) The agency must not use as a home health aide (on a full-time,
temporary, per diem, or other basis), any individual to provide items or
services described in section 1395x(m) of this title on or after January
1, 1990, unless the individual --
(i) has completed a training and competency evaluation program, or a
competency evaluation program, that meets the minimum standards
established by the Secretary under subparagraph (D), and
(ii) is competent to provide such items and services.
For purposes of clause (i), an individual is not considered to have
completed a training and competency evaluation program, or a competency
evaluation program if, since the individual's most recent completion of
such a program, there has been a continuous period of 24 consecutive
months during none of which the individual provided items and services
described in section 1395x(m) of this title for compensation.
(B)(i) The agency must provide, with respect to individuals used as a
home health aide by the agency as of July 1, 1989, for a competency
evaluation program (as described in subparagraph (A)(i)) and such
preparation as may be necessary for the individual to complete such a
program by January 1, 1990.
(ii) The agency must provide such regular performance review and
regular in-service education as assures that individuals used to provide
items and services described in section 1395x(m) of this title are
competent to provide those items and services.
(C) The agency must not permit an individual, other than in a
training and competency evaluation program that meets the minimum
standards established by the Secretary under subparagraph (D), to
provide items or services of a type for which the individual has not
demonstrated competency.
(D)(i) The Secretary shall establish minimum standards for the
programs described in subparagraph (A) by not later than October 1,
1988.
(ii) Such standards shall include the content of the curriculum,
minimum hours of training, qualification of instructors, and procedures
for determination of competency.
(iii) Such standards may permit approval of programs offered by or in
home health agencies, as well as outside agencies (including employee
organizations), and of programs in effect on December 22, 1987; except
that they may not provide for the approval of a program offered by or in
a home health agency which, within the previous 2 years --
(I) has been determined to be out of compliance with subparagraph
(A), (B), or (C);
(II) has been subject to an extended (or partial extended) survey
under subsection (c)(2)(D) of this section;
(III) has been assessed a civil money penalty described in subsection
(f)(2)(A)(i) of this section of not less than $5,000; or
(IV) has been subject to the remedies described in subsection (e)(1)
of this section or in clauses (ii) or (iii) of subsection (f)(2)(A) of
this section.
(iv) Such standards shall permit a determination that an individual
who has completed (before July 1, 1989) a training and competency
evaluation program or a competency evaluation program shall be deemed
for purposes of subparagraph (A) to have completed a program that is
approved by the Secretary under the standards established under this
subparagraph if the Secretary determines that, at the time the program
was offered, the program met such standards.
(E) In this paragraph, the term ''home health aide'' means any
individual who provides the items and services described in section
1395x(m) of this title, but does not include an individual --
(i) who is a licensed health professional (as defined in subparagraph
(F)), or
(ii) who volunteers to provide such services without monetary
compensation.
(F) 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, or
licensed or certified social worker.
(4) The agency includes an individual's plan of care required under
section 1395x(m) of this title as part of the clinical records described
in section 1395x(o)(3) of this title.
(5) The agency operates and provides 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 items and services in such an agency.
(6) The agency complies with the requirement of section 1395cc(f) of
this title (relating to maintaining written policies and procedures
respecting advance directives).
(b) Duty of Secretary
It is the duty and responsibility of the Secretary to assure that the
conditions of participation and requirements specified in or pursuant to
section 1395x(o) of this title and subsection (a) of this section and
the enforcement of such conditions and requirements are adequate to
protect the health and safety of individuals under the care of a home
health agency and to promote the effective and efficient use of public
moneys.
(c) Surveys of home health agencies
(1) Any agreement entered into or renewed by the Secretary pursuant
to section 1395aa of this title relating to home health agencies shall
provide that the appropriate State or local agency shall conduct,
without any prior notice, a standard survey of each home health agency.
Any individual who notifies (or causes to be notified) a home health
agency 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 this paragraph
in the same manner as such provisions apply to a penalty or proceeding
under section 1320a-7a of this title. The Secretary shall review each
State's or local agency's procedures for scheduling and conduct of
standard surveys to assure that the State or agency has taken all
reasonable steps to avoid giving notice of such a survey through the
scheduling procedures and the conduct of the surveys themselves.
(2)(A) Except as provided in subparagraph (B), each home health
agency shall be subject to a standard survey not later than 15 months
after the date of the previous standard survey conducted under this
paragraph. The statewide average interval between standard surveys of
any home health agency shall not exceed 12 months.
(B) If not otherwise conducted under subparagraph (A), a standard
survey (or an abbreviated standard survey) of an agency --
(i) may be conducted within 2 months of any change of ownership,
administration, or management of the agency to determine whether the
change has resulted in any decline in the quality of care furnished by
the agency, and
(ii) shall be conducted within 2 months of when a significant number
of complaints have been reported with respect to the agency to the
Secretary, the State, the entity responsible for the licensing of the
agency, the State or local agency responsible for maintaining a
toll-free hotline and investigative unit (under section 1395aa(a) of
this title), or any other appropriate Federal, State, or local agency.
(C) A standard survey conducted under this paragraph with respect to
a home health agency --
(i) shall include (to the extent practicable), for a case-mix
stratified sample of individuals furnished items or services by the
agency --
(I) visits to the homes of such individuals, but only with the
consent of such individuals, for the purpose of evaluating (in
accordance with a standardized reproducible assessment instrument (or
instruments) approved by the Secretary under subsection (d) of this
section) the extent to which the quality and scope of items and services
furnished by the agency attained and maintained the highest practicable
functional capacity of each such individual as reflected in such
individual's written plan of care required under section 1395x(m) of
this title and clinical records required under section 1395x(o)(3) of
this title; and
(II) a survey of the quality of care and services furnished by the
agency as measured by indicators of medical, nursing, and rehabilitative
care;
(ii) shall be based upon a protocol that is developed, tested, and
validated by the Secretary not later than January 1, 1989; and
(iii) shall be conducted by an individual --
(I) who meets minimum qualifications established by the Secretary not
later than July 1, 1989,
(II) who is not serving (or has not served within the previous 2
years) as a member of the staff of, or as a consultant to, the home
health agency surveyed respecting compliance with the conditions of
participation specified in or pursuant to section 1395x(o) of this title
or subsection (a) of this section, and
(III) who has no personal or familial financial interest in the home
health agency surveyed.
(D) Each home health agency that is found, under a standard survey,
to have provided substandard care shall be subject to an extended survey
to review and identify the policies and procedures which produced such
substandard care and to determine whether the agency has complied with
the conditions of participation specified in or pursuant to section
1395x(o) of this title or subsection (a) of this section. Any other
agency may, at the Secretary's or State's discretion, be subject to such
an extended survey (or a partial extended survey). The extended survey
shall be conducted immediately after the standard survey (or, if not
practical, not later than 2 weeks after the date of completion of the
standard survey).
(E) Nothing in this paragraph shall be construed as requiring an
extended (or partial extended) survey as a prerequisite to imposing a
sanction against an agency under subsection (e) of this section on the
basis of the findings of a standard survey.
(d) Assessment process; reports to Congress
(1) Not later than January 1, 1989, the Secretary shall designate an
assessment instrument (or instruments) for use by an agency in complying
with subsection (c)(2)(C)(I) /1/ of this section.
(2)(A) Not later than January 1, 1992, the Secretary shall --
(i) evaluate the assessment process,
(ii) report to Congress on the results of such evaluation, and
(iii) based on such evaluation, make such modifications in the
assessment process as the Secretary determines are appropriate.
(B) The Secretary shall periodically update the evaluation conducted
under subparagraph (A), report the results of such update to Congress,
and, based on such update, make such modifications in the assessment
process as the Secretary determines are appropriate.
(3) The Secretary shall provide for the comprehensive training of
State and Federal surveyors in matters relating to the performance of
standard and extended surveys under this section, including the use of
any assessment instrument (or instruments) designated under paragraph
(1).
(e) Enforcement
(1) If the Secretary determines on the basis of a standard, extended,
or partial extended survey or otherwise, that a home health agency that
is certified for participation under this subchapter is no longer in
compliance with the requirements specified in or pursuant to section
1395x(o) of this title or subsection (a) of this section and determines
that the deficiencies involved immediately jeopardize the health and
safety of the individuals to whom the agency furnishes items and
services, the Secretary shall take immediate action to remove the
jeopardy and correct the deficiencies through the remedy specified in
subsection (f)(2)(A)(iii) of this section or terminate the certification
of the agency, and may provide, in addition, for 1 or more of the other
remedies described in subsection (f)(2)(A) of this section.
(2) If the Secretary determines on the basis of a standard, extended,
or partial extended survey or otherwise, that a home health agency that
is certified for participation under this subchapter is no longer in
compliance with the requirements specified in or pursuant to section
1395x(o) of this title or subsection (a) of this section and determines
that the deficiencies involved do not immediately jeopardize the health
and safety of the individuals to whom the agency furnishes items and
services, the Secretary may (for a period not to exceed 6 months) impose
intermediate sanctions developed pursuant to subsection (f) of this
section, in lieu of terminating the certification of the agency. If,
after such a period of intermediate sanctions, the agency is still no
longer in compliance with the requirements specified in or pursuant to
section 1395x(o) of this title or subsection (a) of this section, the
Secretary shall terminate the certification of the agency.
(3) If the Secretary determines that a home health agency that is
certified for participation under this subchapter is in compliance with
the requirements specified in or pursuant to section 1395x(o) of this
title or subsection (a) of this section but, as of a previous period,
did not meet such requirements, the Secretary may provide for a civil
money penalty under subsection (f)(2)(A)(i) of this section for the days
in which it finds that the agency was not in compliance with such
requirements.
(4) The Secretary may continue payments under this subchapter with
respect to a home health agency not in compliance with the requirements
specified in or pursuant to section 1395x(o) of this title or subsection
(a) of this section over a period of not longer than 6 months, if --
(A) the State or local survey agency finds that it is more
appropriate to take alternative action to assure compliance of the
agency with the requirements than to terminate the certification of the
agency,
(B) the agency has submitted a plan and timetable for corrective
action to the Secretary for approval and the Secretary approves the plan
of corrective action, and
(C) the agency 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 home health agencies under this subparagraph.
(f) Intermediate sanctions
(1) The Secretary shall develop and implement, by not later than
April 1, 1989 --
(A) a range of intermediate sanctions to apply to home health
agencies under the conditions described in subsection (e) of this
section, and
(B) appropriate procedures for appealing determinations relating to
the imposition of such sanctions.
(2)(A) The intermediate sanctions developed under paragraph (1) shall
include --
(i) civil money penalties in an amount not to exceed $10,000 for each
day of noncompliance,
(ii) suspension of all or part of the payments to which a home health
agency would otherwise be entitled under this subchapter with respect to
items and services furnished by a home health agency on or after the
date on which the Secretary determines that intermediate sanctions
should be imposed pursuant to subsection (e)(2) of this section, and
(iii) the appointment of temporary management to oversee the
operation of the home health agency and to protect and assure the health
and safety of the individuals under the care of the agency while
improvements are made in order to bring the agency into compliance with
all the requirements specified in or pursuant to section 1395x(o) of
this title or subsection (a) of this section.
The provisions of section 1320a-7a of this title (other than
subsections (a) and (b)) shall apply to a civil money penalty under
clause (i) in the same manner as such provisions apply to a penalty or
proceeding under section 1320a-7a(a) of this title. The temporary
management under clause (iii) shall not be terminated until the
Secretary has determined that the agency has the management capability
to ensure continued compliance with all the requirements referred to in
that clause.
(B) The sanctions specified in subparagraph (A) are in addition to
sanctions otherwise available under State or Federal law and shall not
be construed as limiting other remedies, including any remedy available
to an individual at common law.
(C) A finding to suspend payment under subparagraph (A)(ii) shall
terminate when the Secretary finds that the home health agency is in
substantial compliance with all the requirements specified in or
pursuant to section 1395x(o) of this title and subsection (a) of this
section.
(3) The Secretary shall develop and implement, by not later than
April 1, 1989, specific procedures with respect to the conditions under
which each of the intermediate sanctions developed under paragraph (1)
is to be applied, including the amount of any fines and the severity of
each of these sanctions. Such procedures shall be designed so as to
minimize the time between identification of deficiencies and imposition
of these sanctions and shall provide for the imposition of incrementally
more severe fines for repeated or uncorrected deficiencies.
(Aug. 14, 1935, ch. 531, title XVIII, 1891, as added and amended
Dec. 22, 1987, Pub. L. 100-203, title IV, 4021(b), 4022(a), 4023(a),
101 Stat. 1330-67, 1330-69, 1330-71; July 1, 1988, Pub. L. 100-360,
title IV, 411(d)(1)(A), (2)-(3)(B), 102 Stat. 773, 774; Oct. 13, 1988,
Pub. L. 100-485, title VI, 608(d)(20)(A), 102 Stat. 2419; Nov. 5,
1990, Pub. L. 101-508, title IV, 4206(d)(2), 4027(4207)(i)(1), 104
Stat. 1388-116, 1388-123.)
1990 -- Subsec. (a)(3)(D)(iii). Pub. L. 101-508, 4027(4207)(i)(1),
substituted ''which, within the previous 2 years -- '' and subcls. (I)
to (IV) for ''which has been determined to be out of compliance with the
requirements specified in or pursuant to section 1395x(o) of this title
or subsection (a) of this section within the previous 2 years.''
Subsec. (a)(6). Pub. L. 101-508, 4206(d)(2), added par. (6).
1988 -- Subsec. (a)(3)(A). Pub. L. 100-360, 411(d)(1)(A)(i), struck
out ''who is not a licensed health care professional (as defined in
subparagraph (F))'' after ''any individual'' in introductory provisions.
Subsec. (a)(3)(F). Pub. L. 100-360, 411(d)(1)(A)(ii), inserted
''physical or occupational therapy assistant,'' after ''occupational
therapist''.
Subsec. (a)(4) to (6). Pub. L. 100-360, 411(d)(1)(A)(iii),
redesignated pars. (5) and (6) as (4) and (5), respectively, and struck
out former par. (4) which read as follows: ''With respect to durable
medical equipment furnished to individuals for whom the agency provides
items and services, suppliers of such equipment do not use (on a
full-time, temporary, per diem, or other basis) any individual who does
not meet minimum training standards (established by the Secretary by
October 1, 1988) for the demonstration and use of any such equipment
furnished to individuals with respect to whom payments may be made under
this subchapter.''
Subsec. (c)(1). Pub. L. 100-360, 411(d)(2)(A), as amended by Pub.
L. 100-485, 608(d)(20)(A), 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. (d)(2)(A). Pub. L. 100-360, 411(d)(2)(B), substituted
''1992'' for ''1991'' in introductory provisions.
Subsecs. (e), (f). Pub. L. 100-360, 411(d)(3)(A), made technical
amendment to Pub. L. 100-203, 4023(a), see 1987 Amendment note below.
Subsec. (f)(2)(A). Pub. L. 100-360, 411(d)(3)(B)(iii), inserted
before last sentence ''The provisions of section 1320a-7a of this title
(other than subsections (a) and (b)) shall apply to a civil money
penalty under clause (i) in the same manner as such provisions apply to
a penalty or proceeding under section 1320a-7a(a) of this title.''
Pub. L. 100-360, 411(d)(3)(B)(i), realigned the margins of cls. (i)
to (iii) and concluding provisions.
Subsec. (f)(2)(A)(i). Pub. L. 100-360, 411(d)(3)(B)(ii), substituted
''in an amount not to exceed $10,000 for each day of noncompliance'' for
''for each day of noncompliance''.
1987 -- Subsecs. (c), (d). Pub. L. 100-203, 4022(a), added
subsecs. (c) and (d).
Subsecs. (e), (f). Pub. L. 100-203, 4023(a), as amended by Pub. L.
100-360, 411(d)(3)(A), added subsecs. (e) and (f).
Amendment by section 4206(d)(2) of Pub. L. 101-508 applicable with
respect to services furnished on or after the first day of the first
month beginning more than 1 year after Nov. 5, 1990, see section
4206(e)(1) of Pub. L. 101-508, set out as a note under section 1395i-3
of this title.
Section 4027(4207)(i)(1) of Pub. L. 101-508 provided that the
amendment made by that section is effective as if included in the
enactment of the Omnibus Budget Reconciliation Act of 1987, Pub. L.
100-203.
Section 4027(4207)(i)(2) of Pub. L. 101-508 provided that: ''The
amendments made by paragraph (1) (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 the Secretary
may not permit approval of a training and competency evaluation program
or a competency evaluation program offered by or in a home health agency
which, pursuant to any Federal or State law within the 2-year period
beginning on October 1, 1988 --
''(i) had its participation terminated under title XVIII of the
Social Security Act (this subchapter);
''(ii) was assessed a civil money penalty not less than $5,000 for
deficiencies in applicable quality standards for home health agencies;
''(iii) was subject to suspension by the Secretary of all or part of
the payments to which it would otherwise be entitled under such
title.(;)
''(iv) operated under a temporary management appointed to oversee the
operation of the agency and to ensure the health and safety of the
agency's patients; or
''(v) pursuant to State action, was closed or had its residents
transferred.''
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
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.
Section 4022(b) of Pub. L. 100-203 provided that: ''Except as
otherwise specifically provided in section 1891(d) of the Social
Security Act (subsec. (d) of this section) (as added by subsection (a)),
the amendment made by subsection (a) (amending this section) shall
become effective on the first day of the 18th calendar month to begin
after the date of the enactment of this Act (Dec. 22, 1987).''
Section 4023(b) of Pub. L. 100-203, as amended by Pub. L. 100-360,
title IV, 411(d)(3)(C), July 1, 1988, 102 Stat. 774, provided that:
''Except as otherwise specifically provided in subsections (e) and (f)
of section 1891 of the Social Security Act (subsecs. (e) and (f) of this
section) (as added by subsection (a)), the amendment made by subsection
(a) (amending this section) shall become effective on the first day of
the 18th calendar month to begin after the date of the enactment of this
Act (Dec. 22, 1987), and no intermediate sanction described in section
1891(f)(2)(A) of such Act (subsec. (f)(2)(A) of this section) shall be
imposed for violations occurring before such effective date.''
Section applicable to home health agencies as of the first day of the
18th calendar month that begins after Dec. 22, 1987, except as
otherwise provided, see section 4021(c) of Pub. L. 100-203, set out as
an Effective Date of 1987 Amendment note under section 1395x of this
title.
/1/ So in original. Probably should be subsection
''(c)(2)(C)(i)(I)''.
42 USC 1395ccc. Offset of payments to individuals to collect past-due
obligations arising from breach of scholarship and loan contract
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) In general
(1)(A) Subject to subparagraph (B), the Secretary shall enter into an
agreement under this section with any individual who, by reason of a
breach of a contract entered into by such individual pursuant to the
National Health Service Corps Scholarship Program, the Physician
Shortage Area Scholarship Program, or the Health Education Assistance
Loan Program, owes a past-due obligation to the United States (as
defined in subsection (b) of this section).
(B) The Secretary shall not enter into an agreement with an
individual under this section to the extent --
(i)(I) the individual has entered into a contract with the Secretary
pursuant to section 204(a)(1) of the Public Health Service Amendments of
1987, and
(II) the individual has fulfilled or (as determined by the Secretary)
is fulfilling the terms of such contract; or
(ii) the liability of the individual under such section 204(a)(1) has
otherwise been relieved under such section; or
(iii) the individual is performing such physician's /1/ service
obligation under a forbearance agreement entered into with the Secretary
under subpart II of part D of title III of the Public Health Service Act
(42 U.S.C. 254d et seq.).
(2) The agreement under this section shall provide that --
(A) deductions shall be made from the amounts otherwise payable to
the individual under this subchapter, in accordance with a formula and
schedule agreed to by the Secretary and the individual, until such
past-due obligation (and accrued interest) have been repaid;
(B) payment under this subchapter for services provided by such
individual shall be made only on an assignment-related basis;
(C) if the individual does not provide services, for which payment
would otherwise be made under this subchapter, of a sufficient quantity
to maintain the offset collection according to the agreed upon formula
and schedule --
(i) the Secretary shall immediately inform the Attorney General, and
the Attorney General shall immediately commence an action to recover the
full amount of the past-due obligation, and
(ii) subject to paragraph (4), the Secretary shall immediately
exclude the individual from the program under this subchapter, until
such time as the entire past-due obligation has been repaid.
(3) If the individual refuses to enter into an agreement or breaches
any provision of the agreement --
(A) the Secretary shall immediately inform the Attorney General, and
the Attorney General shall immediately commence an action to recover the
full amount of the past-due obligation, and
(B) subject to paragraph (4), the Secretary shall immediately exclude
the individual from the program under this subchapter, until such time
as the entire past-due obligation has been repaid.
(4) The Secretary shall not exclude an individual pursuant to
paragraph (2)(C)(ii) or paragraph (3)(B) if such individual is a sole
community practitioner or sole source of essential specialized services
in a community if a State requests that the individual not be excluded.
(b) Past-due obligation
For purposes of this section, a past-due obligation is any amount --
(1) owed by an individual to the United States by reason of a breach
of a scholarship contract under section 338E of the Public Health
Service Act (42 U.S.C. 254o) or under subpart III of part F of title VII
of such Act (as in effect before October 1, 1976) and which has not been
paid by the deadline established by the Secretary pursuant to such
respective section, and has not been canceled, waived, or suspended by
the Secretary pursuant to such section; or
(2) owed by an individual to the United States by reason of a loan
covered by Federal loan insurance under subpart I of part C of title VII
of the Public Health Service Act (42 U.S.C. 294 et seq.) and payment for
which has not been cancelled, waived, or suspended by the Secretary
under such subpart.
(c) Collection under this section shall not be exclusive
This section shall not preclude the United States from applying other
provisions of law otherwise applicable to the collection of obligations
owed to the United States, including (but not limited to) the use of tax
refund offsets pursuant to section 3720A of title 31 and the application
of other procedures provided under chapter 37 of title 31.
(d) Collection from providers and health maintenance organizations
(1) In the case of an individual who owes a past-due obligation, and
who is an employee of, or affiliated by a medical services agreement
with, a provider having an agreement under section 1395cc of this title
or a health maintenance organization or competitive medical plan having
a contract under section 1395l of this title or section 1395mm of this
title, the Secretary shall deduct the amounts of such past-due
obligation from amounts otherwise payable under this subchapter to such
provider, organization, or plan.
(2) Deductions shall be in accordance with a formula and schedule
agreed to by the Secretary, the individual and the provider,
organization, or plan. The deductions shall be made from the amounts
otherwise payable to the individual under this subchapter as long as the
individual continues to be employed or affiliated by a medical services
agreement.
(3) Such deduction shall not be made until 6 months after the
Secretary notifies the provider, organization, or plan of the amount to
be deducted and the particular physicians /2/ to whom the deductions are
attributable.
(4) A deduction made under this subsection shall relieve the
individual of the obligation (to the extent of the amount collected) to
the United States, but the provider, organization, or plan shall have a
right of action to collect from such individual the amount deducted
pursuant to this subsection (including accumulated interest).
(5) No deduction shall be made under this subsection if, within the
6-month period after notice is given to the provider, organization, or
plan, the individual pays the past-due obligation, or ceases to be
employed by the provider, organization, or plan.
(6) The Secretary shall also apply the provisions of this subsection
in the case of an individual who is a member of a group practice, if
such group practice submits bills under this program as a group, rather
than by individual physicians. /2/
(e) Transfer from trust funds
Amounts equal to the amounts deducted pursuant to this section shall
be transferred from the Trust Fund from which the payment to the
individual, provider, or other entity would otherwise have been made, to
the general fund in the Treasury, and shall be credited as payment of
the past-due obligation of the individual from whom (or with respect to
whom) the deduction was made.
(Aug. 14, 1935, ch. 531, title XVIII, 1892, as added Dec. 22, 1987,
Pub. L. 100-203, title IV, 4052(a), 101 Stat. 1330-95, and amended July
1, 1988, Pub. L. 100-360, title IV, 411(f)(10)(A), (C)(i), 102 Stat.
780; Oct. 13, 1988, Pub. L. 100-485, title VI, 608(d)(21)(E)-(H), 102
Stat. 2420.)
Section 204(a)(1) of the Public Health Service Amendments of 1987,
referred to in subsec. (a)(1)(B), is section 204(a)(1) of Pub. L.
100-177, title II, Dec. 1, 1987, 101 Stat. 1000, which is set out as a
note under section 254o of this title.
The Public Health Service Act, referred to in subsecs.
(a)(1)(B)(iii) and (b), is act July 1, 1944, ch. 373, 58 Stat. 682, as
amended. Subpart II of part D of title III and subpart I of part C of
title VII, of the Public Health Service Act are classified generally to
subpart II ( 254d et seq.) of part D of subchapter II and subpart I (
294 et seq.) of part C of subchapter V, respectively, of chapter 6A of
this title. Subpart III of part F of title VII of the Public Health
Service Act (as in effect before October 1, 1976) was classified to
subpart III ( 295g-21 et seq.) of part F of subchapter V of chapter 6A
of this title, prior to repeal by Pub. L. 94-484, title IV, 409(a),
Oct. 12, 1976, 90 Stat. 2290. For complete classification of this Act
to the Code, see Short Title note set out under section 201 of this
title and Tables.
1988 -- Pub. L. 100-360, 411(f)(10)(C)(i)(I), substituted
''individuals'' for ''physicians'' and inserted ''and loan'' in section
catchline.
Subsec. (a)(1)(A). Pub. L. 100-360, 411(f)(10)(C)(i)(IV), as amended
by Pub. L. 100-485, 608(d)(21)(H), inserted '', the Physician Shortage
Area Scholarship Program, or the Health Education Assistance Loan
Program''.
Pub. L. 100-360, 411(f)(10)(C)(i)(II), as amended by Pub. L.
100-485, 608(d)(21)(G), substituted ''individual'' for ''physician'' in
two places.
Subsec. (a)(1)(B). Pub. L. 100-360, 411(f)(10)(C)(i)(II), as amended
by Pub. L. 100-485, 608(d)(21)(G), substituted ''an individual'' for
''a physician'' in introductory provisions and ''individual'' for
''physician'' in cls. (i)(I) and (II), (ii), and (iii).
Subsec. (a)(2)(A) to (C). Pub. L. 100-360, 411(f)(10)(C)(i)(II), as
amended by Pub. L. 100-485, 608(d)(21)(G), substituted ''individual''
for ''physician'' wherever appearing.
Subsec. (a)(2)(C)(ii). Pub. L. 100-360, 411(f)(10)(A)(i),
substituted ''paragraph (4)'' for ''paragraph (3)''.
Subsec. (a)(3). Pub. L. 100-360, 411(f)(10)(C)(i)(II), as amended by
Pub. L. 100-485, 608(d)(21)(G), substituted ''individual'' for
''physician'' in introductory provisions.
Subsec. (a)(3)(B). Pub. L. 100-360, 411(f)(10)(C)(i)(II), as amended
by Pub. L. 100-485, 608(d)(21)(G), substituted ''individual'' for
''physician''.
Pub. L. 100-360, 411(f)(10)(A)(i), substituted ''paragraph (4)'' for
''paragraph (3)''.
Subsec. (a)(4). Pub. L. 100-360, 411(f)(10)(C)(i)(III), substituted
''community practitioner'' for ''community physician''.
Pub. L. 100-360, 411(f)(10)(C)(i)(II), as amended by Pub. L.
100-485, 608(d)(21)(G), substituted ''an individual'' for ''a
physician'' and ''such individual'' for ''such physician''.
Pub. L. 100-360, 411(f)(10)(A)(iii), as amended by Pub. L.
100-360, 608(d)(21)(E), inserted before period at end ''if a State
requests that the individual not be excluded''.
Pub. L. 100-360, 411(f)(10)(A)(ii), substituted ''exclude'' for
''bar''.
Subsec. (b). Pub. L. 100-360, 411(f)(10)(C)(i)(V), as amended by
Pub. L. 100-485, 608(d)(21)(F)(i), substituted ''or under subpart III
of part F of title VII of such Act (as in effect before October 1, 1976)
and which has not been paid by the deadline established by the Secretary
pursuant to such respective section'' for '', and (2) which has not been
paid by the deadline established by the Secretary pursuant to section
338E of the Public Health Service Act''.
Subsec. (b)(1). Pub. L. 100-360, 411(f)(10)(C)(i)(II), as amended by
Pub. L. 100-485, 608(d)(21)(G), substituted ''an individual'' for ''a
physician''.
Subsec. (b)(2). Pub. L. 100-360, 411(f)(10)(C)(i)(VI), as amended by
Pub. L. 100-485, 608(d)(21)(F)(i), added par. (2).
Subsec. (d)(1). Pub. L. 100-360, 411(f)(10)(C)(i)(II), as amended by
Pub. L. 100-485, 608(d)(21)(G), substituted ''an individual'' for ''a
physician''.
Subsec. (d)(2). Pub. L. 100-360, 411(f)(10)(C)(i)(VII), as added by
Pub. L. 100-485, 608(d)(21)(F), substituted ''continues'' for
''continued''.
Pub. L. 100-360, 411(f)(10)(C)(i)(II), as amended by Pub. L.
100-485, 608(d)(21)(G), substituted ''individual'' for ''physician'' in
three places.
Subsec. (d)(4) to (6). Pub. L. 100-360, 411(f)(10)(C)(i)(II), as
amended by Pub. L. 100-485, 608(d)(21)(G), substituted ''individual''
for ''physician'' wherever appearing.
Subsec. (e). Pub. L. 100-360, 411(f)(10)(C)(i)(II), as amended by
Pub. L. 100-485, 608(d)(21)(G), substituted ''individual'' for
''physician'' in two places.
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(f)(10)(A) of Pub. L. 100-360, as it relates to
a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L.
100-203, effective as if included in the enactment of that provision in
Pub. L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a
Reference to OBRA; Effective Date note under section 106 of Title 1,
General Provisions.
Amendment by section 411(f)(10)(C)(i) of Pub. L. 100-360 effective
30 days after July 1, 1988, see section 411(f)(10)(C)(iii) of Pub. L.
100-360, set out as a note under section 294f of this title.
Section 4052(c) of Pub. L. 100-203 provided that: ''The amendments
made by this section (enacting this section and amending section 254o of
this title) shall be effective on the date of the enactment of this Act
(Dec. 22, 1987).''
/1/ So in original. Probably should be ''individual's''.
/2/ So in original. Probably should be ''individuals''.
42 USC SUBCHAPTER XIX -- GRANTS TO STATES FOR MEDICAL ASSISTANCE
PROGRAMS
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
, 3178; title 8 sections 1255a, 1522;
title 10 sections 1079, 1095;
title 12 sections
1715w, 1715z-7; title 20 sections 1413, 1481; title
24 section 170a; title 25 sections 1622, 1680c;
title 26 section 6103; title 29 sections 1144, 1583,
2215; title 38 sections 1722, 1729, 5503, 7423.
42 USC 1396. Appropriations
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
For the purpose of enabling each State, as far as practicable under
the conditions in such State, to furnish (1) medical assistance on
behalf of families with dependent children and of aged, blind, or
disabled individuals, whose income and resources are insufficient to
meet the costs of necessary medical services, and (2) rehabilitation and
other services to help such families and individuals attain or retain
capability for independence or self-care, there is hereby authorized to
be appropriated for each fiscal year a sum sufficient to carry out the
purposes of this subchapter. The sums made available under this section
shall be used for making payments to States which have submitted, and
had approved by the Secretary, State plans for medical assistance.
(Aug. 14, 1935, ch. 531, title XIX, 1901, as added July 30, 1965,
Pub. L. 89-97, title I, 121(a), 79 Stat. 343, and amended Dec. 31,
1973, Pub. L. 93-233, 13(a)(1), 87 Stat. 960; July 18, 1984, Pub. L.
98-369, div. B, title VI, 2663(j)(3)(C), 98 Stat. 1171.)
1984 -- Pub. L. 98-369 struck out ''Health, Education, and Welfare''
after ''Secretary''.
1973 -- Pub. L. 93-233 substituted ''disabled individuals'' for
''permanently and totally disabled individuals'' in cl. (1).
Amendment by Pub. L. 98-369 effective July 18, 1984, but not to be
construed as changing or affecting any right, liability, status, or
interpretation which existed (under the provisions of law involved)
before that date, see section 2664(b) of Pub. L. 98-369, set out as a
note under section 401 of this title.
Amendment by Pub. L. 93-233 effective with respect to payments under
section 1396b of this title for calendar quarters commencing after Dec.
31, 1973, see section 13(d) of Pub. L. 93-233, set out as a note under
section 1396a of this title.
42 USC 1396a. State plans for medical assistance
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Contents
A State plan for medical assistance must --
(1) provide that it shall be in effect in all political subdivisions
of the State, and, if administered by them, be mandatory upon them;
(2) provide for financial participation by the State equal to not
less than 40 per centum of the non-Federal share of the expenditures
under the plan with respect to which payments under section 1396b of
this title are authorized by this subchapter; and, effective July 1,
1969, provide for financial participation by the State equal to all of
such non-Federal share or provide for distribution of funds from Federal
or State sources, for carrying out the State plan, on an equalization or
other basis which will assure that the lack of adequate funds from local
sources will not result in lowering the amount, duration, scope, or
quality of care and services available under the plan;
(3) provide for granting an opportunity for a fair hearing before the
State agency to any individual whose claim for medical assistance under
the plan is denied or is not acted upon with reasonable promptness;
(4) provide (A) such methods of administration (including methods
relating to the establishment and maintenance of personnel standards on
a merit basis, except that the Secretary shall exercise no authority
with respect to the selection, tenure of office, and compensation of any
individual employed in accordance with such methods, and including
provision for utilization of professional medical personnel in the
administration and, where administered locally, supervision of
administration of the plan) as are found by the Secretary to be
necessary for the proper and efficient operation of the plan, (B) for
the training and effective use of paid subprofessional staff, with
particular emphasis on the full-time or part-time employment of
recipients and other persons of low income, as community service aides,
in the administration of the plan and for the use of nonpaid or
partially paid volunteers in a social service volunteer program in
providing services to applicants and recipients and in assisting any
advisory committees established by the State agency, and (C) that each
State or local officer or employee who is responsible for the
expenditure of substantial amounts of funds under the State plan, each
individual who formerly was such an officer or employee, and each
partner of such an officer or employee shall be prohibited from
committing any act, in relation to any activity under the plan, the
commission of which, in connection with any activity concerning the
United States Government, by an officer or employee of the United States
Government, an individual who was such an officer or employee, or a
partner of such an officer or employee is prohibited by section 207 or
208 of title 18;
(5) either provide for the establishment or designation of a single
State agency to administer or to supervise the administration of the
plan; or provide for the establishment or designation of a single State
agency to administer or to supervise the administration of the plan,
except that the determination of eligibility for medical assistance
under the plan shall be made by the State or local agency administering
the State plan approved under subchapter I or XVI of this chapter
(insofar as it relates to the aged) if the State is eligible to
participate in the State plan program established under subchapter XVI
of this chapter, or by the agency or agencies administering the
supplemental security income program established under subchapter XVI or
the State plan approved under part A of subchapter IV of this chapter if
the State is not eligible to participate in the State plan program
established under subchapter XVI of this chapter;
(6) provide that the State agency will make such reports, in such
form and containing such information, as the Secretary may from time to
time require, and comply with such provisions as the Secretary may from
time to time find necessary to assure the correctness and verification
of such reports;
(7) provide safeguards which restrict the use or disclosure of
information concerning applicants and recipients to purposes directly
connected with the administration of the plan;
(8) provide that all individuals wishing to make application for
medical assistance under the plan shall have opportunity to do so, and
that such assistance shall be furnished with reasonable promptness to
all eligible individuals;
(9) provide --
(A) that the State health agency, or other appropriate State medical
agency (whichever is utilized by the Secretary for the purpose specified
in the first sentence of section 1395aa(a) of this title), shall be
responsible for establishing and maintaining health standards for
private or public institutions in which recipients of medical assistance
under the plan may receive care or services,
(B) for the establishment or designation of a State authority or
authorities which shall be responsible for establishing and maintaining
standards, other than those relating to health, for such institutions,
and
(C) that any laboratory services paid for under such plan must be
provided by a laboratory which meets the applicable requirements of
section 1395x(e)(9) of this title or paragraphs (15) and (16) of section
1395x(s) of this title, or, in the case of a laboratory which is in a
rural health clinic, of section 1395x(aa)(2)(G) of this title;
(10) provide --
(A) for making medical assistance available, including at least the
care and services listed in paragraphs (1) through (5), (17) and (21) of
section 1396d(a) of this title, to --
(i) all individuals --
(I) who are receiving aid or assistance under any plan of the State
approved under subchapter I, X, XIV, or XVI of this chapter, or part A
or part E of subchapter IV of this chapter (including individuals
eligible under this subchapter by reason of section 602(a)(37), 606(h),
or 673(b) of this title, or considered by the State to be receiving such
aid as authorized under section 682(e)(6) of this title),
(II) with respect to whom supplemental security income benefits are
being paid under subchapter XVI of this chapter or who are qualified
severely impaired individuals (as defined in section 1396d(q) of this
title),
(III) who are qualified pregnant women or children as defined in
section 1396d(n) of this title,
(IV) who are described in subparagraph (A) or (B) of subsection
(l)(1) of this section and whose family income does not exceed the
minimum income level the State is required to establish under subsection
(l)(2)(A) of this section for such a family; /1/
(V) who are qualified family members as defined in section
1396d(m)(1) of this title,
(VI) who are described in subparagraph (C) of subsection (l)(1) of
this section and whose family income does not exceed the income level
the State is required to establish under subsection (l)(2)(B) of this
section for such a family, or
(VII) who are described in subparagraph (D) of subsection (l)(1) of
this section and whose family income does not exceed the income level
the State is required to establish under subsection (l)(2)(C) of this
section for such a family; /2/
(ii) at the option of the State, to any group or groups of
individuals described in section 1396d(a) of this title (or, in the case
of individuals described in section 1396d(a)(i) of this title, to any
reasonable categories of such individuals) who are not individuals
described in clause (i) of this subparagraph but --
(I) who meet the income and resources requirements of the appropriate
State plan described in clause (i) or the supplemental security income
program (as the case may be),
(II) who would meet the income and resources requirements of the
appropriate State plan described in clause (i) if their work-related
child care costs were paid from their earnings rather than by a State
agency as a service expenditure,
(III) who would be eligible to receive aid under the appropriate
State plan described in clause (i) if coverage under such plan was as
broad as allowed under Federal law,
(IV) with respect to whom there is being paid, or who are eligible,
or would be eligible if they were not in a medical institution, to have
paid with respect to them, aid or assistance under the appropriate State
plan described in clause (i), supplemental security income benefits
under subchapter XVI of this chapter, or a State supplementary payment;
/1/
(V) who are in a medical institution for a period of not less than 30
consecutive days (with eligibility by reason of this subclause beginning
on the first day of such period), who meet the resource requirements of
the appropriate State plan described in clause (i) or the supplemental
security income program, and whose income does not exceed a separate
income standard established by the State which is consistent with the
limit established under section 1396b(f)(4)(C) of this title,
(VI) who would be eligible under the State plan under this subchapter
if they were in a medical institution, with respect to whom there has
been a determination that but for the provision of home or
community-based services described in subsection (c), (d), or (e) of
section 1396n of this title they would require the level of care
provided in a hospital, nursing facility or intermediate care facility
for the mentally retarded the cost of which could be reimbursed under
the State plan, and who will receive home or community-based services
pursuant to a waiver granted by the Secretary under subsection (c), (d),
or (e) of section 1396n of this title,
(VII) who would be eligible under the State plan under this
subchapter if they were in a medical institution, who are terminally
ill, and who will receive hospice care pursuant to a voluntary election
described in section 1396d(o) of this title; /3/
(VIII) who is a child described in section 1396d(a)(i) of this title
--
(aa) for whom there is in effect an adoption assistance agreement
(other than an agreement under part E of subchapter IV of this chapter)
between the State and an adoptive parent or parents,
(bb) who the State agency responsible for adoption assistance has
determined cannot be placed with adoptive parents without medical
assistance because such child has special needs for medical or
rehabilitative care, and
(cc) who was eligible for medical assistance under the State plan
prior to the adoption assistance agreement being entered into, or who
would have been eligible for medical assistance at such time if the
eligibility standards and methodologies of the State's foster care
program under part E of subchapter IV of this chapter were applied
rather than the eligibility standards and methodologies of the State's
aid to families with dependent children program under part A of
subchapter IV of this chapter; /3/
(IX) who are described in subsection (l)(1) of this section and are
not described in clause (i)(IV), clause (i)(VI), or clause (i)(VII);
/3/
(X) who are described in subsection (m)(1) of this section; /3/ or
(XI) who receive only an optional State supplementary payment based
on need and paid on a regular basis, equal to the difference between the
individual's countable income and the income standard used to determine
eligibility for such supplementary payment (with countable income being
the income remaining after deductions as established by the State
pursuant to standards that may be more restrictive than the standards
for supplementary security income benefits under subchapter XVI of this
chapter), which are available to all individuals in the State (but which
may be based on different income standards by political subdivision
according to cost of living differences), and which are paid by a State
that does not have an agreement with the Secretary under section 1382e
or 1383c of this title;
(B) that the medical assistance made available to any individual
described in subparagraph (A) --
(i) shall not be less in amount, duration, or scope than the medical
assistance made available to any other such individual, and
(ii) shall not be less in amount, duration, or scope than the medical
assistance made available to individuals not described in subparagraph
(A);
(C) that if medical assistance is included for any group of
individuals described in section 1396d(a) of this title who are not
described in subparagraph (A) or (E), then --
(i) the plan must include a description of (I) the criteria for
determining eligibility of individuals in the group for such medical
assistance, (II) the amount, duration, and scope of medical assistance
made available to individuals in the group, and (III) the single
standard to be employed in determining income and resource eligibility
for all such groups, and the methodology to be employed in determining
such eligibility, which shall be no more restrictive than the
methodology which would be employed under the supplemental security
income program in the case of groups consisting of aged, blind, or
disabled individuals in a State in which such program is in effect, and
which shall be no more restrictive than the methodology which would be
employed under the appropriate State plan (described in subparagraph
(A)(i)) to which such group is most closely categorically related in the
case of other groups;
(ii) the plan must make available medical assistance --
(I) to individuals under the age of 18 who (but for income and
resources) would be eligible for medical assistance as an individual
described in subparagraph (A)(i), and
(II) to pregnant women, during the course of their pregnancy, who
(but for income and resources) would be eligible for medical assistance
as an individual described in subparagraph (A);
(iii) such medical assistance must include (I) with respect to
children under 18 and individuals entitled to institutional services,
ambulatory services, and (II) with respect to pregnant women, prenatal
care and delivery services; and
(iv) if such medical assistance includes services in institutions for
mental diseases or in an intermediate care facility for the mentally
retarded (or both) for any such group, it also must include for all
groups covered at least the care and services listed in paragraphs (1)
through (5) and (17) of section 1396d(a) of this title or the care and
services listed in any 7 of the paragraphs numbered (1) through (21) of
such section;
(D) for the inclusion of home health services for any individual who,
under the State plan, is entitled to nursing facility services;
(E)(i) for making medical assistance available for medicare
cost-sharing (as defined in section 1396d(p)(3) of this title) for
qualified medicare beneficiaries described in section 1396d(p)(1) of
this title;
(ii) for making medical assistance available for payment of medicare
cost-sharing described in section 1396d(p)(3)(A)(i) of this title for
qualified disabled and working individuals described in section 1396d(s)
of this title; and
(iii) for making medical assistance available for medicare cost
sharing described in section 1396d(p)(3)(A)(ii) of this title subject to
section 1396d(p)(4) of this title, for individuals who would be
qualified medicare beneficiaries described in section 1396d(p)(1) of
this title but for the fact that their income exceeds the income level
established by the State under section 1396d(p)(2) of this title but is
less than 110 percent in 1993 and 1994, and 120 percent in 1995 and
years thereafter of the official poverty line (referred to in such
section) for a family of the size involved; and
(F) at the option of a State, for making medical assistance available
for COBRA premiums (as defined in subsection (u)(2) of this section) for
qualified COBRA continuation beneficiaries described in subsection
(u)(1) of this section;
except that (I) the making available of the services described in
paragraph (4), (14), or (16) of section 1396d(a) of this title to
individuals meeting the age requirements prescribed therein shall not,
by reason of this paragraph (10), require the making available of any
such services, or the making available of such services of the same
amount, duration, and scope, to individuals of any other ages, (II) the
making available of supplementary medical insurance benefits under part
B of subchapter XVIII of this chapter to individuals eligible therefor
(either pursuant to an agreement entered into under section 1395v of
this title or by reason of the payment of premiums under such subchapter
by the State agency on behalf of such individuals), or provision for
meeting part or all of the cost of deductibles, cost sharing, or similar
charges under part B of subchapter XVIII of this chapter for individuals
eligible for benefits under such part, shall not, by reason of this
paragraph (10), require the making available of any such benefits, or
the making available of services of the same amount, duration, and
scope, to any other individuals, (III) the making available of medical
assistance equal in amount, duration, and scope to the medical
assistance made available to individuals described in clause (A) to any
classification of individuals approved by the Secretary with respect to
whom there is being paid, or who are eligible, or would be eligible if
they were not in a medical institution, to have paid with respect to
them, a State supplementary payment shall not, by reason of this
paragraph (10), require the making available of any such assistance, or
the making available of such assistance of the same amount, duration,
and scope, to any other individuals not described in clause (A), (IV)
the imposition of a deductible, cost sharing, or similar charge for any
item or service furnished to an individual not eligible for the
exemption under section 1396o(a)(2) or (b)(2) of this title shall not
require the imposition of a deductible, cost sharing, or similar charge
for the same item or service furnished to an individual who is eligible
for such exemption, (V) the making available to pregnant women covered
under the plan of services relating to pregnancy (including prenatal,
delivery, and postpartum services) or to any other condition which may
complicate pregnancy shall not , by reason of this paragraph (10),
require the making available of such services, or the making available
of such services of the same amount, duration, and scope, to any other
individuals, provided such services are made available (in the same
amount, duration, and scope) to all pregnant women covered under the
State plan, (VI) with respect to the making available of medical
assistance for hospice care to terminally ill individuals who have made
a voluntary election described in section 1396d(o) of this title to
receive hospice care instead of medical assistance for certain other
services, such assistance may not be made available in an amount,
duration, or scope less than that provided under subchapter XVIII of
this chapter, and the making available of such assistance shall not, by
reason of this paragraph (10), require the making available of medical
assistance for hospice care to other individuals or the making available
of medical assistance for services waived by such terminally ill
individuals, (VII) the medical assistance made available to an
individual described in subsection (l)(1)(A) of this section who is
eligible for medical assistance only because of subparagraph (A)(i)(IV)
or (A)(ii)(IX) shall be limited to medical assistance for services
related to pregnancy (including prenatal, delivery, postpartum, and
family planning services) and to other conditions which may complicate
pregnancy, (VIII) the medical assistance made available to a qualified
medicare beneficiary described in section 1396d(p)(1) of this title who
is only entitled to medical assistance because the individual is such a
beneficiary shall be limited to medical assistance for medicare
cost-sharing (described in section 1396d(p)(3) of this title), subject
to the provisions of subsection (n) of this section and section 1396o(b)
of this title, (IX) the making available of respiratory care services in
accordance with subsection (e)(9) of this section shall not, by reason
of this paragraph (10), require the making available of such services,
or the making available of such services of the same amount, duration,
and scope, to any individuals not included under subsection (e)(9)(A) of
this section, provided such services are made available (in the same
amount, duration, and scope) to all individuals described in such
subsection, (X) if the plan provides for any fixed durational limit on
medical assistance for inpatient hospital services (whether or not such
a limit varies by medical condition or diagnosis), the plan must
establish exceptions to such a limit for medically necessary inpatient
hospital services furnished with respect to individuals under one year
of age in a hospital defined under the State plan, pursuant to section
1396r-4(a)(1)(A) of this title, as a disproportionate share hospital and
subparagraph (B) (relating to comparability) shall not be construed as
requiring such an exception for other individuals, services, or
hospitals; and /4/ (XI) /5/ the making available of medical assistance
to cover the costs of premiums, deductibles, coinsurance, and other
cost-sharing obligations for certain individuals for private health
coverage as described in section 1396e of this title shall not, by
reason of paragraph (10), require the making available of any such
benefits or the making available of services of the same amount,
duration, and scope of such private coverage to any other individuals,
and (XI) /5/ the medical assistance made available to an individual
described in subsection (u)(1) of this section who is eligible for
medical assistance only because of subparagraph (F) shall be limited to
medical assistance for COBRA continuation premiums (as defined in
subsection (u)(2) of this section);
(11)(A) provide for entering into cooperative arrangements with the
State agencies responsible for administering or supervising the
administration of health services and vocational rehabilitation services
in the State looking toward maximum utilization of such services in the
provision of medical assistance under the plan, (B) effective July 1,
1969, provide, to the extent prescribed by the Secretary, for entering
into agreements, with any agency, institution, or organization receiving
payments under (or through an allotment under) subchapter V of this
chapter, (i) providing for utilizing such agency, institution, or
organization in furnishing care and services which are available under
such subchapter or allotment and which are included in the State plan
approved under this section and (ii) making such provision as may be
appropriate for reimbursing such agency, institution, or organization
for the cost of any such care and services furnished any individual for
which payment would otherwise be made to the State with respect to him
under section 1396b of this title, and (C) provide for coordination of
the operations under this subchapter with the State's operations under
the special supplemental food program for women, infants, and children
under section 1786 of this title;
(12) provide that, in determining whether an individual is blind,
there shall be an examination by a physician skilled in the diseases of
the eye or by an optometrist, whichever the individual may select;
(13) provide --
(A) for payment (except where the State agency is subject to an order
under section 1396m of this title) of the hospital services, nursing
facility services, and services in an intermediate care facility for the
mentally retarded provided under the plan through the use of rates
(determined in accordance with methods and standards developed by the
State which, in the case of nursing facilities, take into account the
costs (including the costs of services required to attain or maintain
the highest practicable physical, mental, and psychosocial well-being of
each resident eligible for benefits under this subchapter) of complying
with subsections (b) (other than paragraph (3)(F) thereof), (c), and (d)
of section 1396r of this title and provide (in the case of a nursing
facility with a waiver under section 1396r(b)(4)(C)(ii) of this title)
for an appropriate reduction to take into account the lower costs (if
any) of the facility for nursing care, and which, in the case of
hospitals, take into account the situation of hospitals which serve a
disproportionate number of low income patients with special needs and
provide, in the case of hospital patients receiving services at an
inappropriate level of care (under conditions similar to those described
in section 1395x(v)(1)(G) of this title), for lower reimbursement rates
reflecting the level of care actually received (in a manner consistent
with section 1395x(v)(1)(G) of this title)) which the State finds, and
makes assurances satisfactory to the Secretary, are reasonable and
adequate to meet the costs which must be incurred by efficiently and
economically operated facilities in order to provide care and services
in conformity with applicable State and Federal laws, regulations, and
quality and safety standards and to assure that individuals eligible for
medical assistance have reasonable access (taking into account
geographic location and reasonable travel time) to inpatient hospital
services of adequate quality; and such State makes further assurances,
satisfactory to the Secretary, for the filing of uniform cost reports by
each hospital, nursing facility, and intermediate care facility for the
mentally retarded and periodic audits by the State of such reports;
(B) that the State shall provide assurances satisfactory to the
Secretary that the payment methodology utilized by the State for
payments to hospitals can reasonably be expected not to increase such
payments, solely as a result of a change of ownership, in excess of the
increase which would result from the application of section
1395x(v)(1)(O) of this title;
(C) that the State shall provide assurances satisfactory to the
Secretary that the valuation of capital assets, for purposes of
determining payment rates for nursing facilities and for intermediate
care facilities for the mentally retarded, will not be increased (as
measured from the date of acquisition by the seller to the date of the
change of ownership), solely as a result of a change of ownership, by
more than the lesser of --
(i) one-half of the percentage increase (as measured over the same
period of time, or, if necessary, as extrapolated retrospectively by the
Secretary) in the Dodge Construction Systems Costs for Nursing Homes,
applied in the aggregate with respect to those facilities which have
undergone a change of ownership during the fiscal year, or
(ii) one-half of the percentage increase (as measured over the same
period of time) in the Consumer Price Index for All Urban Consumers
(United States city average);
(D) for payment for hospice care in amounts no lower than the
amounts, using the same methodology, used under part A of subchapter
XVIII of this chapter and for payment of amounts under section
1396d(o)(3) of this title; except that in the case of hospice care
which is furnished to an individual who is a resident of a nursing
facility or intermediate care facility for the mentally retarded, and
who would be eligible under the plan for nursing facility services or
services in an intermediate care facility for the mentally retarded if
he had not elected to receive hospice care, there shall be paid an
additional amount, to take into account the room and board furnished by
the facility, equal to at least 95 percent of the rate that would have
been paid by the State under the plan for facility services in that
facility for that individual;
(E) for payment for services described in clause (B) or (C) of
section 1396d(a)(2) of this title under the plan of 100 percent of costs
which are reasonable and related to the cost of furnishing such services
or based on such other tests of reasonableness, as the Secretary
prescribes in regulations under section 1395l(a)(3) of this title, or,
in the case of services to which those regulations do not apply, on the
same methodology used under section 1395l(a)(3) of this title; and
(F) for payment for home and community care (as defined in section
1396t(a) of this title and provided under such section) through rates
which are reasonable and adequate to meet the costs of providing care,
efficiently and economically, in conformity with applicable State and
Federal laws, regulations, and quality and safety standards;
(14) provide that enrollment fees, premiums, or similar charges, and
deductions, cost sharing, or similar charges, may be imposed only as
provided in section 1396o of this title;
(15) Repealed. Pub. L. 100-360, title III, 301(e)(2)(C), as added
by Pub. L. 100-485, title VI, 608(d)(14)(I)(iii), Oct. 13, 1988, 102
Stat. 2416;
(16) provide for inclusion, to the extent required by regulations
prescribed by the Secretary, of provisions (conforming to such
regulations) with respect to the furnishing of medical assistance under
the plan to individuals who are residents of the State but are absent
therefrom;
(17) except as provided in subsections (l)(3), (m)(3), and (m)(4) of
this section, include reasonable standards (which shall be comparable
for all groups and may, in accordance with standards prescribed by the
Secretary, differ with respect to income levels, but only in the case of
applicants or recipients of assistance under the plan who are not
receiving aid or assistance under any plan of the State approved under
subchapter I, X, XIV, or XVI, or part A of subchapter IV of this
chapter, and with respect to whom supplemental security income benefits
are not being paid under subchapter XVI of this chapter, based on the
variations between shelter costs in urban areas and in rural areas) for
determining eligibility for and the extent of medical assistance under
the plan which (A) are consistent with the objectives of this
subchapter, (B) provide for taking into account only such income and
resources as are, as determined in accordance with standards prescribed
by the Secretary, available to the applicant or recipient and (in the
case of any applicant or recipient who would, except for income and
resources, be eligible for aid or assistance in the form of money
payments under any plan of the State approved under subchapter I, X,
XIV, or XVI, or part A of subchapter IV, or to have paid with respect to
him supplemental security income benefits under subchapter XVI of this
chapter) as would not be disregarded (or set aside for future needs) in
determining his eligibility for such aid, assistance, or benefits, (C)
provide for reasonable evaluation of any such income or resources, and
(D) do not take into account the financial responsibility of any
individual for any applicant or recipient of assistance under the plan
unless such applicant or recipient is such individual's spouse or such
individual's child who is under age 21 or (with respect to States
eligible to participate in the State program established under
subchapter XVI of this chapter), is blind or permanently and totally
disabled, or is blind or disabled as defined in section 1382c of this
title (with respect to States which are not eligible to participate in
such program); and provide for flexibility in the application of such
standards with respect to income by taking into account, except to the
extent prescribed by the Secretary, the costs (whether in the form of
insurance premiums, payments made to the State under section
1396b(f)(2)(B) of this title, or otherwise and regardless of whether
such costs are reimbursed under another public program of the State or
political subdivision thereof) incurred for medical care or for any
other type of remedial care recognized under State law;
(18) comply with the provisions of section 1396p of this title with
respect to liens, adjustments and recoveries of medical assistance
correctly paid, and transfers of assets;
(19) provide such safeguards as may be necessary to assure that
eligibility for care and services under the plan will be determined, and
such care and services will be provided, in a manner consistent with
simplicity of administration and the best interests of the recipients;
(20) if the State plan includes medical assistance in behalf of
individuals 65 years of age or older who are patients in institutions
for mental diseases --
(A) provide for having in effect such agreements or other
arrangements with State authorities concerned with mental diseases, and,
where appropriate, with such institutions, as may be necessary for
carrying out the State plan, including arrangements for joint planning
and for development of alternate methods of care, arrangements providing
assurance of immediate readmittance to institutions where needed for
individuals under alternate plans of care, and arrangements providing
for access to patients and facilities, for furnishing information, and
for making reports;
(B) provide for an individual plan for each such patient to assure
that the institutional care provided to him is in his best interests,
including, to that end, assurances that there will be initial and
periodic review of his medical and other needs, that he will be given
appropriate medical treatment within the institution, and that there
will be a periodic determination of his need for continued treatment in
the institution; and
(C) provide for the development of alternate plans of care, making
maximum utilization of available resources, for recipients 65 years of
age or older who would otherwise need care in such institutions,
including appropriate medical treatment and other aid or assistance;
for services referred to in section 303(a)(4)(A)(i) and (ii) or section
1383(a)(4)(A)(i) and (ii) of this title which are appropriate for such
recipients and for such patients; and for methods of administration
necessary to assure that the responsibilities of the State agency under
the State plan with respect to such recipients and such patients will be
effectively carried out;
(21) if the State plan includes medical assistance in behalf of
individuals 65 years of age or older who are patients in public
institutions for mental diseases, show that the State is making
satisfactory progress toward developing and implementing a comprehensive
mental health program, including provision for utilization of community
mental health centers, nursing facilities, and other alternatives to
care in public institutions for mental diseases;
(22) include descriptions of (A) the kinds and numbers of
professional medical personnel and supporting staff that will be used in
the administration of the plan and of the responsibilities they will
have, (B) the standards, for private or public institutions in which
recipients of medical assistance under the plan may receive care or
services, that will be utilized by the State authority or authorities
responsible for establishing and maintaining such standards, (C) the
cooperative arrangements with State health agencies and State vocational
rehabilitation agencies entered into with a view to maximum utilization
of and coordination of the provision of medical assistance with the
services administered or supervised by such agencies, and (D) other
standards and methods that the State will use to assure that medical or
remedial care and services provided to recipients of medical assistance
are of high quality;
(23) except as provided in subsection (g) of this section and in
section 1396n and except in the case of Puerto Rico, the Virgin Islands,
and Guam, provide that (A) any individual eligible for medical
assistance (including drugs) may obtain such assistance from any
institution, agency, community pharmacy, or person, qualified to perform
the service or services required (including an organization which
provides such services, or arranges for their availability, on a
prepayment basis), who undertakes to provide him such services, and (B)
an enrollment of an individual eligible for medical assistance in a
primary care case-management system (described in section 1396n(b)(1) of
this title), a health maintenance organization, or a similar entity
shall not restrict the choice of the qualified person from whom the
individual may receive services under section 1396d(a)(4)(C) of this
title;
(24) effective July 1, 1969, provide for consultative services by
health agencies and other appropriate agencies of the State to
hospitals, nursing facilities, home health agencies, clinics,
laboratories, and such other institutions as the Secretary may specify
in order to assist them (A) to qualify for payments under this chapter,
(B) to establish and maintain such fiscal records as may be necessary
for the proper and efficient administration of this chapter, and (C) to
provide information needed to determine payments due under this chapter
on account of care and services furnished to individuals;
(25) provide --
(A) that the State or local agency administering such plan will take
all reasonable measures to ascertain the legal liability of third
parties (including health insurers) to pay for care and services
available under the plan, including --
(i) the collection of sufficient information (as specified by the
Secretary in regulations) to enable the State to pursue claims against
such third parties, with such information being collected at the time of
any determination or redetermination of eligibility for medical
assistance, and
(ii) the submission to the Secretary of a plan (subject to approval
by the Secretary) for pursuing claims against such third parties, which
plan shall --
(I) be integrated with, and be monitored as a part of the Secretary's
review of, the State's mechanized claims processing and information
retrieval system under section 1396b(r) of this title, and
(II) be subject to the provisions of section 1396b(r)(4) of this
title relating to reductions in Federal payments for failure to meet
conditions of approval, but shall not be subject to any other financial
penalty as a result of any other monitoring, quality control, or
auditing requirements;
(B) that in any case where such a legal liability is found to exist
after medical assistance has been made available on behalf of the
individual and where the amount of reimbursement the State can
reasonably expect to recover exceeds the costs of such recovery, the
State or local agency will seek reimbursement for such assistance to the
extent of such legal liability;
(C) that in the case of an individual who is entitled to medical
assistance under the State plan with respect to a service for which a
third party is liable for payment, the person furnishing the service may
not seek to collect from the individual (or any financially responsible
relative or representative of that individual) payment of an amount for
that service (i) if the total of the amount of the liabilities of third
parties for that service is at least equal to the amount payable for
that service under the plan (disregarding section 1396o of this title),
or (ii) in an amount which exceeds the lesser of (I) the amount which
may be collected under section 1396o of this title, or (II) the amount
by which the amount payable for that service under the plan
(disregarding section 1396o of this title) exceeds the total of the
amount of the liabilities of third parties for that service;
(D) that a person who furnishes services and is participating under
the plan may not refuse to furnish services to an individual (who is
entitled to have payment made under the plan for the services the person
furnishes) because of a third party's potential liability for payment
for the service;
(E) that in the case of prenatal or preventive pediatric care
(including early and periodic screening and diagnosis services under
section 1396d(a)(4)(B) of this title) covered under the State plan, the
State shall --
(i) make payment for such service in accordance with the usual
payment schedule under such plan for such services without regard to the
liability of a third party for payment for such services; and
(ii) seek reimbursement from such third party in accordance with
subparagraph (B);
(F) that in the case of any services covered under such plan which
are provided to an individual on whose behalf child support enforcement
is being carried out by the State agency under part D of subchapter IV
of this chapter, the State shall --
(i) make payment for such service in accordance with the usual
payment schedule under such plan for such services without regard to any
third-party liability for payment for such services, if such third-party
liability is derived (through insurance or otherwise) from the parent
whose obligation to pay support is being enforced by such agency, if
payment has not been made by such third party within 30 days after such
services are furnished; and
(ii) seek reimbursement from such third party in accordance with
subparagraph (B); and
(G) that the State plan shall meet the requirements of section 1396e
of this title (relating to enrollment of individuals under group health
plans in certain cases);
(26) if the State plan includes medical assistance for inpatient
mental hospital services, provide --
(A) with respect to each patient receiving such services, for a
regular program of medical review (including medical evaluation) of his
need for such services, and for a written plan of care;
(B) for periodic inspections to be made in all mental institutions
within the State by one or more medical review teams (composed of
physicians and other appropriate health and social service personnel) of
the care being provided to each person receiving medical assistance,
including (i) the adequacy of the services available to meet his current
health needs and promote his maximum physical well-being, (ii) the
necessity and desirability of his continued placement in the
institution, and (iii) the feasibility of meeting his health care needs
through alternative institutional or noninstitutional services; and
(C) for full reports to the State agency by each medical review team
of the findings of each inspection under subparagraph (B), together with
any recommendations;
(27) provide for agreements with every person or institution
providing services under the State plan under which such person or
institution agrees (A) to keep such records as are necessary fully to
disclose the extent of the services provided to individuals receiving
assistance under the State plan, and (B) to furnish the State agency or
the Secretary with such information, regarding any payments claimed by
such person or institution for providing services under the State plan,
as the State agency or the Secretary may from time to time request;
(28) provide --
(A) that any nursing facility receiving payments under such plan must
satisfy all the requirements of subsections (b) through (d) of section
1396r of this title as they apply to such facilities;
(B) for including in ''nursing facility services'' at least the items
and services specified (or deemed to be specified) by the Secretary
under section 1396r(f)(7) of this title and making available upon
request a description of the items and services so included;
(C) for procedures to make available to the public the data and
methodology used in establishing payment rates for nursing facilities
under this subchapter; and
(D) for compliance (by the date specified in the respective sections)
with the requirements of --
(i) section 1396r(e) of this title;
(ii) section 1396r(g) of this title (relating to responsibility for
survey and certification of nursing facilities); and
(iii) sections 1396r(h)(2)(B) and 1396r(h)(2)(D) of this title
(relating to establishment and application of remedies);
(29) include a State program which meets the requirements set forth
in section 1396g of this title, for the licensing of administrators of
nursing homes;
(30)(A) provide such methods and procedures relating to the
utilization of, and the payment for, care and services available under
the plan (including but not limited to utilization review plans as
provided for in section 1396b(i)(4) of this title) as may be necessary
to safeguard against unnecessary utilization of such care and services
and to assure that payments are consistent with efficiency, economy, and
quality of care and are sufficient to enlist enough providers so that
care and services are available under the plan at least to the extent
that such care and services are available to the general population in
the geographic area;
(B) provide, under the program described in subparagraph (A), that --
(i) each admission to a hospital, intermediate care facility for the
mentally retarded, or hospital for mental diseases is reviewed or
screened in accordance with criteria established by medical and other
professional personnel who are not themselves directly responsible for
the care of the patient involved, and who do not have a significant
financial interest in any such institution and are not, except in the
case of a hospital, employed by the institution providing the care
involved, and
(ii) the information developed from such review or screening, along
with the data obtained from prior reviews of the necessity for admission
and continued stay of patients by such professional personnel, shall be
used as the basis for establishing the size and composition of the
sample of admissions to be subject to review and evaluation by such
personnel, and any such sample may be of any size up to 100 percent of
all admissions and must be of sufficient size to serve the purpose of
(I) identifying the patterns of care being provided and the changes
occurring over time in such patterns so that the need for modification
may be ascertained, and (II) subjecting admissions to early or more
extensive review where information indicates that such consideration is
warranted to a hospital, intermediate care facility for the mentally
retarded, or hospital for mental diseases; and
(C) use a utilization and quality control peer review organization
(under part B of subchapter XI of this chapter), an entity which meets
the requirements of section 1320c-1 of this title, as determined by the
Secretary, or a private accreditation body to conduct (on an annual
basis) an independent, external review of the quality of services
furnished under each contract under section 1396b(m) of this title, with
the results of such review made available to the State and, upon
request, to the Secretary, the Inspector General in the Department of
Health and Human Services, and the Comptroller General;
(31) with respect to services in an intermediate care facility for
the mentally retarded (where the State plan includes medical assistance
for such services) provide --
(A) with respect to each patient receiving such services, for a
written plan of care, prior to admission to or authorization of benefits
in such facility, in accordance with regulations of the Secretary, and
for a regular program of independent professional review (including
medical evaluation) which shall periodically review his need for such
services;
(B) with respect to each intermediate care facility for the mentally
retarded within the State, for periodic onsite inspections of the care
being provided to each person receiving medical assistance, by one or
more independent professional review teams (composed of a physician or
registered nurse and other appropriate health and social service
personnel), including with respect to each such person (i) the adequacy
of the services available to meet his current health needs and promote
his maximum physical well-being, (ii) the necessity and desirability of
his continued placement in the facility, and (iii) the feasibility of
meeting his health care needs through alternative institutional or
noninstitutional services; and
(C) for full reports to the State agency by each independent
professional review team of the findings of each inspection under
subparagraph (B), together with any recommendations;
(32) provide that no payment under the plan for any care or service
provided to an individual shall be made to anyone other than such
individual or the person or institution providing such care or service,
under an assignment or power of attorney or otherwise; except that --
(A) in the case of any care or service provided by a physician,
dentist, or other individual practitioner, such payment may be made (i)
to the employer of such physician, dentist, or other practitioner if
such physician, dentist, or practitioner is required as a condition of
his employment to turn over his fee for such care or service to his
employer, or (ii) (where the care or service was provided in a hospital,
clinic, or other facility) to the facility in which the care or service
was provided if there is a contractual arrangement between such
physician, dentist, or practitioner and such facility under which such
facility submits the bill for such care or service;
(B) nothing in this paragraph shall be construed (i) to prevent the
making of such a payment in accordance with an assignment from the
person or institution providing the care or service involved 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
(ii) to preclude an agent of such person or institution 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 person or institution under the plan 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; and
(C) in the case of services furnished (during a period that does not
exceed 14 continuous days in the case of an informal reciprocal
arrangement or 90 continuous days (or such longer period as the
Secretary may provide) in the case of an arrangement involving per diem
or other fee-for-time compensation) by, or incident to the services of,
one physician to the patients of another physician who submits the claim
for such services, payment shall be made to the physician submitting the
claim (as if the services were furnished by, or incident to, the
physician's services), but only if the claim identifies (in a manner
specified by the Secretary) the physician who furnished the services.
/6/
(33) provide --
(A) that the State health agency, or other appropriate State medical
agency, shall be responsible for establishing a plan, consistent with
regulations prescribed by the Secretary, for the review by appropriate
professional health personnel of the appropriateness and quality of care
and services furnished to recipients of medical assistance under the
plan in order to provide guidance with respect thereto in the
administration of the plan to the State agency established or designated
pursuant to paragraph (5) and, where applicable, to the State agency
described in the second sentence of this subsection; and
(B) that, except as provided in section 1396r(g) of this title, the
State or local agency utilized by the Secretary for the purpose
specified in the first sentence of section 1395aa(a) of this title, or,
if such agency is not the State agency which is responsible for
licensing health institutions, the State agency responsible for such
licensing, will perform for the State agency administering or
supervising the administration of the plan approved under this
subchapter the function of determining whether institutions and agencies
meet the requirements for participation in the program under such plan,
except that, if the Secretary has cause to question the adequacy of such
determinations, the Secretary is authorized to validate State
determinations and, on that basis, make independent and binding
determinations concerning the extent to which individual institutions
and agencies meet the requirements for participation;
(34) provide that in the case of any individual who has been
determined to be eligible for medical assistance under the plan, such
assistance will be made available to him for care and services included
under the plan and furnished in or after the third month before the
month in which he made application (or application was made on his
behalf in the case of a deceased individual) for such assistance if such
individual was (or upon application would have been) eligible for such
assistance at the time such care and services were furnished;
(35) provide that any disclosing entity (as defined in section
1320a-3(a)(2) of this title) receiving payments under such plan complies
with the requirements of section 1320a-3 of this title;
(36) provide that within 90 days following the completion of each
survey of any health care facility, laboratory, agency, clinic, or
organization, by the appropriate State agency described in paragraph
(9), such agency shall (in accordance with regulations of the Secretary)
make public in readily available form and place the pertinent findings
of each such survey relating to the compliance of each such health care
facility, laboratory, clinic, agency, or organization with (A) the
statutory conditions of participation imposed under this subchapter, and
(B) the major additional conditions which the Secretary finds necessary
in the interest of health and safety of individuals who are furnished
care or services by any such facility, laboratory, clinic, agency, or
organization;
(37) provide for claims payment procedures which (A) ensure that 90
per centum of claims for payment (for which no further written
information or substantiation is required in order to make payment) made
for services covered under the plan and furnished by health care
practitioners through individual or group practices or through shared
health facilities are paid within 30 days of the date of receipt of such
claims and that 99 per centum of such claims are paid within 90 days of
the date of receipt of such claims, and (B) provide for procedures of
prepayment and postpayment claims review, including review of
appropriate data with respect to the recipient and provider of a service
and the nature of the service for which payment is claimed, to ensure
the proper and efficient payment of claims and management of the
program;
(38) require that an entity (other than an individual practitioner or
a group of practitioners) that furnishes, or arranges for the furnishing
of, items or services under the plan, shall supply (within such period
as may be specified in regulations by the Secretary or by the single
State agency which administers or supervises the administration of the
plan) upon request specifically addressed to such entity by the
Secretary or such State agency, the information described in section
1320a-7(b)(9) of this title;
(39) provide that the State agency shall exclude any specified
individual or entity from participation in the program under the State
plan for the period specified by the Secretary, when required by him to
do so pursuant to section 1320a-7 of this title or section 1320a-7a of
this title, and provide that no payment may be made under the plan with
respect to any item or service furnished by such individual or entity
during such period;
(40) require each health services facility or organization which
receives payments under the plan and of a type for which a uniform
reporting system has been established under section 1320a(a) of this
title to make reports to the Secretary of information described in such
section in accordance with the uniform reporting system (established
under such section) for that type of facility or organization;
(41) provide that whenever a provider of services or any other person
is terminated, suspended, or otherwise sanctioned or prohibited from
participating under the State plan, the State agency shall promptly
notify the Secretary and, in the case of a physician and notwithstanding
paragraph (7), the State medical licensing board of such action;
(42) provide that the records of any entity participating in the plan
and providing services reimbursable on a cost-related basis will be
audited as the Secretary determines to be necessary to insure that
proper payments are made under the plan;
(43) provide for --
(A) informing all persons in the State who are under the age of 21
and who have been determined to be eligible for medical assistance
including services described in section 1396d(a)(4)(B) of this title, of
the availability of early and periodic screening, diagnostic, and
treatment services as described in section 1396d(r) of this title,
(B) providing or arranging for the provision of such screening
services in all cases where they are requested,
(C) arranging for (directly or through referral to appropriate
agencies, organizations, or individuals) corrective treatment the need
for which is disclosed by such child health screening services, and
(D) reporting to the Secretary (in a uniform form and manner
established by the Secretary, by age group and by basis of eligibility
for medical assistance, and by not later than April 1 after the end of
each fiscal year, beginning with fiscal year 1990) the following
information relating to early and periodic screening, diagnostic, and
treatment services provided under the plan during each fiscal year:
(i) the number of children provided child health screening services,
(ii) the number of children referred for corrective treatment (the
need for which is disclosed by such child health screening services),
(iii) the number of children receiving dental services, and
(iv) the State's results in attaining the participation goals set for
the State under section 1396d(r) of this title;
(44) in each case for which payment for inpatient hospital services,
services in an intermediate care facility for the mentally retarded, or
inpatient mental hospital services is made under the State plan --
(A) a physician (or, in the case of skilled nursing facility services
or intermediate care facility services, a physician, or a nurse
practitioner or clinical nurse specialist who is not an employee of the
facility but is working in collaboration with a physician) certifies at
the time of admission, or, if later, the time the individual applies for
medical assistance under the State plan (and a physician, a physician
assistant under the supervision of a physician, or, in the case of
skilled nursing facility services or intermediate care facility
services, a physician, or a nurse practitioner or clinical nurse
specialist who is not an employee of the facility but is working in
collaboration with a physician, recertifies, where such services are
furnished over a period of time, in such cases, at least as often as
required under section 1396b(g)(6) of this title (or, in the case of
services that are services provided in an intermediate care facility for
the mentally retarded, every year), and accompanied by such supporting
material, appropriate to the case involved, as may be provided in
regulations of the Secretary), that such services are or were required
to be given on an inpatient basis because the individual needs or needed
such services, and
(B) such services were furnished under a plan established and
periodically reviewed and evaluated by a physician, or, in the case of
skilled nursing facility services or intermediate care facility
services, a physician, or a nurse practitioner or clinical nurse
specialist who is not an employee of the facility but is working in
collaboration with a physician;
(45) provide for mandatory assignment of rights of payment for
medical support and other medical care owed to recipients, in accordance
with section 1396k of this title;
(46) provide that information is requested and exchanged for purposes
of income and eligibility verification in accordance with a State system
which meets the requirements of section 1320b-7 of this title;
(47) at the option of the State, provide for making ambulatory
prenatal care available to pregnant women during a presumptive
eligibility period in accordance with section 1396r-1 of this title;
(48) provide a method of making cards evidencing eligibility for
medical assistance available to an eligible individual who does not
reside in a permanent dwelling or does not have a fixed home or mailing
address;
(49) provide that the State will provide information and access to
certain information respecting sanctions taken against health care
practitioners and providers by State licensing authorities in accordance
with section 1396r-2 of this title;
(50) provide, in accordance with subsection (q) of this section, for
a monthly personal needs allowance for certain institutionalized
individuals and couples;
(51)(A) meet the requirements of section 1396r-5 of this title
(relating to protection of community spouses), and (B) meet the
requirement of section 1396p(c) of this title (relating to transfer of
assets);
(52) meet the requirements of section 1396r-6 of this title (relating
to extension of eligibility for medical assistance);
(53) provide --
(A) for notifying in a timely manner all individuals in the State who
are determined to be eligible for medical assistance and who are
pregnant women, breastfeeding or postpartum women (as defined in section
1786 of this title), or children below the age of 5, of the availability
of benefits furnished by the special supplemental food program under
such section, and
(B) for referring any such individual to the State agency responsible
for administering such program;
(54)(A) provide that, any formulary or similar restriction (except as
provided in section 1396r-8(d) of this title) on the coverage of covered
outpatient drugs under the plan shall permit the coverage of covered
outpatient drugs of any manufacturer which has entered into and complies
with an agreement under section 1396r-8(a) of this title, which are
prescribed for a medically accepted indication (as defined in subsection
/7/ 1396r-8(k)(6) of this title), and
(B) comply with the reporting requirements of section
1396r-8(b)(2)(A) of this title and the requirements of subsections (d)
and (g) of section 1396r-8 of this title; and /8/
(55) provide for receipt and initial processing of applications of
individuals for medical assistance under subsection (a)(10)(A)(i)(IV),
(a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or (a)(10)(A)(ii)(IX) of this
section --
(A) at locations which are other than those used for the receipt and
processing of applications for aid under part A of subchapter IV of this
chapter and which include facilities defined as disproportionate share
hospitals under section 1396r-4(a)(1)(A) of this title and
Federally-qualified health centers described in section 1396d(1)(2)(B)
/9/ of this title, and
(B) using applications which are other than those used for
applications for aid under such part. /10/
(55) /11/ provide, in accordance with subsection (s) of this section,
for adjusted payments for certain inpatient hospital services. /10/
(57) provide that each hospital, nursing facility, provider of home
health care or personal care services, hospice program, or health
maintenance organization (as defined in section 1396b(m)(1)(A) of this
title) receiving funds under the plan shall comply with the requirements
of subsection (w) of this section;
(58) provide that the State, acting through a State agency,
association, or other private nonprofit entity, develop a written
description of the law of the State (whether statutory or as recognized
by the courts of the State) concerning advance directives that would be
distributed by providers or organizations under the requirements of
subsection (w) of this section. /12/
(58) /13/ maintain a list (updated not less often than monthly, and
containing each physician's unique identifier provided under the system
established under subsection (v) /14/ of this section) of all physicians
who are certified to participate under the State plan.
Notwithstanding paragraph (5), if on January 1, 1965, and on the date
on which a State submits its plan for approval under this subchapter,
the State agency which administered or supervised the administration of
the plan of such State approved under subchapter X of this chapter (or
subchapter XVI of this chapter, insofar as it relates to the blind) was
different from the State agency which administered or supervised the
administration of the State plan approved under subchapter I of this
chapter (or subchapter XVI of this chapter, insofar as it relates to the
aged), the State agency which administered or supervised the
administration of such plan approved under subchapter X of this chapter
(or subchapter XVI of this chapter, insofar as it relates to the blind)
may be designated to administer or supervise the administration of the
portion of the State plan for medical assistance which relates to blind
individuals and a different State agency may be established or
designated to administer or supervise the administration of the rest of
the State plan for medical assistance; and in such case the part of the
plan which each such agency administers, or the administration of which
each such agency supervises, shall be regarded as a separate plan for
purposes of this subchapter (except for purposes of paragraph (10)).
The provisions of paragraphs (9)(A), (31), and (33) and of section
1396b(i)(4) of this title shall not apply to a Christian Science
sanatorium operated, or listed and certified, by the First Church of
Christ, Scientist, Boston, Massachusetts.
For purposes of paragraph (10) any individual who, for the month of
August 1972, was eligible for or receiving aid or assistance under a
State plan approved under subchapter I, X, XIV, or XVI of this chapter,
or part A of subchapter IV of this chapter and who for such month was
entitled to monthly insurance benefits under subchapter II of this
chapter shall for purposes of this subchapter only be deemed to be
eligible for financial aid or assistance for any month thereafter if
such individual would have been eligible for financial aid or assistance
for such month had the increase in monthly insurance benefits under
subchapter II of this chapter resulting from enactment of Public Law
92-336 not been applicable to such individual.
The requirement of clause (A) of paragraph (37) with respect to a
State plan may be waived by the Secretary if he finds that the State has
exercised good faith in trying to meet such requirement. For purposes
of this subchapter, any child who meets the requirements of paragraph
(1) or (2) of section 673(b) of this title shall be deemed to be a
dependent child as defined in section 606 of this title and shall be
deemed to be a recipient of aid to families with dependent children
under part A of subchapter IV of this chapter in the State where such
child resides. Notwithstanding paragraph (10)(B) or any other provision
of this subsection, a State plan shall provide medical assistance with
respect to an alien who is not lawfully admitted for permanent residence
or otherwise permanently residing in the United States under color of
law only in accordance with section 1396b(v) of this title.
(b) Approval by Secretary
The Secretary shall approve any plan which fulfills the conditions
specified in subsection (a) of this section, except that he shall not
approve any plan which imposes, as a condition of eligibility for
medical assistance under the plan --
(1) an age requirement of more than 65 years; or
(2) any residence requirement which excludes any individual who
resides in the State, regardless of whether or not the residence is
maintained permanently or at a fixed address; or
(3) any citizenship requirement which excludes any citizen of the
United States.
(c) Lower payment levels or applying for benefits as condition of
applying for, or receiving, medical assistance
Notwithstanding subsection (b) of this section, the Secretary shall
not approve any State plan for medical assistance if --
(1) the State has in effect, under its plan established under part A
of subchapter IV of this chapter, payment levels that are less than the
payment levels in effect under such plan on May 1, 1988; or
(2) the State requires individuals described in subsection (l)(1) of
this section to apply for benefits under such part as a condition of
applying for, or receiving, medical assistance under this subchapter.
(d) Performance of medical or utilization review functions
If a State contracts with an entity which meets the requirements of
section 1320c-1 of this title, as determined by the Secretary, for the
performance of the quality review functions described in subsection
(a)(30)(C) of this section, or a utilization and quality control peer
review organization having a contract with the Secretary under part B of
subchapter XI of this chapter for the performance of medical or
utilization review functions (including quality review functions
described in subsection (a)(30)(C) of this section) required under this
subchapter of a State plan with respect to specific services or
providers (or services or providers in a geographic area of the State),
such requirements shall be deemed to be met for those services or
providers (or services or providers in that area) by delegation to such
an entity or organization under the contract of the State's authority to
conduct such review activities if the contract provides for the
performance of activities not inconsistent with part B of subchapter XI
of this chapter and provides for such assurances of satisfactory
performance by such an entity or organization as the Secretary may
prescribe.
(e) Continued eligibility of families determined ineligible because
of income and resources or hours of work limitations of plan;
individuals enrolled with health maintenance organizations; persons
deemed recipients of supplemental security income or State supplemental
payments; entitlement for certain newborns; postpartum eligibility for
pregnant women
(1)(A) Notwithstanding any other provision of this subchapter,
effective January 1, 1974, subject to subparagraph (B) each State plan
approved under this subchapter must provide that each family which was
receiving aid pursuant to a plan of the State approved under part A of
subchapter IV of this chapter in at least 3 of the 6 months immediately
preceding the month in which such family became ineligible for such aid
because of increased hours of, or increased income from, employment,
shall, while a member of such family is employed, remain eligible for
assistance under the plan approved under this subchapter (as though the
family was receiving aid under the plan approved under part A of
subchapter IV of this chapter) for 4 calendar months beginning with the
month in which such family became ineligible for aid under the plan
approved under part A of subchapter IV of this chapter because of income
and resources or hours of work limitations contained in such plan.
(B) Subparagraph (A) shall not apply with respect to families that
cease to be eligible for aid under part A of subchapter IV of this
chapter during the period beginning on April 1, 1990, and ending on
September 30, 1998. During such period, for provisions relating to
extension of eligibility for medical assistance for certain families who
have received aid pursuant to a State plan approved under part A of
subchapter IV of this chapter and have earned income, see section
1396r-6 of this title.
(2)(A) In the case of an individual who is enrolled with a qualified
health maintenance organization (as defined in title XIII of the Public
Health Service Act (42 U.S.C. 300e et seq.)) or with an entity described
in paragraph (2)(B)(iii), (2)(E), (2)(G), or (6) of section 1396b(m) of
this title under a contract described in section 1396b(m)(2)(A) of this
title or with an eligible organization with a contract under section
1395mm of this title and who would (but for this paragraph) lose
eligibility for benefits under this subchapter before the end of the
minimum enrollment period (defined in subparagraph (B)), the State plan
may provide, notwithstanding any other provision of this subchapter,
that the individual shall be deemed to continue to be eligible for such
benefits until the end of such minimum period, but, except for benefits
furnished under section 1396d(a)(4)(C) of this title, only with respect
to such benefits provided to the individual as an enrollee of such
organization or entity.
(B) For purposes of subparagraph (A), the term ''minimum enrollment
period'' means, with respect to an individual's enrollment with an
organization or entity under a State plan, a period, established by the
State, of not more than six months beginning on the date the
individual's enrollment with the organization or entity becomes
effective.
(3) At the option of the State, any individual who --
(A) is 18 years of age or younger and qualifies as a disabled
individual under section 1382c(a) of this title;
(B) with respect to whom there has been a determination by the State
that --
(i) the individual requires a level of care provided in a hospital,
nursing facility, or intermediate care facility for the mentally
retarded,
(ii) it is appropriate to provide such care for the individual
outside such an institution, and
(iii) the estimated amount which would be expended for medical
assistance for the individual for such care outside an institution is
not greater than the estimated amount which would otherwise be expended
for medical assistance for the individual within an appropriate
institution; and
(C) if the individual were in a medical institution, would be
eligible for medical assistance under the State plan under this
subchapter,
shall be deemed, for purposes of this subchapter only, to be an
individual with respect to whom a supplemental security income payment,
or State supplemental payment, respectively, is being paid under
subchapter XVI of this chapter.
(4) A child born to a woman eligible for and receiving medical
assistance under a State plan on the date of the child's birth shall be
deemed to have applied for medical assistance and to have been found
eligible for such assistance under such plan on the date of such birth
and to remain eligible for such assistance for a period of one year so
long as the child is a member of the woman's household and the woman
remains (or would remain if pregnant) eligible for such assistance.
During the period in which a child is deemed under the preceding
sentence to be eligible for medical assistance, the medical assistance
eligibility identification number of the mother shall also serve as the
identification number of the child, and all claims shall be submitted
and paid under such number (unless the State issues a separate
identification number for the child before such period expires).
(5) A woman who, while pregnant, is eligible for, has applied for,
and has received medical assistance under the State plan, shall continue
to be eligible under the plan, as though she were pregnant, for all
pregnancy-related and postpartum medical assistance under the plan,
through the end of the month in which the 60-day period (beginning on
the last day of her pregnancy) ends.
(6) In the case of a pregnant woman described in subsection (a)(10)
of this section who, because of a change in income of the family of
which she is a member, would not otherwise continue to be described in
such subsection, the woman shall be deemed to continue to be an
individual described in subsection (a)(10)(A)(i)(IV) of this section and
subsection (l)(1)(A) of this section without regard to such change of
income through the end of the month in which the 60-day period
(beginning on the last day of her pregnancy) ends. The preceding
sentence shall not apply in the case of a woman who has been provided
ambulatory prenatal care pursuant to section 1396r-1 of this title
during a presumptive eligibility period and is then, in accordance with
such section, determined to be ineligible for medical assistance under
the State plan.
(7) In the case of an infant or child described in subparagraph (B),
(C), or (D) of subsection (l)(1) of this section or paragraph (2) of
section 1396d(n) of this title --
(A) who is receiving inpatient services for which medical assistance
is provided on the date the infant or child attains the maximum age with
respect to which coverage is provided under the State plan for such
individuals, and
(B) who, but for attaining such age, would remain eligible for
medical assistance under such subsection,
the infant or child shall continue to be treated as an individual
described in such respective provision until the end of the stay for
which the inpatient services are furnished.
(8) If an individual is determined to be a qualified medicare
beneficiary (as defined in section 1396d(p)(1) of this title), such
determination shall apply to services furnished after the end of the
month in which the determination first occurs. For purposes of payment
to a State under section 1396b(a) of this title, such determination
shall be considered to be valid for an individual for a period of 12
months, except that a State may provide for such determinations more
frequently, but not more frequently than once every 6 months for an
individual.
(9)(A) At the option of the State, the plan may include as medical
assistance respiratory care services for any individual who --
(i) is medically dependent on a ventilator for life support at least
six hours per day;
(ii) has been so dependent for at least 30 consecutive days (or the
maximum number of days authorized under the State plan, whichever is
less) as an inpatient;
(iii) but for the availability of respiratory care services, would
require respiratory care as an inpatient in a hospital, nursing
facility, or intermediate care facility for the mentally retarded and
would be eligible to have payment made for such inpatient care under the
State plan;
(iv) has adequate social support services to be cared for at home;
and
(v) wishes to be cared for at home.
(B) The requirements of subparagraph (A)(ii) may be satisfied by a
continuous stay in one or more hospitals, nursing facilities, or
intermediate care facilities for the mentally retarded.
(C) For purposes of this paragraph, respiratory care services means
services provided on a part-time basis in the home of the individual by
a respiratory therapist or other health care professional trained in
respiratory therapy (as determined by the State), payment for which is
not otherwise included within other items and services furnished to such
individual as medical assistance under the plan.
(10)(A) The fact that an individual, child, or pregnant woman may be
denied aid under part A of subchapter IV of this chapter pursuant to
section 602(a)(43) of this title shall not be construed as denying (or
permitting a State to deny) medical assistance under this subchapter to
such individual, child, or woman who is eligible for assistance under
this subchapter on a basis other than the receipt of aid under such
part.
(B) If an individual, child, or pregnant woman is receiving aid under
part A of subchapter IV of this chapter and such aid is terminated
pursuant to section 602(a)(43) of this title, the State may not
discontinue medical assistance under this subchapter for the individual,
child, or woman until the State has determined that the individual,
child, or woman is not eligible for assistance under this subchapter on
a basis other than the receipt of aid under such part.
(11)(A) In the case of an individual who is enrolled with a group
health plan under section 1396e of this title and who would (but for
this paragraph) lose eligibility for benefits under this subchapter
before the end of the minimum enrollment period (defined in subparagraph
(B)), the State plan may provide, notwithstanding any other provision of
this subchapter, that the individual shall be deemed to continue to be
eligible for such benefits until the end of such minimum period, but
only with respect to such benefits provided to the individual as an
enrollee of such plan.
(B) For purposes of subparagraph (A), the term ''minimum enrollment
period'' means, with respect to an individual's enrollment with a group
health plan, a period established by the State, of not more than 6
months beginning on the date the individual's enrollment under the plan
becomes effective.
(f) Effective date of State plan as determinative of duty of State to
provide medical assistance to aged, blind, or disabled individuals
Notwithstanding any other provision of this subchapter, except as
provided in subsection (e) of this section and section 1382h(b)(3) of
this title and section 1396r-5 of this title, except with respect to
qualified disabled and working individuals (described in section
1396d(s) of this title), and except with respect to qualified medicare
beneficiaries, qualified severely impaired individuals, and individuals
described in subsection (m)(1) of this subsection, no State not eligible
to participate in the State plan program established under subchapter
XVI of this chapter shall be required to provide medical assistance to
any aged, blind, or disabled individual (within the meaning of
subchapter XVI of this chapter) for any month unless such State would be
(or would have been) required to provide medical assistance to such
individual for such month had its plan for medical assistance approved
under this subchapter and in effect on January 1, 1972, been in effect
in such month, except that for this purpose any such individual shall be
deemed eligible for medical assistance under such State plan if (in
addition to meeting such other requirements as are or may be imposed
under the State plan) the income of any such individual as determined in
accordance with section 1396b(f) of this title (after deducting any
supplemental security income payment and State supplementary payment
made with respect to such individual, and incurred expenses for medical
care as recognized under State law regardless of whether such expenses
are reimbursed under another public program of the State or political
subdivision thereof) is not in excess of the standard for medical
assistance established under the State plan as in effect on January 1,
1972. In States which provide medical assistance to individuals
pursuant to paragraph (10)(C) of subsection (a) of this section, an
individual who is eligible for medical assistance by reason of the
requirements of this section concerning the deduction of incurred
medical expenses from income shall be considered an individual eligible
for medical assistance under paragraph (10)(A) of that subsection if
that individual is, or is eligible to be (1) an individual with respect
to whom there is payable a State supplementary payment on the basis of
which similarly situated individuals are eligible to receive medical
assistance equal in amount, duration, and scope to that provided to
individuals eligible under paragraph (10)(A), or (2) an eligible
individual or eligible spouse, as defined in subchapter XVI of this
chapter, with respect to whom supplemental security income benefits are
payable; otherwise that individual shall be considered to be an
individual eligible for medical assistance under paragraph (10)(C) of
that subsection. In States which do not provide medical assistance to
individuals pursuant to paragraph (10)(C) of that subsection, an
individual who is eligible for medical assistance by reason of the
requirements of this section concerning the deduction of incurred
medical expenses from income shall be considered an individual eligible
for medical assistance under paragraph (10)(A) of that subsection.
(g) Reduction of aid or assistance to providers of services
attempting to collect from beneficiary in violation of third-party
provisions
In addition to any other sanction available to a State, a State may
provide for a reduction of any payment amount otherwise due with respect
to a person who furnishes services under the plan in an amount equal to
up to three times the amount of any payment sought to be collected by
that person in violation of subsection (a)(25)(C) of this section.
(h) Payments for hospitals serving disproportionate number of
low-income patients and for home and community care
Nothing in this subchapter (including subsections (a)(13) and (a)(30)
of this section) shall be construed as authorizing the Secretary to
limit the amount of payment that may be made under a plan under this
subchapter for home and community care.
(i) Termination of certification for participation of and suspension
of State payments to intermediate care facilities for the mentally
retarded
(1) In addition to any other authority under State law, where a State
determines that a /15/ intermediate care facility for the mentally
retarded which is certified for participation under its plan no longer
substantially meets the requirements for such a facility under this
subchapter and further determines that the facility's deficiencies --
(A) immediately jeopardize the health and safety of its patients, the
State shall provide for the termination of the facility's certification
for participation under the plan and may provide, or
(B) do not immediately jeopardize the health and safety of its
patients, the State may, in lieu of providing for terminating the
facility's certification for participation under the plan, provide
that no payment will be made under the State plan with respect to any
individual admitted to such facility after a date specified by the
State.
(2) The State shall not make such a decision with respect to a
facility until the facility has had a reasonable opportunity, following
the initial determination that it no longer substantially meets the
requirements for such a facility under this subchapter, to correct its
deficiencies, and, following this period, has been given reasonable
notice and opportunity for a hearing.
(3) The State's decision to deny payment may be made effective only
after such notice to the public and to the facility as may be provided
for by the State, and its effectiveness shall terminate (A) when the
State finds that the facility is in substantial compliance (or is making
good faith efforts to achieve substantial compliance) with the
requirements for such a facility under this subchapter, or (B) in the
case described in paragraph (1)(B), with the end of the eleventh month
following the month such decision is made effective, whichever occurs
first. If a facility to which clause (B) of the previous sentence
applies still fails to substantially meet the provisions of the
respective section on the date specified in such clause, the State shall
terminate such facility's certification for participation under the plan
effective with the first day of the first month following the month
specified in such clause.
(j) Waiver or modification of subchapter requirements with respect to
medical assistance program in American Samoa
Notwithstanding any other requirement of this subchapter, the
Secretary may waive or modify any requirement of this subchapter with
respect to the medical assistance program in American Samoa and the
Northern Mariana Islands, other than a waiver of the Federal medical
assistance percentage, the limitation in section 1308(c) of this title,
or the requirement that payment may be made for medical assistance only
with respect to amounts expended by American Samoa or the Northern
Mariana Islands for care and services described in paragraphs (1)
through (22) of section 1396d(a) of this title.
(k) Treatment of potential payments from medicaid qualifying trusts
(1) In the case of a medicaid qualifying trust (described in
paragraph (2)), the amounts from the trust deemed available to a
grantor, for purposes of subsection (a)(17) of this section, is the
maximum amount of payments that may be permitted under the terms of the
trust to be distributed to the grantor, assuming the full exercise of
discretion by the trustee or trustees for the distribution of the
maximum amount to the grantor. For purposes of the previous sentence,
the term ''grantor'' means the individual referred to in paragraph (2).
(2) For purposes of this subsection, a ''medicaid qualifying trust''
is a trust, or similar legal device, established (other than by will) by
an individual (or an individual's spouse) under which the individual may
be the beneficiary of all or part of the payments from the trust and the
distribution of such payments is determined by one or more trustees who
are permitted to exercise any discretion with respect to the
distribution to the individual.
(3) This subsection shall apply without regard to --
(A) whether or not the medicaid qualifying trust is irrevocable or is
established for purposes other than to enable a grantor to qualify for
medical assistance under this subchapter; or
(B) whether or not the discretion described in paragraph (2) is
actually exercised.
(4) The State may waive the application of this subsection with
respect to an individual where the State determines that such
application would work an undue hardship.
(l) Description of group
(1) Individuals described in this paragraph are --
(A) women during pregnancy (and during the 60-day period beginning on
the last day of the pregnancy),
(B) infants under one year of age,
(C) children children /16/ who have attained one year of age but have
not attained 6 years of age, and
(D) children born after September 30, 1983, who have attained 6 years
of age but have not attained 19 years of age,
who are not described in any of subclauses (I) through (III) of
subsection (a)(10)(A)(i) of this section and whose family income does
not exceed the income level established by the State under paragraph (2)
for a family size equal to the size of the family, including the woman,
infant, or child.
(2)(A)(i) For purposes of paragraph (1) with respect to individuals
described in subparagraph (A) or (B) of that paragraph, the State shall
establish an income level which is a percentage (not less than the
percentage provided under clause (ii) and not more than 185 percent) of
the income official poverty line (as defined by the Office of Management
and Budget, and revised annually in accordance with section 9902(2) of
this title) applicable to a family of the size involved.
(ii) The percentage provided under this clause, with respect to
eligibility for medical assistance on or after --
(I) July 1, 1989, is 75 percent, or, if greater, the percentage
provided under clause (iii), and
(II) April 1, 1990, 133 percent, or, if greater, the percentage
provided under clause (iv).
(iii) In the case of a State which, as of July 1, 1988, has elected
to provide, and provides, medical assistance to individuals described in
this subsection or has enacted legislation authorizing, or appropriating
funds, to provide such assistance to such individuals before July 1,
1989, the percentage provided under clause (ii)(I) shall not be less
than --
(I) the percentage specified by the State in an amendment to its
State plan (whether approved or not) as of July 1, 1988, or
(II) if no such percentage is specified as of July 1, 1988, the
percentage established under the State's authorizing legislation or
provided for under the State's appropriations;
but in no case shall this clause require the percentage provided
under clause (ii)(I) to exceed 100 percent.
(iv) In the case of a State which, as of December 19, 1989, has
established under clause (i), or has enacted legislation authorizing, or
appropriating funds, to provide for, a percentage (of the income
official poverty line) that is greater than 133 percent, the percentage
provided under clause (ii) for medical assistance on or after April 1,
1990, shall not be less than --
(I) the percentage specified by the State in an amendment to its
State plan (whether approved or not) as of December 19, 1989, or
(II) if no such percentage is specified as of December 19, 1989, the
percentage established under the State's authorizing legislation or
provided for under the State's appropriations.
(B) For purposes of paragraph (1) with respect to individuals
described in subparagraph (C) of such paragraph, the State shall
establish an income level which is equal to 133 percent of the income
official poverty line described in subparagraph (A) applicable to a
family of the size involved.
(C) For purposes of paragraph (1) with respect to individuals
described in subparagraph (D) of that paragraph, the State shall
establish an income level which is equal to 100 percent of the income
official poverty line described in subparagraph (A) applicable to a
family of the size involved.
(3) Notwithstanding subsection (a)(17) of this section, for
individuals who are eligible for medical assistance because of
subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10) (A)(i)(VII),,
/16/ or (a)(10)(A)(ii)(IX) of this section --
(A) application of a resource standard shall be at the option of the
State;
(B) any resource standard or methodology that is applied with respect
to an individual described in subparagraph (A) of paragraph (1) may not
be more restrictive than the resource standard or methodology that is
applied under subchapter XVI of this chapter;
(C) any resource standard or methodology that is applied with respect
to an individual described in subparagraph (B), (C), or (D) of paragraph
(1) may not be more restrictive than the corresponding methodology that
is applied under the State plan under part A of subchapter IV of this
chapter;
(D) the income standard to be applied is the appropriate income
standard established under paragraph (2); and
(E) family income shall be determined in accordance with the
methodology employed under the State plan under part A or E of
subchapter IV of this chapter (except to the extent such methodology is
inconsistent with clause (D) of subsection (a)(17) of this section), and
costs incurred for medical care or for any other type of remedial care
shall not be taken into account.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(17) of this section,
require or permit such treatment for other individuals.
(4)(A) In the case of any State which is providing medical assistance
to its residents under a waiver granted under section 1315 of this
title, the Secretary shall require the State to provide medical
assistance for pregnant women and infants under age 1 described in
subsection (a)(10)(A)(i)(IV) of this section and for children described
in subsection (a)(10)(A)(i)(VI) of this section or subsection
(a)(10)(A)(i)(VII) of this section in the same manner as the State would
be required to provide such assistance for such individuals if the State
had in effect a plan approved under this subchapter.
(B) In the case of a State which is not one of the 50 States or the
District of Columbia, the State need not meet the requirement of
subsection (a)(10)(A)(i)(IV) /17/ (a)(10)(A)(i)(VI), or
(a)(10)(A)(i)(VII) of this section and, for purposes of paragraph
(2)(A), the State may substitute for the percentage provided under
clause (ii) of such paragraph any percentage.
(m) Description of individuals
(1) Individuals described in this paragraph are individuals --
(A) who are 65 years of age or older or are disabled individuals (as
determined under section 1382c(a)(3) of this title),
(B) whose income (as determined under section 1382a of this title for
purposes of the supplemental security income program, except as provided
in paragraph (2)(C)) does not exceed an income level established by the
State consistent with paragraph (2)(A), and
(C) whose resources (as determined under section 1382b of this title
for purposes of the supplemental security income program) do not exceed
(except as provided in paragraph (2)(B)) the maximum amount of resources
that an individual may have and obtain benefits under that program.
(2)(A) The income level established under paragraph (1)(B) may not
exceed a percentage (not more than 100 percent) of the official poverty
line (as defined by the Office of Management and Budget, and revised
annually in accordance with section 9902(2) of this title) applicable to
a family of the size involved.
(B) In the case of a State that provides medical assistance to
individuals not described in subsection (a)(10)(A) of this section and
at the State's option, the State may use under paragraph (1)(C) such
resource level (which is higher than the level described in that
paragraph) as may be applicable with respect to individuals described in
paragraph (1)(A) who are not described in subsection (a)(10)(A) of this
section.
(C) The provisions of section 1396d(p)(2)(D) of this title shall
apply to determinations of income under this subsection in the same
manner as they apply to determinations of income under section 1396d(p)
of this title.
(3) Notwithstanding subsection (a)(17) of this section, for
individuals described in paragraph (1) who are covered under the State
plan by virtue of subsection (a)(10)(A)(ii)(X) of this section --
(A) the income standard to be applied is the income standard
described in paragraph (1)(B), and
(B) except as provided in section 1382a(b)(4)(B)(ii) of this title,
costs incurred for medical care or for any other type of remedial care
shall not be taken into account in determining income.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(17) of this section,
require or permit such treatment for other individuals.
(4) Notwithstanding subsection (a)(17) of this section, for qualified
medicare beneficiaries described in section 1396d(p)(1) of this title --
(A) the income standard to be applied is the income standard
described in section 1396d(p)(1)(B) of this title, and
(B) except as provided in section 1382a(b)(4)(B)(ii) of this title,
costs incurred for medical care or for any other type of remedial care
shall not be taken into account in determining income.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(17) of this section,
require or permit such treatment for other individuals.
(n) Payment amounts
In the case of medical assistance furnished under this subchapter for
medicare cost-sharing respecting the furnishing of a service or item to
a qualified medicare beneficiary, the State plan may provide payment in
an amount with respect to the service or item that results in the sum of
such payment amount and any amount of payment made under subchapter
XVIII of this chapter with respect to the service or item exceeding the
amount that is otherwise payable under the State plan for the item or
service for eligible individuals who are not qualified medicare
beneficiaries.
(o) Certain benefits disregarded for purposes of determining
post-eligibility contributions
Notwithstanding any provision of subsection (a) of this section to
the contrary, a State plan under this subchapter shall provide that any
supplemental security income benefits paid by reason of subparagraph (E)
or (G) of section 1382(e)(1) of this title to an individual who --
(1) is eligible for medical assistance under the plan, and
(2) is in a hospital, skilled nursing facility, or intermediate care
facility at the time such benefits are paid,
will be disregarded for purposes of determining the amount of any
post-eligibility contribution by the individual to the cost of the care
and services provided by the hospital, skilled nursing facility, or
intermediate care facility.
(p) Exclusion power of State; exclusion as prerequisite for medical
assistance payments; ''exclude'' defined
(1) In addition to any other authority, a State may exclude any
individual or entity for purposes of participating under the State plan
under this subchapter for any reason for which the Secretary could
exclude the individual or entity from participation in a program under
subchapter XVIII of this chapter under section 1320a-7, 1320a-7a, or
1395cc(b)(2) of this title.
(2) In order for a State to receive payments for medical assistance
under section 1396b(a) of this title, with respect to payments the State
makes to a health maintenance organization (as defined in section
1396b(m) of this title) or to an entity furnishing services under a
waiver approved under section 1396n(b)(1) of this title, the State must
provide that it will exclude from participation, as such an organization
or entity, any organization or entity that --
(A) could be excluded under section 1320a-7(b)(8) of this title
(relating to owners and managing employees who have been convicted of
certain crimes or received other sanctions),
(B) has, directly or indirectly, a substantial contractual
relationship (as defined by the Secretary) with an individual or entity
that is described in section 1320a-7(b)(8)(B) of this title, or
(C) employs or contracts with any individual or entity that is
excluded from participation under this subchapter under section 1320a-7
or 1320a-7a of this title for the provision of health care, utilization
review, medical social work, or administrative services or employs or
contracts with any entity for the provision (directly or indirectly)
through such an excluded individual or entity of such services.
(3) As used in this subsection, the term ''exclude'' includes the
refusal to enter into or renew a participation agreement or the
termination of such an agreement.
(q) Minimum monthly personal needs allowance deduction;
''institutionalized individual or couple'' defined
(1)(A) In order to meet the requirement of subsection (a)(50) of this
section, the State plan must provide that, in the case of an
institutionalized individual or couple described in subparagraph (B), in
determining the amount of the individual's or couple's income to be
applied monthly to payment for the cost of care in an institution, there
shall be deducted from the monthly income (in addition to other
allowances otherwise provided under the State plan) a monthly personal
needs allowance --
(i) which is reasonable in amount for clothing and other personal
needs of the individual (or couple) while in an institution, and
(ii) which is not less (and may be greater) than the minimum monthly
personal needs allowance described in paragraph (2).
(B) In this subsection, the term ''institutionalized individual or
couple'' means an individual or married couple --
(i) who is an inpatient (or who are inpatients) in a medical
institution or nursing facility for which payments are made under this
subchapter throughout a month, and
(ii) who is or are determined to be eligible for medical assistance
under the State plan.
(2) The minimum monthly personal needs allowance described in this
paragraph /18/ is $30 for an institutionalized individual and $60 for an
institutionalized couple (if both are aged, blind, or disabled, and
their incomes are considered available to each other in determining
eligibility).
(r) Disregarding payments for certain medical expenses by
institutionalized individuals
(1) For purposes of sections 1396a(a)(17) and 1396r-5(d)(1)(D) of
this title and for purposes of a waiver under section 1396n of this
title, with respect to the post-eligibility treatment of income of
individuals who are institutionalized or receiving home or
community-based services under such a waiver /19/ there shall be
disregarded reparation payments made by the Federal Republic of Germany
and, /20/ there shall be taken into account amounts for incurred
expenses for medical or remedial care that are not subject to payment by
a third party, including --
(i) medicare and other health insurance premiums, deductibles, or
coinsurance, and
(ii) necessary medical or remedial care recognized under State law
but not covered under the State plan under this subchapter, subject to
reasonable limits the State may establish on the amount of these
expenses.
(2)(A) The methodology to be employed in determining income and
resource eligibility for individuals under subsection
(a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)
(A)(i)(VII), (a)(10)(A)(ii), (a)(10)(C)(i)(III), or (f) of this section
or under section 1396d(p) of this title may be less restrictive, and
shall be no more restrictive, than the methodology --
(i) in the case of groups consisting of aged, blind, or disabled
individuals, under the supplemental security income program under
subchapter XVI of this chapter, or
(ii) in the case of other groups, under the State plan most closely
categorically related.
(B) For purposes of this subsection and subsection (a)(10) of this
section, methodology is considered to be ''no more restrictive'' if,
using the methodology, additional individuals may be eligible for
medical assistance and no individuals who are otherwise eligible are
made ineligible for such assistance.
(s) Adjustment in payment for hospital services furnished to
low-income children under age of 6 years
In order to meet the requirements of subsection (a)(55) /21/ of this
section, the State plan must provide that payments to hospitals under
the plan for inpatient hospital services furnished to infants who have
not attained the age of 1 year, and to children who have not attained
the age of 6 years and who receive such services in a disproportionate
share hospital described in section 1396r-4(b)(1) of this title, shall
--
(1) if made on a prospective basis (whether per diem, per case, or
otherwise) provide for an outlier adjustment in payment amounts for
medically necessary inpatient hospital services involving exceptionally
high costs or exceptionally long lengths of stay,
(2) not be limited by the imposition of day limits with respect to
the delivery of such services to such individuals, and
(3) not be limited by the imposition of dollar limits (other than
such limits resulting from prospective payments as adjusted pursuant to
paragraph (1)) with respect to the delivery of such services to any such
individual who has not attained their first birthday (or in the case of
such an individual who is an inpatient on his first birthday until such
individual is discharged).
(t) Limitation on payments to States for expenditures attributable to
taxes
Nothing in this subchapter (including sections 1396b(a) and 1396d(a)
of this title) shall be construed as authorizing the Secretary to deny
or limit payments to a State for expenditures, for medical assistance
for items or services, attributable to taxes of general applicability
imposed with respect to the provision of such items or services.
(u) Qualified COBRA continuation beneficiaries
(1) Individuals described in this paragraph are individuals --
(A) who are entitled to elect COBRA continuation coverage (as defined
in paragraph (3)),
(B) whose income (as determined under section 1382a of this title for
purposes of the supplemental security income program) does not exceed
100 percent of the official poverty line (as defined by the Office of
Management and Budget, and revised annually in accordance with section
9902(2) of this title) applicable to a family of the size involved,
(C) whose resources (as determined under section 1382b of this title
for purposes of the supplemental security income program) do not exceed
twice the maximum amount of resources that an individual may have and
obtain benefits under that program, and
(D) with respect to whose enrollment for COBRA continuation coverage
the State has determined that the savings in expenditures under this
subchapter resulting from such enrollment is likely to exceed the amount
of payments for COBRA premiums made.
(2) For purposes of subsection (a)(10)(F) of this section and this
subsection, the term ''COBRA premiums'' means the applicable premium
imposed with respect to COBRA continuation coverage.
(3) In this subsection, the term ''COBRA continuation coverage''
means coverage under a group health plan provided by an employer with 75
or more employees provided pursuant to title XXII of the Public Health
Service Act (42 U.S.C. 300bb-1 et seq.), section 4980B of the Internal
Revenue Code of 1986, or title VI /22/ of the Employee Retirement Income
Security Act of 1974.
(4) Notwithstanding subsection (a)(17) of this section, for
individuals described in paragraph (1) who are covered under the State
plan by virtue of subsection (a)(10)(A)(ii)(XI) of this section --
(A) the income standard to be applied is the income standard
described in paragraph (1)(B), and
(B) except as provided in section 1382a(b)(4)(B)(ii) of this title,
costs incurred for medical care or for any other type of remedial care
shall not be taken into account in determining income.
Any different treatment provided under this paragraph for such
individuals shall not, because of subsection (a)(10)(B) or (a)(17) of
this section, require or permit such treatment for other individuals.
(v) State agency disability and blindness determinations for medical
assistance eligibility
(1) /23/ A State plan may provide for the making of determinations of
disability or blindness for the purpose of determining eligibility for
medical assistance under the State plan by the single State agency or
its designee, and make medical assistance available to individuals whom
it finds to be blind or disabled and who are determined otherwise
eligible for such assistance during the period of time prior to which a
final determination of disability or blindness is made by the Social
Security Administration with respect to such an individual. In making
such determinations, the State must apply the definitions of disability
and blindness found in section 1382c(a) of this title.
(w) Maintenance of written policies and procedures respecting advance
directives
(1) For purposes of subsection (a)(57) of this section and sections
1396b(m)(1)(A) and 1396r(c)(2)(E) of this title, the requirement of this
subsection is that a provider or organization (as the case may be)
maintain written policies and procedures with respect to all adult
individuals receiving medical care by or through the provider or
organization --
(A) to provide written information to each such individual concerning
--
(i) an individual's rights under State law (whether statutory or as
recognized by the courts of the State) to make decisions concerning such
medical care, including the right to accept or refuse medical or
surgical treatment and the right to formulate advance directives (as
defined in paragraph (3)), and
(ii) the provider's or organization's written policies respecting the
implementation of such rights;
(B) to document in the individual's medical record whether or not the
individual has executed an advance directive;
(C) not to condition the provision of care or otherwise discriminate
against an individual based on whether or not the individual has
executed an advance directive;
(D) to ensure compliance with requirements of State law (whether
statutory or as recognized by the courts of the State) respecting
advance directives; and
(E) to provide (individually or with others) for education for staff
and the community on issues concerning advance directives.
Subparagraph (C) shall not be construed as requiring the provision of
care which conflicts with an advance directive.
(2) The written information described in paragraph (1)(A) shall be
provided to an adult individual --
(A) in the case of a hospital, at the time of the individual's
admission as an inpatient,
(B) in the case of a nursing facility, at the time of the
individual's admission as a resident,
(C) in the case of a provider of home health care or personal care
services, in advance of the individual coming under the care of the
provider,
(D) in the case of a hospice program, at the time of initial receipt
of hospice care by the individual from the program, and
(E) in the case of a health maintenance organization, at the time of
enrollment of the individual with the organization.
(3) Nothing in this section shall be construed to prohibit the
application of a State law which allows for an objection on the basis of
conscience for any health care provider or any agent of such provider
which as a matter of conscience cannot implement an advance directive.
(4) In this subsection, the term ''advance directive'' means a
written instruction, such as a living will or durable power of attorney
for health care, recognized under State law (whether statutory or as
recognized by the courts of the State) and relating to the provision of
such care when the individual is incapacitated.
(x) Physician identifier system; establishment
The Secretary shall establish a system, for implementation by not
later than July 1, 1991, which provides for a unique identifier for each
physician who furnishes services for which payment may be made under a
State plan approved under this subchapter.
(y) Intermediate sanctions for psychiatric hospitals
(1) In addition to any other authority under State law, where a State
determines that a psychiatric hospital which is certified for
participation under its plan no longer meets the requirements for a
psychiatric hospital (referred to in section 1396d(h) of this title) and
further finds that the hospital's deficiencies --
(A) immediately jeopardize the health and safety of its patients, the
State shall terminate the hospital's participation under the State plan;
or
(B) do not immediately jeopardize the health and safety of its
patients, the State may terminate the hospital's participation under the
State plan, or provide that no payment will be made under the State plan
with respect to any individual admitted to such hospital after the
effective date of the finding, or both.
(2) Except as provided in paragraph (3), if a psychiatric hospital
described in paragraph (1)(B) has not complied with the requirements for
a psychiatric hospital under this subchapter --
(A) within 3 months after the date the hospital is found to be out of
compliance with such requirements, the State shall provide that no
payment will be made under the State plan with respect to any individual
admitted to such hospital after the end of such 3-month period, or
(B) within 6 months after the date the hospital is found to be out of
compliance with such requirements, no Federal financial participation
shall be provided under section 1396b(a) of this title with respect to
further services provided in the hospital until the State finds that the
hospital is in compliance with the requirements of this subchapter.
(3) The Secretary may continue payments, over a period of not longer
than 6 months from the date the hospital is found to be out of
compliance with such requirements, if --
(A) the State finds that it is more appropriate to take alternative
action to assure compliance of the hospital with the requirements than
to terminate the certification of the hospital,
(B) 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
(C) the State agrees to repay to the Federal Government payments
received under this paragraph if the corrective action is not taken in
accordance with the approved plan and timetable.
(Aug. 14, 1935, ch. 531, title XIX, 1902, as added July 30, 1965,
Pub. L. 89-97, title I, 121(a), 79 Stat. 344, and amended Jan. 2, 1968,
Pub. L. 90-248, title II, 210(a)(6), 223(a), 224(a), (c)(1), 227(a),
228(a), 229(a), 231, 234(a), 235(a), 236(a), 237, 238, 241(f)(1)-(4),
title III, 302(b), 81 Stat. 896, 901-906, 908, 911, 917, 929; Aug. 9,
1969, Pub. L. 91-56, 2(c), (d), 83 Stat. 99; Dec. 28, 1971, Pub. L.
92-223, 4(b), 85 Stat. 809; Oct. 30, 1972, Pub. L. 92-603, title II,
208(a), 209(a), (b)(1), 221(c)(5), 231, 232(a), 236(b), 237(a)(2),
239(a), (b), 240, 246(a), 249(a), 255(a), 268(a), 274(a),
278(a)(18)-(20), (b)(14), 298, 299A, 299D(b), 86 Stat. 1381, 1389, 1410,
1415-1418, 1424, 1426, 1446, 1450, 1452-1454, 1460, 1462; Dec. 31,
1973, Pub. L. 93-233, 13(a)(2)-(10), 18(o)-(q), (x)(1)-(4), 87 Stat.
960-962, 971, 972; Aug. 7, 1974, Pub. L. 93-368, 9(a), 88 Stat. 422;
July 1, 1975, Pub. L. 94-48, 1, 2, 89 Stat. 247; Dec. 31, 1975, Pub.
L. 94-182, title I, 111(a), 89 Stat. 1054; Oct. 18, 1976, Pub. L.
94-552, 1, 90 Stat. 2540; Oct. 25, 1977, Pub. L. 95-142, 2(a)(3),
(b)(1), 3(c)(1), 7(b), (c), 9, 19(b)(2), 20(b), 91 Stat. 1176, 1178,
1193, 1195, 1204, 1207; Dec. 13, 1977, Pub. L. 95-210, 2(c), 91 Stat.
1488; Nov. 1, 1978, Pub. L. 95-559, 14(a)(1), 92 Stat. 2140; June 17,
1980, Pub. L. 96-272, title III, 308(c), 94 Stat. 531; Dec. 5, 1980,
Pub. L. 96-499, title IX, 902(b), 903(b), 905(a), 912(b), 913(c), (d),
914(b)(1), 916(b)(1), 918(b)(1), 962(a), 965(b), 94 Stat. 2613, 2615,
2618-2621, 2624, 2626, 2650, 2652; Dec. 28, 1980, Pub. L. 96-611,
5(b), 94 Stat. 3568; Aug. 13, 1981, Pub. L. 97-35, title XXI,
2105(c), 2113(m), 2171(a), (b), 2172(a), 2173(a), (b)(1), 2174(a),
2175(a), (d)(1), 2178(b), 2181(a)(2), 2182, 2193(c)(9), 95 Stat. 792,
795, 807-809, 811, 814-816, 828; Sept. 3, 1982, Pub. L. 97-248, title
I, 131(a), (c), formerly (b), 132(a), (c), 134(a), 136(d), 137(a)(3),
(b)(7)-(10), (e), 146(a), 96 Stat. 367, 369, 370, 373, 375-378, 381,
394; Jan. 12, 1983, Pub. L. 97-448, title III, 309(a)(8), 96 Stat.
2408; July 18, 1984, Pub. L. 98-369, div. B, title III, 2303(g)(1),
2314(b), 2335(e), 2361(a), 2362(a), 2363(a)(1), 2367(a), 2368(a), (b),
2373(b)(1)-(10), title VI, 2651(c), 98 Stat. 1066, 1079, 1091, 1104,
1105, 1108, 1109, 1111, 1149; Aug. 16, 1984, Pub. L. 98-378, 20(c), 98
Stat. 1322; Nov. 8, 1984, Pub. L. 98-617, 3(a)(7), (b)(10), 98 Stat.
3295, 3296; Apr. 7, 1986, Pub. L. 99-272, title IX, 9501(b), (c),
9503(a), 9505(b), (c)(1), (d), 9506(a), 9509(a), 9510(a), 9517(b),
9529(a)(1), (b)(1), title XII, 12305(b)(3), 100 Stat. 201, 202, 205,
208-212, 216, 220, 293; Oct. 21, 1986, Pub. L. 99-509, title IX,
9320(h)(3), 9401(a)-(e)(1), 9402(a), (b), 9403(a), (c), (e)-(g)(1),
(4)(A), 9404(a), 9405, 9406(b), 9407(a), 9408(a), (b), (c)(2), (3),
9431(a), (b)(1), 9433(a), 9435(b)(1), 100 Stat. 2016, 2050-2058, 2060,
2061, 2066, 2068, 2069; Oct. 22, 1986, Pub. L. 99-514, title XVIII,
1895(c)(1), (3)(B), (C), (7), 100 Stat. 2935, 2936; Oct. 27, 1986, Pub.
L. 99-570, title XI, 11005(b), 100 Stat. 3207-169; Nov. 10, 1986,
Pub. L. 99-643, 3(b), 7(b), 100 Stat. 3575, 3579; Aug. 18, 1987,
Pub. L. 100-93, 5(a), 7, 8(f), 101 Stat. 689, 691, 694; Dec. 22,
1987, Pub. L. 100-203, title IV, 4072(d), 4101(a)(1), (2),
(b)(1)-(2)(B), (c)(2), (e)(1)-(5), 4102(b)(1), 4104, 4113(a)(2), (b)(1),
(2), (c)(1), (2), (d)(2), 4116, 4118(c)(1), (h)(1), (2), (m)(1)(B),
(p)(1)-(4), (6)-(8), 4211(b)(1), (h)(1)-(5), 4212(d)(2), (3), (e)(1),
4213(b)(1), 4218(a), title IX, 9115(b), 9119(d)(1), 101 Stat.
1330-117, 1330-140 to 1330-143, 1330-146, 1330-147, 1330-151, 1330-152,
1330-154 to 1330-157, 1330-159, 1330-203, 1330-205, 1330-213, 1330-219,
1330-220, 1330-305, as amended July 1, 1988, Pub. L. 100-360, title IV,
411(k)(5)(A), (7)(B)-(D), (10)(G)(ii), (iv), (l)(3)(H), (J), (8)(C),
(n)(2), (4), formerly (3), 102 Stat. 791, 794, 796, 803, 805, 807, as
amended Oct. 13, 1988, Pub. L. 100-485, title VI, 608(d)(14)(I),
(15)(A), (27)(F)-(H), (28), 102 Stat. 2416, 2423; July 1, 1988, Pub. L.
100-360, title II, 204(d)(3), title III, 301(a)(1), (e)(2), 302(a),
(b)(1), (c)(1), (2), (d)-(e)(3), 303(d), (e), title IV, 411(k)(5)(B),
(17)(B), (l)(3)(E), (6)(C), (D), 102 Stat. 729, 748-753, 762, 763, 792,
800, 803, 804; Oct. 13, 1988, Pub. L. 100-485, title II, 202(c)(4),
title III, 303(a)(2), (b)(1), (d), title IV, 401(d)(1), title VI,
608(d)(15)(B), (16)(C), 102 Stat. 2378, 2391, 2392, 2396, 2416, 2418;
Nov. 10, 1988, Pub. L. 100-647, title VIII, 8434(b)(1), (2), 102 Stat.
3805; Dec. 13, 1989, Pub. L. 101-234, title II, 201(a), 103 Stat.
1981; Dec. 19, 1989, Pub. L. 101-239, title VI, 6115(c), 6401(a),
6402(a), (c)(2), 6403(b), (d)(1), 6404(c), 6405(b), 6406(a), 6408(c)(1),
(d)(1), (4)(C), 6411(a)(1), (d)(3)(B), (e)(2), 103 Stat. 2219, 2258,
2260, 2261, 2263-2265, 2268-2271; Nov. 5, 1990, Pub. L. 101-508, title
IV, 4401(a)(2), 4402(a)(1), (c), (d)(1), 4501(b), (e)(2), 4601(a)(1),
4602(a), 4603(a), 4604(a), (b), 4701(b)(1), 4704(a), (e)(1), 4708(a),
4711(c)(1), (d), 4713(a), 4715(a), 4723(b), 4724(a), 4732(b)(1),
4751(a), 4752(a)(1)(A), (c)(1), 4754(a), 4755(a)(2), (c)(1),
4801(e)(1)(A), (11)(A), 104 Stat. 1388-143, 1388-161, 1388-163 to
1388-173, 1388-186, 1388-187, 1388-190, 1388-192, 1388-194, 1388-195,
1388-204, 1388-206, 1388-208 to 1388-210, 1388-215, 1388-217; Dec. 12,
1991, Pub. L. 102-234, 2(b)(1), 3(a), 105 Stat. 1799.)
For contingent effective date of amendment by section 4072(d) of Pub.
L. 100-203, amending subsection (a)(9)(C) of this section, see section
4072(e) of Pub. L. 100-203, set out as an Effective Date of 1987
Amendment note under section 1395x of this title.
Pub. L. 101-508, title IV, 4801(e)(11), Nov. 5, 1990, 104 Stat.
1388-217, provided that, effective on the date on which the Secretary
promulgates standards regarding the qualifications of nursing facility
administrators under section 1396r(f)(4) of this title, subsection
(a)(29) of this section is repealed.
Parts A, D, and E of subchapter IV of this chapter, referred to in
subsecs. (a), (c)(1), (e)(1), (10), and (l)(3), are classified to
sections 601 et seq., 651 et seq., and 670 et seq., respectively, of
this title.
Parts A and B of subchapter XVIII of this chapter, referred to in
subsec. (a)(10), (13)(D), are classified to sections 1395c et seq. and
1395j et seq., respectively, of this title.
Section 303(a)(4)(A) of this title, referred to in subsec.
(a)(20)(C), was amended generally by Pub. L. 97-35, title XXIII,
2353(a)(1)(A), Aug. 13, 1981, 95 Stat. 871, and, as so amended, does
not contain cls. (i) and (ii).
Section 1383(a)(4)(A)(i) and (ii) of this title, referred to in
subsec. (a)(20)(C), is a reference to section 1383(a)(4)(A)(i) and (ii)
existing prior to the general revision of subchapter XVI of this chapter
by Pub. L. 92-603, title III, 301, Oct. 30, 1972, 86 Stat. 1465,
eff. Jan. 1, 1974. The prior section (which is set out as a note under
section 1383 of this title) continues in effect for Puerto Rico, Guam,
and the Virgin Islands.
Part B of subchapter XI of this chapter, referred to in subsecs.
(a)(30)(C) and (d), is classified to section 1320c et seq. of this
title.
Public Law 92-336, referred to in provisions following subsec.
(a)(52), is Pub. L. 92-336, July 1, 1972, 86 Stat. 406, which amended
sections 401, 403, 409, 411, 415, 427, 428, and 430 of this title and
sections 165, 1401, 1402, 3101, 3111, 3121, 3122, 3125, 6413, and 6654
of Title 26, Internal Revenue Code, and enacted provisions set out as
notes under sections 403, 409, 415, and 428 of this title and sections
165 and 1401 of Title 26.
The Public Health Service Act, referred to in subsecs. (e)(2)(A) and
(u)(3), is act July 1, 1944, ch. 373, 58 Stat. 682, as amended.
Titles XIII and XXII of the Act are classified generally to subchapters
XI ( 300e et seq.) and XX ( 300bb-1 et seq.), respectively, of chapter
6A of this title. For complete classification of this Act to the Code,
see Short Title note set out under section 201 of this title and Tables.
Subsection (a)(55) of this section, referred to in subsec. (s),
probably means the par. (55) of subsec. (a) providing for adjusted
payments which was added by section 4604(b)(3) of Pub. L. 101-508. See
1990 Amendment note below.
The Internal Revenue Code of 1986, referred to in subsec. (u)(3), is
classified generally to Title 26.
The Employee Retirement Income Security Act of 1974, referred to in
subsec. (u)(3), is Pub. L. 93-406, Sept. 2, 1974, 88 Stat. 829, as
amended. Title VI of the Act probably means part 6 of subtitle B of
title I of the Act which is classified generally to part 6 ( 1161 et
seq.) of subtitle B of subchapter I of chapter 18 of Title 29, Labor,
because the Act has no title VI. For complete classification of this
Act to the Code, see Short Title note set out under section 1001 of
Title 29 and Tables.
1991 -- Subsec. (h). Pub. L. 102-234, 3(a), struck out ''to limit
the amount of payment adjustments that may be made under a plan under
this subchapter with respect to hospitals that serve a disproportionate
number of low-income patients with special needs or'' after
''Secretary''.
Subsec. (t). Pub. L. 102-234, 2(b)(1), substituted ''Nothing'' for
''Except as provided in section 1396b(i) of this title, nothing'' and
''taxes of general applicability'' for ''taxes (whether or not of
general applicability)''.
1990 -- Subsec. (a)(10). Pub. L. 101-508, 4713(a)(1)(D), which
directed amendment of par. (10) by adding subdiv. (XI), relating to
medical assistance available to an individual described in subsection
(u)(1), in the matter following subparagraph (E), was executed in the
matter following subpar. (F) to reflect the probable intent of Congress
and the intervening amendment by Pub. L. 101-508, 4713(a)(1)(A)-(C),
which added subpar. (F). See below. Direction by section 4713(a)(1)(D)
to strike ''and'' before ''(X)'' could not be executed because ''and''
did not appear after amendment by Pub. L. 101-508, 4402(d)(1). See
below.
Pub. L. 101-508, 4402(d)(1), in closing provisions, struck out
''and'' at end of subdiv. (IX), inserted ''and'' at end of subdiv.
(X), and added subdiv. (XI) relating to medical assistance to cover
costs of premiums, etc.
Subsec. (a)(10)(A)(i)(VII). Pub. L. 101-508, 4601(a)(1)(A), added
subcl. (VII).
Subsec. (a)(10)(A)(ii)(IX). Pub. L. 101-508, 4601(a)(1)(B),
substituted '', clause (i)(VI), or clause (i)(VII)'' for ''or clause
(i)(VI)''.
Subsec. (a)(10)(C)(iv). Pub. L. 101-508, 4711(d)(2), 4755(c)(1)(A),
amended cl. (iv) identically, substituting ''through (21)'' for
''through (20)''.
Subsec. (a)(10)(E)(iii). Pub. L. 101-508, 4501(b), added cl. (iii).
Subsec. (a)(10)(F). Pub. L. 101-508, 4713(a)(1)(A)-(C), added
subpar. (F).
Subsec. (a)(13)(A). Pub. L. 101-508, 4801(e)(1)(A), inserted
''(including the costs of services required to attain or maintain the
highest practicable physical, mental, and psychosocial well-being of
each resident eligible for benefits under this subchapter)'' after
''take into account the costs''.
Subsec. (a)(13)(E). Pub. L. 101-508, 4704(e)(1), repealed Pub. L.
101-239, 6402(c)(2). See 1989 Amendment note below.
Pub. L. 101-508, 4704(a), substituted ''prescribes'' for ''may
prescribe'' and ''on the same methodology used under section 1395l(a)(3)
of this title'' for ''on such tests of reasonableness as the Secretary
may prescribe in regulations under this subparagraph''.
Subsec. (a)(13)(F). Pub. L. 101-508, 4711(c)(1)(A), added subpar.
(F).
Subsec. (a)(17). Pub. L. 101-508, 4723(b), inserted '', payments
made to the State under section 1396b(f)(2)(B) of this title,'' after
''insurance premiums''.
Subsec. (a)(25)(G). Pub. L. 101-508, 4402(a)(1), added subpar. (G).
Subsec. (a)(32)(C). Pub. L. 101-508, 4708(a), added subpar. (C).
Subsec. (a)(41). Pub. L. 101-508, 4754(a), substituted ''shall
promptly notify the Secretary and, in the case of a physician and
notwithstanding paragraph (7), the State medical licensing board'' for
''shall promptly notify the Secretary''.
Subsec. (a)(52). Pub. L. 101-508, 4401(a)(2)(A), struck out ''and''
after semicolon at end.
Subsec. (a)(53). Pub. L. 101-508, 4604(b)(1), which directed
amendment of par. (53) by striking ''and'' at end, could not be
executed because ''and'' did not appear at end after amendment by Pub.
L. 101-508, 4602(a)(1). See below.
Pub. L. 101-508, 4602(a)(1), struck out ''and'' after semicolon at
end.
Pub. L. 101-508, 4401(a)(2)(B), substituted ''; and'' for period at
end.
Subsec. (a)(54). Pub. L. 101-508, 4604(b)(2), which directed
amendment of par. (54) by substituting ''; and'' for period at end,
could not be executed because there was no period at end after amendment
by Pub. L. 101-508, 4602(a)(2). See below.
Pub. L. 101-508, 4602(a)(2), substituted ''; and'' for period at
end.
Pub. L. 101-508, 4401(a)(2)(C), added par. (54).
Subsec. (a)(55). Pub. L. 101-508, 4604(b)(3), which directed
amendment of subsec. (a) by adding (after par. (54) and before the end
matter), par. (55) relating to providing for adjusted payments, was
executed by adding that par. (55) after par. (55) relating to
providing for receipt and initial processing of applications and before
the end matter to reflect the probable intent of Congress.
Pub. L. 101-508, 4602(a)(3), added par. (55) relating to providing
for receipt and initial processing of applications.
Subsec. (a)(57). Pub. L. 101-508, 4751(a)(1), which directed
amendment of subsec. (a) by striking ''and'' at end of par. (55),
substituting ''; and'' for period at end of par. (56), and adding
pars. (57) and (58) after par. (56), was executed by adding pars.
(57) and (58) after par. (55) relating to providing for adjusted
payments to reflect the probable intent of Congress because there was no
par. (56) and neither par. (55) ended in ''and''.
Subsec. (a)(58). Pub. L. 101-508, 4752(c)(2)(A), which directed
amendment of subsec. (a) by striking ''and'' at end of par. (56),
substituting ''; and'' for period at end of par. (57), and adding par.
(58) relating to maintaining a list after par. (57) was executed by
adding par. (58) after par. (58) relating to providing that a State
develop a written description of advance directive laws to reflect the
probable intent of Congress, because there was no par. (56) and par.
(57) did not end in a period.
Pub. L. 101-508, 4751(a)(1)(C), added par. (58) relating to
providing that a State develop a written description of advance
directive laws. See note for par. (57) above.
Subsec. (e)(2)(A). Pub. L. 101-508, 4732(b)(1), inserted ''or with
an eligible organization with a contract under section 1395mm of this
title'' after ''section 1396b(m)(2)(A) of this title''.
Subsec. (e)(4). Pub. L. 101-508, 4603(a)(1), inserted ''(or would
remain if pregnant)'' after ''remains''.
Subsec. (e)(6). Pub. L. 101-508, 4603(a)(2), substituted ''In'' for
''At the option of a State, in'', substituted ''the woman shall be
deemed to continue to be'' for ''the State plan may nonetheless treat
the woman as being'', and inserted at end ''The preceding sentence shall
not apply in the case of a woman who has been provided ambulatory
prenatal care pursuant to section 1396r-1 of this title during a
presumptive eligibility period and is then, in accordance with such
section, determined to be ineligible for medical assistance under the
State plan.''
Subsec. (e)(11). Pub. L. 101-508, 4402(c), added par. (11).
Subsec. (h). Pub. L. 101-508, 4711(c)(1)(B), inserted before period
at end ''or to limit the amount of payment that may be made under a plan
under this subchapter for home and community care''.
Subsec. (j). Pub. L. 101-508, 4711(d)(1), 4755(c)(1)(B), amended
subsec. (j) identically substituting ''through (22)'' for ''through
(21)''.
Subsec. (l)(1)(C). Pub. L. 101-508, 4601(a)(1)(C)(i), inserted
''children'' after ''(C)''.
Subsec. (l)(1)(D). Pub. L. 101-508, 4601(a)(1)(C)(ii), added subpar.
(D) and struck out former subpar. (D) which read as follows: ''at the
option of the State, children born after September 30, 1983, who have
attained 6 years of age but have not attained 7 or 8 years of age (as
selected by the State),''.
Subsec. (l)(2)(C). Pub. L. 101-508, 4601(a)(1)(C)(iii), added
subpar. (C) and struck out former subpar. (C) which read as follows:
''If a State elects, under subsection (a)(10)(A)(ii)(IX) of this
section, to cover individuals not described in subparagraph (A) or (B)
of paragraph (1), for purposes of that paragraph and with respect to
individuals not described in such subparagraphs the State shall
establish an income level which is a percentage (not more than 100
percent) of the income official poverty line described in subparagraph
(A).''
Subsec. (l)(3). Pub. L. 101-508, 4601(a)(1)(C)(iv), inserted '',
(a)(10)(A)(i)(VII),'' after ''(a)(10)(A)(i)(VI)''.
Subsec. (l)(4)(A). Pub. L. 101-508, 4601(a)(1)(C)(v), inserted ''or
subsection (a)(10)(A)(i)(VII) of this section'' after
''(a)(10)(A)(i)(VI) of this section''.
Subsec. (l)(4)(B). Pub. L. 101-508, 4601(a)(1)(C)(vi), substituted
''(a)(10)(A)(i)(VI), or (a)(10)(A)(i)(VII)'' for ''or
(a)(10)(A)(i)(VI)''.
Subsec. (m)(1)(B). Pub. L. 101-508, 4501(e)(2)(A), inserted '',
except as provided in paragraph (2)(C)'' after ''program''.
Subsec. (m)(2)(C). Pub. L. 101-508, 4501(e)(2)(B), added subpar.
(C).
Subsec. (r)(1). Pub. L. 101-508, 4715(a), inserted ''there shall be
disregarded reparation payments made by the Federal Republic of Germany
and'' after ''under such a waiver''.
Subsec. (r)(2)(A). Pub. L. 101-508, 4601(a)(1)(D), inserted
''(a)(10)(A)(i)(VII),'' after ''(a)(10)(A)(i)(VI),''.
Subsec. (s). Pub. L. 101-508, 4604(a), added subsec. (s).
Subsec. (t). Pub. L. 101-508, 4701(b)(1), added subsec. (t).
Subsec. (u). Pub. L. 101-508, 4713(a)(2), added subsec. (u).
Subsec. (v). Pub. L. 101-508, 4724(a), added subsec. (v).
Subsec. (w). Pub. L. 101-508, 4751(a)(2), added subsec. (w).
Subsec. (x). Pub. L. 101-508, 4752(a)(1)(A), added subsec. (x).
Subsec. (y). Pub. L. 101-508, 4755(a)(2), added subsec. (y).
1989 -- Subsec. (a)(9)(C). Pub. L. 101-239, 6115(c), substituted
''paragraphs (15) and (16)'' for ''paragraphs (14) and (15)''.
Pub. L. 101-234 repealed Pub. L. 100-360, 204(d)(3), and provided
that the provisions of law amended or repealed by such section are
restored or revived as if such section had not been enacted, see 1988
Amendment note below.
Subsec.(a)(10)(A). Pub. L. 101-239, 6405(b), substituted ''(1)
through (5), (17) and (21)'' for ''(1) through (5) and (17)'' in
introductory provisions.
Subsec. (a)(10)(A)(i)(VI). Pub. L. 101-239, 6401(a)(1), added subcl.
(VI).
Subsec. (a)(10)(A)(ii)(IX). Pub. L. 101-239, 6401(a)(2), inserted
''or clause (i)(VI)'' after ''clause (i)(IV)''.
Subsec. (a)(10)(E). Pub. L. 101-239, 6408(d)(1), designated existing
provisions as cl. (i) and added cl. (ii).
Subsec. (a)(11)(C). Pub. L. 101-239, 6406(a)(1), added subpar. (C).
Subsec. (a)(13)(D). Pub. L. 101-239, 6408(c)(1), substituted ''in
amounts no lower than the amounts, using the same methodology, used''
for ''in the same amounts, and using the same methodology, as used'',
''in the case of'' for ''a separate rate may be paid for'', and ''there
shall be paid an additional amount, to take into account the room and
board furnished by the facility, equal to at least 95 percent of the
rate that would have been paid by the State under the plan for facility
services in that facility for that individual'' for ''to take into
account the room and board furnished by such facility''.
Subsec. (a)(13)(E). Pub. L. 101-239, 6404(c), substituted ''clause
(B) or (C) of section 1396d(a)(2) of this title'' for ''section
1396d(a)(2)(B) of this title provided by a rural health clinic''.
Pub. L. 101-239, 6402(c)(2), which directed insertion of '', and for
payment for services described in section 1396d(a)(2)(C) of this title
under the plan,'' after ''provided by a rural health clinic under the
plan'', was repealed by Pub. L. 101-508, 4704(e)(1).
Subsec. (a)(30)(A). Pub. L. 101-239, 6402(a), inserted before
semicolon at end ''and are sufficient to enlist enough providers so that
care and services are available under the plan at least to the extent
that such care and services are available to the general population in
the geographic area''.
Subsec. (a)(43)(A). Pub. L. 101-239, 6403(d)(1), substituted
''section 1396d(r)'' for ''section 1396d(a)(4)(B)''.
Subsec. (a)(43)(D). Pub. L. 101-239, 6403(b), added subpar. (D).
Subsec. (a)(53). Pub. L. 101-239, 6406(a)(2)-(4), added par. (53).
Subsec. (e)(7). Pub. L. 101-239, 6401(a)(8), substituted '', (C), or
(D)'' for ''or (C)'' in introductory provisions.
Subsec. (f). Pub. L. 101-239, 6411(e)(2), inserted ''and section
1396r-5 of this title'' after ''section 1382h(b)(3) of this title''.
Pub. L. 101-239, 6411(a)(1), inserted ''and except with respect to
qualified medicare beneficiaries, qualified severely impaired
individuals, and individuals described in subsection (m)(1) of this
subsection'' before '', no State''.
Pub. L. 101-239, 6408(d)(4)(C), inserted '', except with respect to
qualified disabled and working individuals (described in section
1396d(s) of this title),'' after ''section 1382h(b)(3) of this title''.
Subsec. (l)(1)(C), (D). Pub. L. 101-239, 6401(a)(3), added subpars.
(C) and (D) and struck out former subpar. (C) which read as follows:
''at the option of the State, children born after September 30, 1983,
who have attained one year of age but have not attained 2, 3, 4, 5, 6,
7, or 8 years of age (as selected by the State),''.
Subsec. (l)(2)(A)(ii)(II). Pub. L. 101-239, 6401(a)(4)(A), amended
subcl. (II) generally. Prior to amendment, subcl. (II) read as
follows: ''July 1, 1990, is 100 percent.''
Subsec. (l)(2)(A)(iv). Pub. L. 101-239, 6401(a)(4)(B), added cl.
(iv).
Subsec. (l)(2)(B), (C). Pub. L. 101-239, 6401(a)(5), (6), added
subpar. (B), struck out '', or, if less, the percentage established
under subparagraph (A)'' after ''not more than 100 percent'' in former
subpar. (B), and redesignated former subpar. (B) as (C).
Subsec. (l)(3). Pub. L. 101-239, 6401(a)(6)(A), inserted '',
(a)(10)(A)(i)(VI),'' after ''(a)(10)(A)(i)(IV)'' in introductory
provisions.
Subsec. (l)(3)(C). Pub. L. 101-239, 6401(a)(6)(B), substituted
''(C), or (D)'' for ''or (C)''.
Subsec. (l)(4)(A). Pub. L. 101-239, 6401(a)(7)(A), inserted ''and
for children described in subsection (a)(10)(A)(i)(VI) of this section''
after ''(a)(10)(A)(i)(IV) of this section''.
Subsec. (l)(4)(B). Pub. L. 101-239, 6401(a)(7)(B), inserted ''or
(a)(10)(A)(i)(VI)'' after ''(a)(10)(A)(i)(IV)''.
Subsec. (p)(2)(C). Pub. L. 101-239, 6411(d)(3)(B), added subpar.
(C).
Subsec. (r)(2)(A). Pub. L. 101-239, 6401(a)(9), inserted
''(a)(10)(A)(i)(VI),'' after ''(a)(10)(A)(i)(IV),'' in introductory
provisions.
1988 -- Subsec. (a)(9)(C). Pub. L. 100-360, 204(d)(3), substituted
''paragraphs (14) and (15)'' for ''paragraphs (13) and (14)''.
Subsec. (a)(10). Pub. L. 100-647, 8434(b)(1), inserted ''who is only
entitled to medical assistance because the individual is such a
beneficiary'' after ''section 1396d(p)(1) of this title'' in subdiv.
(VIII) of closing provisions.
Pub. L. 100-360, 302(a)(1)(C), inserted ''(A)(i)(IV) or'' before
''(A)(ii)(X)'' in subdiv. (VII) of closing provisions.
Pub. L. 100-360, 302(b)(1), added subdiv. (X) in closing
provisions.
Subsec. (a)(10)(A)(i)(I). Pub. L. 100-485, 202(c)(4), substituted
''section 682(e)(6) of this title'' for ''section 614(g) of this
title''.
Subsec. (a)(10)(A)(i)(IV). Pub. L. 100-360, 302(a)(1)(A), added
subcl. (IV).
Subsec. (a)(10)(A)(i)(V). Pub. L. 100-485, 401(d)(1), added subcl.
(V).
Subsec. (a)(10)(A)(ii)(VI). Pub. L. 100-360, 411(k)(17)(B),
substituted ''(c), (d), or (e)'' for ''(c) or (d)'' in two places.
Subsec. (a)(10)(A)(ii)(IX). Pub. L. 100-360, 302(a)(1)(B), amended
subcl. (IX) generally. Prior to amendment, subcl. (IX) read as
follows: ''subject to subsection (l)(4) of this section, who are
described in subsection (l)(1) of this section;''.
Subsec. (a)(10)(A)(ii)(X). Pub. L. 100-360, 301(e)(2)(A), struck out
''subject to subsection (m)(3) of this section,'' before ''who are
described''.
Subsec. (a)(10)(A)(ii)(XI). Pub. L. 100-360, 411(k)(5)(B),
substituted ''may be more restrictive'' for ''are more restrictive'' and
a semicolon for the period at end.
Pub. L. 100-360, 411(k)(5)(A), amended Pub. L. 100-203, 4104, see
1987 Amendment note below.
Subsec. (a)(10)(C)(i)(III). Pub. L. 100-360, 303(e)(1), substituted
''no more restrictive than the methodology'' for ''the same
methodology'' in two places.
Subsec. (a)(10)(E). Pub. L. 100-360, 301(e)(2)(B), struck out
''subject to subsection (m)(3) of this section,'' before ''for making
medical''.
Pub. L. 100-360, 301(a)(1), struck out ''at the option of a State,
but'' after ''(E)''.
Subsec. (a)(13)(A). Pub. L. 100-360, 411(l)(3)(J), as added by Pub.
L. 100-485, 608(d)(27)(H), amended Pub. L. 100-203, 4211(h)(2)(B),
see 1987 Amendment note below.
Subsec. (a)(13)(C). Pub. L. 100-360, 411(l)(3)(H)(i), as amended by
Pub. L. 100-485, 608(d)(27)(F), amended Pub. L. 100-203,
4211(h)(2)(C), see 1987 Amendment note below.
Subsec. (a)(13)(D). Pub. L. 100-360, 411(l)(3)(H)(ii), (iii), as
amended by Pub. L. 100-485, 608(d)(27)(G), amended Pub. L. 100-203,
4211(h)(2)(D), see 1987 Amendment note below.
Subsec. (a)(15). Pub. L. 100-360, 301(e)(2)(C), as added by Pub. L.
100-485, 608(d)(14)(I)(iii), struck out par. (15) which read as
follows: ''in the case of eligible individuals 65 years of age or older
who are not qualified medicare beneficiaries (as defined in section
1396d(p)(1) of this title) but are covered by either or both of the
insurance programs established by subchapter XVIII of this chapter,
provide where, under the plan, all of any deductible, cost sharing, or
similar charge imposed with respect to such individual under the
insurance program established by such subchapter is not met, the portion
thereof which is met shall be determined on a basis reasonably related
(as determined in accordance with standards approved by the Secretary
and included in the plan) to such individual's income or his income and
resources;''.
Subsec. (a)(17). Pub. L. 100-360, 411(k)(10)(G)(ii), amended
directory language of Pub. L. 100-203, 4118(h)(1), see 1987 Amendment
note below.
Pub. L. 100-360, 301(e)(2)(D), formerly 301(e)(2)(C), as
redesignated and amended by Pub. L. 100-485, 608(d)(14)(I)(i),
substituted ''(m)(3), and (m)(4)'' for ''(m)(4), and (m)(5)''.
Subsec. (a)(28)(D)(i). Pub. L. 100-360, 411(l)(3)(E), substituted
''section 1396r(e) of this title'' for ''section 1396r(f) of this title
(relating to implementation of nursing facility requirements, including
paragraph (6)(B), relating to specification of resident assessment
instrument)''.
Subsec. (a)(33)(B). Pub. L. 100-360, 411(l)(6)(C), substituted
''section 1396r(g) of this title'' for ''section 1396r(d) of this
title''.
Subsec. (a)(44)(A). Pub. L. 100-360, 411(l)(6)(D), amended Pub. L.
100-203, 4212(e)(1)(B), see 1987 Amendment note below.
Subsec. (a)(50). Pub. L. 100-360, 411(n)(4), formerly 411(n)(3), as
redesignated by Pub. L. 100-485, 608(d)(28), added Pub. L. 100-203,
9119(d)(1)(A), see 1987 Amendment note below.
Subsec. (a)(51). Pub. L. 100-360, 303(e)(2)-(4), added par. (51).
Subsec. (a)(52). Pub. L. 100-485, 303(a)(2), added par. (52).
Subsec. (c). Pub. L. 100-360, 302(c)(1), amended subsec. (c)
generally. Prior to amendment, subsec. (c) read as follows:
''Notwithstanding subsection (b) of this section, the Secretary shall
not approve any State plan for medical assistance if he determines that
the approval and operation of the plan will result in a reduction in aid
or assistance in the form of money payments (other than so much, if any,
of the aid or assistance in such form as was, immediately prior to the
effective date of the State plan under this subchapter, attributable to
medical needs) provided for eligible individuals under a plan of such
State approved under subchapter I, X, XIV, or XVI of this chapter, or
part A of subchapter IV of this chapter.''
Subsec. (d). Pub. L. 100-360, 411(k)(7)(C), amended Pub. L.
100-203, 4113(b)(2)(ii), see 1987 Amendment note below.
Subsec. (e)(1). Pub. L. 100-485, 303(b)(1), designated existing
provisions as subpar. (A), inserted ''subject to subparagraph (B)''
after ''January 1, 1974,'', and added subpar. (B).
Subsec. (e)(2)(A). Pub. L. 100-360, 411(k)(7)(D), repealed Pub. L.
100-203, 4113(d)(2), see 1987 Amendment note below.
Pub. L. 100-360, 411(k)(7)(B), amended Pub. L. 100-203,
4113(a)(2), see 1987 Amendment note below.
Subsec. (e)(6). Pub. L. 100-360, 302(e)(1), amended par. (6)
generally. Prior to amendment, par. (6) read as follows: ''At the
option of a State, if a State plan provides medical assistance for
individuals under subsection (a)(10)(A)(ii)(IX) of this section, the
plan may provide that any woman described in such subsection and
subsection (l)(1)(A) of this section shall continue to be treated as an
individual described in subsection (a)(10)(A)(ii)(IX) of this section
without regard to any change in income of the family of which she is a
member until the end of the 60-day period beginning on the last day of
her pregnancy.''
Subsec. (e)(7). Pub. L. 100-360, 302(e)(2), in introductory
provisions, substituted ''In the case'' for ''If a State plan provides
medical assistance for individuals under subsection (a)(10)(A)(ii)(IX)
of this section, in the case'' and inserted ''or paragraph (2) of
section 1396d(n) of this title'', and, in concluding provisions,
substituted ''such respective provision'' for ''subsection
(a)(10)(A)(ii)(IX) of this section and subsection (l)(1) of this
section''.
Subsec. (e)(10). Pub. L. 100-485, 303(d), added par. (10).
Subsec. (f). Pub. L. 100-360, 411(k)(10)(G)(iv), added Pub. L.
100-203, 4118(h)(2), see 1987 Amendment note below.
Subsec. (i). Pub. L. 100-360, 411(l)(8)(C), amended Pub. L.
100-203, 4213(b)(1), see 1987 Amendment note below.
Subsec. (l)(1). Pub. L. 100-360, 302(e)(3)(A), inserted ''any of
subclauses (I) through (III) of'' after ''described in'' in concluding
provisions.
Subsec. (l)(1)(C). Pub. L. 100-360, 302(a)(2)(A), inserted ''at the
option of the State,'' after ''(C)'' and struck out ''and'' after
''1983,''.
Subsec. (l)(2)(A). Pub. L. 100-360, 302(a)(2)(B), as amended by Pub.
L. 100-485, 608(d)(15)(A), designated existing provisions as cl. (i),
substituted ''(not less than the percentage provided under clause (ii)
and not more than 185 percent)'' for ''(not more than 185 percent)'',
and added cls. (ii) and (iii).
Subsec. (l)(2)(A)(ii). Pub. L. 100-485, 608(d)(15)(B)(i), in
introductory provisions, substituted ''The'' for ''Subject to clause
(iii), the'', and in subcl. (I), inserted ''or, if greater, the
percentage provided under clause (iii),''.
Subsec. (l)(2)(A)(iii). Pub. L. 100-485, 608(d)(15)(B)(ii),
substituted ''clause (ii)(I)'' for ''clause (ii)'' in introductory
provisions and concluding provisions.
Subsec. (l)(3). Pub. L. 100-360, 302(e)(3)(B), inserted
''(a)(10)(A)(i)((IV) or'' after ''of subsection'' in introductory
provisions.
Subsec. (l)(4). Pub. L. 100-360, 302(c)(2), (d), added par. (4) and
struck out former par. (4) which read as follows:
''(A) A State plan may not elect the option of furnishing medical
assistance to individuals described in subsection (a)(10)(A)(ii)(IX) of
this section unless the State has in effect, under its plan established
under part A of subchapter IV of this chapter, payment levels that are
not less than the payment levels in effect under its plan on July 1,
1987.
''(B)(i) A State may not elect, under subsection (a)(10)(A)(ii)(IX)
of this section, to cover only individuals described in paragraph (1)(A)
or to cover only individuals described in paragraph (1)(B).
''(ii) A State may not elect, under subsection (a)(10)(A)(ii)(IX) of
this section, to cover individuals described in subparagraph (C) of
paragraph (1) unless the State has elected, under such subsection, to
cover individuals described in the preceding subparagraphs of such
paragraph.
''(C) A State plan may not provide, in its election of the option of
furnishing medical assistance to individuals described in paragraph (1),
that such individuals must apply for benefits under part A of subchapter
IV of this chapter as a condition of applying for, or receiving, medical
assistance under this subchapter.''
Subsec. (m)(3). Pub. L. 100-360, 301(e)(2)(E), formerly
301(e)(2)(D), as redesignated and amended by Pub. L. 100-485,
608(d)(14)(I)(ii), redesignated par. (4) as (3) and struck out former
par. (3) which read as follows: ''A State plan may not provide
coverage for individuals under subsection (a)(10)(A)(ii)(X) of this
section or coverage under subsection (a)(10)(E) of this section, unless
the plan provides coverage of some or all of the individuals described
in subsection (l)(1) of this section.''
Subsec. (m)(4). Pub. L. 100-360, 301(e)(2)(E), formerly
301(e)(2)(D), as redesignated and amended by Pub. L. 100-485,
608(d)(14)(I)(ii), redesignated par. (5) as (4). Former par. (4)
redesignated (3).
Subsec. (m)(4)(A). Pub. L. 100-647, 8434(b)(2), substituted
''section 1396d(p)(1)(B)'' for ''section 1396d(p)(1)(C)''.
Subsec. (m)(5). Pub. L. 100-360, 301(e)(2)(E), formerly
301(e)(2)(D), as redesignated and amended by Pub. L. 100-485,
608(d)(14)(I)(ii), redesignated par. (5) as (4).
Subsec. (o). Pub. L. 100-360, 411(n)(2), made technical correction
to directory language of Pub. L. 100-203, 9115(b), see 1987 Amendment
note below.
Subsec. (q). Pub. L. 100-360, 411(n)(4), formerly 411(n)(3), as
redesignated by Pub. L. 100-485, 608(d)(28), added Pub. L. 100-203,
9119(d)(1)(B), see 1987 Amendment note below.
Subsec. (r). Pub. L. 100-360, 303(e)(5), designated existing
provisions as par. (1), redesignated subpars. (A) and (B) as cls. (i)
and (ii), respectively, and added par. (2).
Pub. L. 100-360, 303(d), added subsec. (r).
Subsec. (r)(2)(A). Pub. L. 100-485, 608(d)(16)(C), substituted '',
or (f) of this section or under section 1396d(p) of this title'' for
''of this section, or under subsection (f) of this section'' in
introductory provisions.
1987 -- Subsec. (a)(9)(C). Pub. L. 100-203, 4072(d), substituted
''paragraphs (13) and (14)'' for ''paragraphs (12) and (13)''.
Subsec. (a)(10). Pub. L. 100-203, 4101(e)(1), substituted
''postpartum, and family planning services'' for ''and postpartum
services'' in subdiv. (VII) of closing provisions.
Subsec. (a)(10)(A)(ii)(VI). Pub. L. 100-203, 4211(h)(1)(A),
substituted ''nursing facility or intermediate care facility for the
mentally retarded'' for ''skilled nursing facility or intermediate care
facility''.
Pub. L. 100-203, 4102(b)(1), substituted ''subsection (c) or (d) of
section 1396n of this title'' for ''section 1396n(c) of this title'' in
two places.
Subsec. (a)(10)(A)(ii)(IX), (X). Pub. L. 100-203, 4118(p)(1), (2),
realigned margin of subcls. (IX) and (X).
Subsec. (a)(10)(A)(ii)(XI). Pub. L. 100-203, 4104, as amended by
Pub. L. 100-360, 411(k)(5)(A), added subcl. (XI).
Subsec. (a)(10)(C)(iv). Pub. L. 100-203, 4211(h)(1)(B), substituted
''in an intermediate care facility'' for ''intermediate care facility
services''.
Subsec. (a)(10)(D). Pub. L. 100-203, 4211(h)(1)(C), struck out
''skilled'' before ''nursing''.
Subsec. (a)(13)(A). Pub. L. 100-203, 4211(h)(2)(B), as amended by
Pub. L. 100-360, 411(l)(3)(J), as added by Pub. L. 100-485,
608(d)(27)(H), substituted '', nursing facility, and intermediate care
facility for the mentally retarded and'' for '', skilled nursing
facility, and intermediate care facility and''.
Pub. L. 100-203, 4211(h)(2)(A), substituted ''services, nursing
facility services, and services in an intermediate care facility for the
mentally retarded'' for '', skilled nursing facility, and intermediate
care facility services''.
Pub. L. 100-203, 4211(b)(1)(A), inserted ''which, in the case of
nursing facilities, take into account the costs of complying with
subsections (b) (other than paragraph (3)(F) thereof), (c), and (d) of
section 1396r of this title and provide (in the case of a nursing
facility with a waiver under section 1396r(b)(4)(C)(ii) of this title)
for an appropriate reduction to take into account the lower costs (if
any) of the facility for nursing care,'' after second reference to
''State''.
Subsec. (a)(13)(C). Pub. L. 100-203, 4211(h)(2)(C), as amended by
Pub. L. 100-360, 411(l)(3)(H)(i), as amended by Pub. L. 100-485,
608(d)(27)(F), substituted ''nursing facilities and for intermediate
care facilities for the mentally retarded'' for ''skilled nursing
facilities and intermediate care facilities'' in introductory
provisions.
Subsec. (a)(13)(D). Pub. L. 100-203, 4211(h)(2)(D), as amended by
Pub. L. 100-360, 411(l)(3)(H)(ii), (iii), as amended by Pub. L.
100-485, 608(d)(27)(G), substituted ''nursing facility or intermediate
care facility for the mentally retarded'' for ''skilled nursing facility
or intermediate care facility'' and ''nursing facility services or
services in an intermediate care facility for the mentally retarded''
for ''skilled nursing facility services or intermediate care facility
services''.
Subsec. (a)(17). Pub. L. 100-203, 4118(p)(3), substituted
''subsections (l)(3), (m)(4), and (m)(5) of this section'' for
''subsection (l)(3) of this section''.
Pub. L. 100-203, 4118(h)(1), as amended by Pub. L. 100-360,
411(k)(10)(G)(ii), substituted ''(whether in the form of insurance
premiums or otherwise and regardless of whether such costs are
reimbursed under another public program of the State or political
subdivision thereof)'' for ''(whether in the form of insurance premiums
or otherwise)''.
Subsec. (a)(23). Pub. L. 100-203, 4113(c)(1), designated provision
relating to the obtaining of medical assistance by an eligible
individual as cl. (A) and added cl. (B).
Pub. L. 100-93, 8(f)(1), inserted ''subsection (g) of this section
and in'' after ''as provided in''.
Subsec. (a)(28). Pub. L. 100-203, 4211(b)(1)(B), amended par. (28)
generally. Prior to amendment, par. (28) read as follows: ''provide
that any skilled nursing facility receiving payments under such plan
must satisfy all of the requirements contained in section 1395x(j) of
this title, except that the exclusion contained therein with respect to
institutions which are primarily for the care and treatment of mental
diseases shall not apply for purposes of this subchapter;''.
Subsec. (a)(30)(B)(i), (ii). Pub. L. 100-203, 4211(h)(3),
substituted ''intermediate care facility for the mentally retarded'' for
''skilled nursing facility, intermediate care facility''.
Subsec. (a)(30)(C). Pub. L. 100-203, 4118(p)(4), substituted ''use''
for ''provide''.
Pub. L. 100-203, 4113(b)(1), inserted '', an entity which meets the
requirements of section 1320c-1 of this title, as determined by the
Secretary,'' before ''or a private accreditation body''.
Subsec. (a)(31). Pub. L. 100-203, 4212(d)(2), in introductory
provision substituted ''services in an intermediate care facility for
the mentally retarded (where'' for ''skilled nursing facility services
(and with respect to intermediate care facility services where'' and in
subpar. (B) substituted ''intermediate care facility for the mentally
retarded'' for ''skilled nursing or intermediate care facility''.
Subsec. (a)(33)(B). Pub. L. 100-203, 4212(d)(3), inserted '', except
as provided in section 1396r(d) of this title,'' after ''(B) that''.
Subsec. (a)(38). Pub. L. 100-93, 8(f)(2), substituted ''the
information described in section 1320a-7(b)(9) of this title'' for
''respectively, (A) full and complete information as to the ownership of
a subcontractor (as defined by the Secretary in regulations) with whom
such entity has had, during the previous twelve months, business
transactions in an aggregate amount in excess of $25,000, and (B) full
and complete information as to any significant business transactions (as
defined by the Secretary in regulations), occurring during the five-year
period ending on the date of such request, between such entity and any
wholly owned supplier or between such entity and any subcontractor''.
Subsec. (a)(39). Pub. L. 100-93, 8(f)(3), substituted ''exclude''
for ''bar'', ''individual or entity'' for ''person'' in two places, and
inserted reference to section 1320a-7a of this title.
Subsec. (a)(42). Pub. L. 100-203, 4118(m)(1)(B), struck out ''(A)''
after ''provide'', the comma after ''under the plan'', and cls. (B) and
(C) which read as follows: ''(B) that such audits, for such entities
also providing services under subchapter XVIII of this chapter, will be
coordinated and conducted jointly (to such extent and in such manner as
the Secretary shall prescribe) with audits conducted for purposes of
such subchapter, and (C) for payment of such proportion of costs of each
such common audit as is determined under methods specified by the
Secretary under section 1320a-8(a) of this title''.
Subsec. (a)(44). Pub. L. 100-203, 4212(e)(1)(A), substituted
''services in an intermediate care facility for the mentally retarded''
for ''skilled nursing facility services, intermediate care facility
services''.
Subsec. (a)(44)(A). Pub. L. 100-203, 4218(a)(1), substituted
''physician (or, in the case of skilled nursing facility services or
intermediate care facility services, a physician, or a nurse
practitioner or clinical nurse specialist who is not an employee of the
facility but is working in collaboration with a physician) certifies''
for ''physician certifies'' and ''a physician, a physician assistant
under the supervision of a physician, or, in the case of skilled nursing
facility services or intermediate care facility services, a physician,
or a nurse practitioner or clinical nurse specialist who is not an
employee of the facility but is working in collaboration with a
physician,'' for ''the physician, or a physician assistant or nurse
practitioner under the supervision of a physician,''.
Pub. L. 100-203, 4212(e)(1)(B), as amended by Pub. L. 100-360,
411(l)(6)(D), substituted ''that are services provided in an
intermediate care facility for the mentally retarded'' for ''that are
intermediate care facility services provided in an institution for the
mentally retarded''.
Subsec. (a)(44)(B). Pub. L. 100-203, 4218(a)(2), substituted ''a
physician, or, in the case of skilled nursing facility services or
intermediate care facility services, a physician, or a nurse
practitioner or clinical nurse specialist who is not an employee of the
facility but is working in collaboration with a physician;'' for ''a
physician;''.
Subsec. (a)(46). Pub. L. 100-93, 5(a)(1), struck out ''and'' after
''title;''.
Subsec. (a)(47). Pub. L. 100-93, 5(a)(2), (3), substituted semicolon
for period at end of par. (47), relating to ambulatory prenatal care
and redesignated par. (47), relating to cards evidencing eligibility,
as (48).
Subsec. (a)(48). Pub. L. 100-93, 5(a)(3), redesignated par. (47),
relating to cards evidencing eligibility for medical assistance, as
(48), and substituted ''address; and'' for ''address.''
Subsec. (a)(49). Pub. L. 100-93, 5(a)(4), added par. (49).
Subsec. (a)(50). Pub. L. 100-203, 9119(d)(1)(A), as added by Pub.
L. 100-360, 411(n)(4), formerly 411(n)(3), as redesignated by Pub. L.
100-485, 608(d)(28), added par. (50).
Subsec. (d). Pub. L. 100-203, 4113(b)(2)(i), inserted ''an entity
which meets the requirements of section 1320c-1 of this title, as
determined by the Secretary, for the performance of the quality review
functions described in subsection (a)(30)(C) of this section, or'' after
''contracts with''.
Pub. L. 100-203, 4113(b)(2)(ii), as amended by Pub. L. 100-360,
411(k)(7)(C), substituted ''an entity or organization'' for
''organization (or organizations)'' in two places.
Subsec. (e)(2)(A). Pub. L. 100-203, 4113(d)(2), which directed
substitution of ''subparagraph (B)(iii), (E), or (G) of section
1396b(m)(2) of this title'' for ''section 1396a(m)(2)(G) of this
title'', was repealed by Pub. L. 100-360, 411(k)(7)(D).
Pub. L. 100-203, 4113(a)(2), as amended by Pub. L. 100-360,
411(k)(7)(B), substituted ''paragraph (2)(B)(iii), (2)(E), (2)(G), or
(6) of section 1396b(m) of this title'' for ''section 1396b(m)(2)(G) of
this title''.
Pub. L. 100-203, 4113(c)(2), substituted ''but, except for benefits
furnished under section 1396d(a)(4)(C) of this title, only'' for ''but
only''.
Subsec. (e)(3)(B)(i). Pub. L. 100-203, 4211(h)(4), substituted
''nursing facility, or intermediate care facility for the mentally
retarded'' for ''skilled nursing facility, or intermediate care
facility''.
Subsec. (e)(3)(C). Pub. L. 100-203, 4118(c)(1), substituted ''for
medical assistance under the State plan under this subchapter'' for ''to
have a supplemental security income (or State supplemental) payment made
with respect to him under subchapter XVI of this chapter''.
Subsec. (e)(4). Pub. L. 100-203, 4101(a)(2), inserted sentence at
end relating to child's medical assistance eligibility identification
number and submission and payment of claims under such number during
period in which a child is eligible for assistance.
Subsec. (e)(5). Pub. L. 100-203, 4101(e)(2), substituted ''through
the end of the month in which the 60-day period (beginning on the last
day of her pregnancy) ends'' for ''until the end of the 60-day period
beginning on the last day of her pregnancy''.
Subsec. (e)(7). Pub. L. 100-203, 4101(b)(2)(B), substituted
''subparagraph (B) or (C)'' for ''subparagraph (B), (C), (D), (E), or
(F)''.
Subsec. (e)(9). Pub. L. 100-203, 4118(p)(6), realigned margins of
par. (9).
Subsec. (e)(9)(A)(iii). Pub. L. 100-203, 4211(h)(5)(A), substituted
''nursing facility, or intermediate care facility for the mentally
retarded'' for ''skilled nursing facility, or intermediate care
facility,''.
Subsec. (e)(9)(B). Pub. L. 100-203, 4211(h)(5)(B), substituted
''nursing facilities, or intermediate care facilities for the mentally
retarded'' for ''skilled nursing facilities, or intermediate care
facilities''.
Subsec. (f). Pub. L. 100-203, 4118(h)(2), as added by Pub. L.
100-360, 411(k)(10)(G)(iv), inserted ''regardless of whether such
expenses are reimbursed under another public program of the State or
political subdivision thereof'' after ''State law'' in first sentence.
Subsec. (i). Pub. L. 100-203, 4213(b)(1), as amended by Pub. L.
100-360, 411(l)(8)(C), in par. (1), substituted ''intermediate care
facility for the mentally retarded'' for ''skilled nursing facility or
intermediate care facility'' and ''the requirements for such a facility
under this subchapter'' for ''the provisions of section 1395x(j) of this
title or section 1396d(c) of this title, respectively,'', and in pars.
(2) and (3), substituted ''the requirements for such a facility under
this subchapter'' for ''the provisions of section 1395x(j) of this title
or section 1396d(c) of this title (as the case may be)''.
Subsec. (j). Pub. L. 100-203, 4116, inserted reference to Northern
Mariana Islands in two places.
Subsec. (l). Pub. L. 100-93, 7, redesignated subsec. (l), relating
to disregarding certain benefits for purposes of determining
post-eligibility contributions, as (o).
Subsec. (l)(1). Pub. L. 100-203, 4118(p)(7), made technical
corrections in introductory provisions and substituted ''and whose'' for
'', whose'' in closing provisions.
Subsec. (l)(1)(C). Pub. L. 100-203, 4101(c)(2), substituted ''5, 6,
7, or 8 years of age'' for ''or 5 years of age''.
Pub. L. 100-203, 4101(b)(1), added subpar. (C). Former subpar.
(C), which related to children who have attained one year of age but
have not attained two years of age, was struck out.
Subsec. (l)(1)(D) to (F). Pub. L. 100-203, 4101(b)(1)(B), struck
out subpars. (D) to (F) which related to children who have attained two
years of age but have not attained three years of age, children who have
attained three years of age but have not attained four years of age, and
children who have attained four years of age but have not attained five
years of age, respectively.
Subsec. (l)(2). Pub. L. 100-203, 4118(p)(8), struck out ''nonfarm''
after second reference to ''income'' in subpar. (A).
Pub. L. 100-203, 4101(a)(1)(A), designated existing provisions as
subpar. (A), inserted ''with respect to individuals described in
subparagraph (A) or (B) of that paragraph'', substituted ''185 percent''
for ''100 percent'', and added subpar. (B).
Subsec. (l)(3)(C). Pub. L. 100-203, 4101(b)(2)(A)(i), substituted
''subparagraph (B) or (C)'' for ''subparagraph (B), (C), (D), (E), or
(F)''.
Subsec. (l)(3)(D). Pub. L. 100-203, 4101(a)(1)(B), inserted
''appropriate'' after ''applied is the''.
Subsec. (l)(3)(E). Pub. L. 100-203, 4101(e)(3), inserted ''(except
to the extent such methodology is inconsistent with clause (D) of
subsection (a)(17) of this section)'' after ''subchapter IV of this
chapter''.
Subsec. (l)(4)(A). Pub. L. 100-203, 4101(e)(4), substituted ''July
1, 1987'' for ''April 17, 1986''.
Subsec. (l)(4)(B)(ii). Pub. L. 100-203, 4101(b)(2)(A)(ii),
substituted ''subparagraph (C)'' for ''subparagraph (C), (D), (E), or
(F)''.
Subsec. (l)(4)(C). Pub. L. 100-203, 4101(e)(5), added subpar. (C).
Subsec. (m)(2)(A). Pub. L. 100-203, 4118(p)(8), struck out
''nonfarm'' before ''official''.
Subsec. (o). Pub. L. 100-203, 9115(b), as amended by Pub. L.
100-360, 411(n)(2), substituted ''subparagraph (E) or (G) of section
1382(e)(1) of this title'' for ''section 1382(e)(1)(E) of this title''.
Pub. L. 100-93, 7, redesignated subsec. (l), relating to
disregarding certain benefits for purposes of determining
post-eligibility contributions, as (o).
Subsec. (p). Pub. L. 100-93, 7, added subsec. (p).
Subsec. (q). Pub. L. 100-203, 9119(d)(1)(B), as added by Pub. L.
100-360, 411(n)(4), formerly 411(n)(3), as redesignated by Pub. L.
100-485, 608(d)(28), added subsec. (q).
1986 -- Subsec. (a). Pub. L. 99-509, 9406(b), inserted at end
''Notwithstanding paragraph (10)(B) or any other provision of this
subsection, a State plan shall provide medical assistance with respect
to an alien who is not lawfully admitted for permanent residence or
otherwise permanently residing in the United States under color of law
only in accordance with section 1396b(v) of this title.''
Pub. L. 99-272, 9529(a)(1), inserted at end ''For purposes of this
subchapter, any child who meets the requirements of paragraph (1) or (2)
of section 673(b) of this title shall be deemed to be a dependent child
as defined in section 606 of this title and shall be deemed to be a
recipient of aid to families with dependent children under part A of
subchapter IV of this chapter in the State where such child resides.''
Subsec. (a)(9)(C). Pub. L. 99-509, 9320(h)(3), substituted
''paragraphs (12) and (13)'' for ''paragraphs (11) and (12)''.
Subsec. (a)(10). Pub. L. 99-509, 9408(b), added cl. (IX) at end.
Pub. L. 99-509, 9403(c), added cl. (VIII) at end.
Pub. L. 99-509, 9401(c), added cl. (VII) at end.
Pub. L. 99-272, 9505(b)(1), added cl. (VI) at end.
Pub. L. 99-272, 9501(b), added cl. (V) at end.
Subsec. (a)(10)(A)(i)(I). Pub. L. 99-272, 12305(b)(3), substituted
'', 606(h), or 673(b) of this title'' for ''or 606(h) of this title''.
Subsec. (a)(10)(A)(i)(II). Pub. L. 99-509, 9404(a), inserted ''or
who are qualified severely impaired individuals (as defined in section
1396d(q) of this title)'' after ''subchapter XVI of this chapter''.
Subsec. (a)(10)(A)(ii)(V). Pub. L. 99-272, 9510(a), inserted ''for a
period of not less than 30 consecutive days (with eligibility by reason
of this subclause beginning on the first day of such period)'' after
''are in a medical institution''.
Subsec. (a)(10)(A)(ii)(VII). Pub. L. 99-514, 1895(c)(7)(A),
realigned margin of subcl. (VII).
Pub. L. 99-272, 9505(b)(2), added subcl. (VII).
Subsec. (a)(10)(A)(ii)(VIII). Pub. L. 99-514, 1895(c)(7)(B),
realigned margins of subcl. (VIII).
Pub. L. 99-272, 9529(b)(1), added subcl. (VIII).
Subsec. (a)(10)(A)(ii)(IX). Pub. L. 99-509, 9401(a), added subcl.
(IX).
Subsec. (a)(10)(A)(ii)(X). Pub. L. 99-509, 9402(a)(1), added subcl.
(X).
Subsec. (a)(10)(C). Pub. L. 99-509, 9403(g)(1), inserted ''or (E)''
after ''subparagraph (A)'' in introductory text.
Subsec. (a)(10)(C)(iv). Pub. L. 99-509, 9408(c)(3), substituted
''through (20)'' for ''through (19)''.
Pub. L. 99-514, 1895(c)(3)(C), substituted ''through (19)'' for
''through (18)''.
Pub. L. 99-272, 9505(d)(2), substituted ''through (18)'' for
''through (17)''.
Subsec. (a)(10)(E). Pub. L. 99-509, 9403(a), added subpar. (E).
Subsec. (a)(13)(B). Pub. L. 99-272, 9509(a)(1), substituted
''hospitals'' for ''hospitals, skilled nursing facilities, and
intermediate care facilities''.
Subsec. (a)(13)(C). Pub. L. 99-272, 9509(a)(4), added subpar. (C).
Former subpar. (C) redesignated (D).
Pub. L. 99-272, 9505(c)(1), added subpar. (C). Former subpar. (C)
redesignated (D).
Subsec. (a)(13)(D). Pub. L. 99-514, 1895(c)(1), inserted ''and''
after ''facility;''.
Pub. L. 99-509, 9435(b)(1), inserted ''and for payment of amounts
under section 1396d(o)(3) of this title'' before first semicolon.
Pub. L. 99-272, 9509(a)(2), (3), redesignated former subpar. (C) as
(D), and struck out ''and'' at the end thereof. Former subpar. (D)
redesignated (E).
Pub. L. 99-272, 9505(c)(1)(B), redesignated former subpar. (C) as
(D).
Subsec. (a)(13)(E). Pub. L. 99-272, 9509(a)(3), redesignated former
subpar. (D) as (E).
Subsec. (a)(15). Pub. L. 99-509, 9403(g)(4)(A), inserted ''are not
qualified medicare beneficiaries (as defined in section 1396d(p)(1) of
this title) but'' after ''older who''.
Subsec. (a)(17). Pub. L. 99-509, 9401(e)(1), inserted ''except as
provided in subsection (l)(3) of this section'' after ''(17)''.
Subsec. (a)(25). Pub. L. 99-272, 9503(a)(1), amended par. (25)
generally. Prior to amendment, par. (25) read as follows: ''provide
(A) that the State or local agency administering such plan will take all
reasonable measures to ascertain the legal liability of third parties to
pay for care and services (available under the plan) arising out of
injury, disease, or disability, (B) that where the State or local agency
knows that a third party has such a legal liability such agency will
treat such legal liability as a resource of the individual on whose
behalf the care and services are made available for purposes of
paragraph (17)(B), and (C) that in any case where such a legal liability
is found to exist after medical assistance has been made available on
behalf of the individual and where the amount of reimbursement the State
can reasonably expect to recover exceeds the costs of such recovery, the
State or local agency will seek reimbursement for such assistance to the
extent of such legal liability;''.
Subsec. (a)(30)(C). Pub. L. 99-509, 9431(a), added subpar. (C).
Subsec. (a)(47). Pub. L. 99-570 added par. (47) relating to cards
evidencing eligibility for medical assistance.
Pub. L. 99-509, 9407(a), added par. (47) relating to ambulatory
prenatal care.
Subsec. (b)(2). Pub. L. 99-509, 9405, inserted before semicolon '',
regardless of whether or not the residence is maintained permanently or
at a fixed address''.
Subsec. (d). Pub. L. 99-509, 9431(b)(1), inserted ''(including
quality review functions described in subsection (a)(30)(C) of this
section)'' after ''medical or utilization review functions''.
Subsec. (e)(2)(A). Pub. L. 99-272, 9517(b)(1), inserted reference to
an entity described in section 1396b(m)(2)(G) of this title, and
substituted ''such organization or entity'' for ''such organization''.
Subsec. (e)(2)(B). Pub. L. 99-272, 9517(b)(2), substituted ''an
organization or entity'' for ''a health maintenance organization'' and
''the organization or entity'' for ''the organization''.
Subsec. (e)(5). Pub. L. 99-272, 9501(c), added par. (5).
Subsec. (e)(6), (7). Pub. L. 99-509, 9401(d), added pars. (6) and
(7).
Subsec. (e)(8). Pub. L. 99-509, 9403(f)(2), added par. (8).
Subsec. (e)(9). Pub. L. 99-509, 9408(a), added par. (9).
Subsec. (f). Pub. L. 99-643, 7(b), substituted ''subsection (e) of
this section and section 1382h(b)(3) of this title'' for ''subsection
(e) of this section''.
Subsec. (g). Pub. L. 99-272, 9503(a)(2), added subsec. (g).
Subsec. (h). Pub. L. 99-509, 9433(a), added subsec. (d) to section
2173 of Pub. L. 97-35 in turn which added subsec. (h) of this section.
See 1981 Amendment note below.
Subsec. (j). Pub. L. 99-509, 9408(c)(2), substituted ''(21)'' for
''(20)''.
Pub. L. 99-514, 1895(c)(3)(B), substituted ''(20)'' for ''(19)''.
Pub. L. 99-272, 9505(d)(1), substituted ''(19)'' for ''(18)''.
Subsec. (k). Pub. L. 99-272, 9506(a), added subsec. (k).
Subsec. (l). Pub. L. 99-643, 3(b), added subsec. (l) relating to
disregarding of certain benefits for purposes of determining
post-eligibility contributions.
Pub. L. 99-509, 9401(b), added subsec. (l) relating to description
of group.
Subsec. (m). Pub. L. 99-509, 9402(a)(2), (b), added subsec. (m).
Subsec. (m)(3). Pub. L. 99-509, 9403(f)(1)(A), which directed
insertion of ''or coverage under subsection (a)(10)(E) of this section''
after ''subsection (a)(10)(A)(ii)(IX) of this section'', was executed by
making the insertion after ''subsection (a)(10)(A)(ii)(X) of this
section'' as the probable intent of Congress.
Subsec. (m)(5). Pub. L. 99-509, 9403(f)(1)(B), added par. (5).
Subsec. (n). Pub. L. 99-509, 9403(e), added subsec. (n).
1984 -- Subsec. (a)(9)(C). Pub. L. 98-369, 2373(b)(1), realigned
margin of subpar. (C).
Subsec. (a)(10)(A). Pub. L. 98-369, 2373(b)(2), realigned margins of
subpar. (A).
Subsec. (a)(10)(A)(i). Pub. L. 98-369, 2361(a), amended cl. (i)
generally. Prior to the amendment cl. (i) read as follows: ''all
individuals receiving aid or assistance under any plan of the State
approved under subchapter I, X, XIV, or XVI of this chapter, or part A
or part E of subchapter IV of this chapter (including pregnant women
deemed by the State to be receiving such aid as authorized in section
606(g) of this title and individuals considered by the State to be
receiving such aid as authorized under section 614(g) of this title), or
with respect to whom supplemental security income benefits are being
paid under subchapter XVI of this chapter; and''.
Subsec. (a)(10(A)(i)(I). Pub. L. 98-378, 20(c), substituted
''section 602(a)(37) or 606(h) of this title'' for ''section 602(a)(37)
of this title''.
Subsec. (a)(13)(A). Pub. L. 98-369, 2373(b)(3), made clarifying
amendment by striking out ''(A)'' and all that follows through
''hospital'' the first place it appears and inserting in lieu thereof
''(A) for payment (except where the State agency is subject to an order
under section 1396m of this title) of the hospital'', resulting in no
change in text.
Subsec. (a)(13)(B), (C). Pub. L. 98-369, 2314(b), added subpar.
(B) and redesignated former subpar. (B) as (C).
Subsec. (a)(20)(B). Pub. L. 98-369, 2373(b)(4), substituted
''periodic'' for ''periodical''.
Subsec. (a)(20)(C). Pub. L. 98-369, 2373(b)(5), struck out reference
to section 803(a)(1)(A)(i) and (ii) of this title.
Subsec. (a)(26). Pub. L. 98-369, 2368(b), in amending par. (26)
generally, revised existing provisions to continue their application to
review of inpatient mental hospital service programs, and to sever
provisions relating to review of skilled nursing programs. See par.
(31) of this section.
Subsec. (a)(26)(B)(ii). Pub. L. 98-617, 3(a)(7), repealed the
amendment made by Pub. L. 98-369, 2373(b)(6). See below.
Pub. L. 98-369, 2373(b)(6), provided that cl. (ii) is amended by
substituting ''facilities'' for ''homes''.
Subsec. (a)(26)(C). Pub. L. 98-617, 3(b)(10), realigned margin of
subpar. (C).
Subsec. (a)(28). Pub. L. 98-369, 2335(e), struck out ''and
tuberculosis'' after ''mental diseases''.
Subsec. (a)(30). Pub. L. 98-369, 2363(a)(1)(A), designated existing
provisions as subpar. (A) and added subpar. (B).
Subsec. (a)(31). Pub. L. 98-369, 2368(a), in amending par. (31)
generally, revised existing provisions to cover review of skilled
nursing facilities.
Subsec. (a)(33)(A). Pub. L. 98-369, 2373(b)(7), substituted ''second
sentence'' for ''penultimate sentence''.
Subsec. (a)(42). Pub. L. 98-369, 2373(b)(8), substituted
''subchapter'' for ''part'' after ''audits conducted for purposes of
such''.
Subsec. (a)(43). Pub. L. 98-369, 2303(g)(1), redesignated par. (44)
as (43), and struck out former par. (43) which provided that if the
State plan makes provision for payment to a physician for laboratory
services the performance of which such physician, or other physician
with whom he shares his practice, did not personally perform or
supervise, the plan include provision to insure that payment for such
services not exceed the payment authorized by section 1395u(h) of this
title.
Subsec. (a)(44). Pub. L. 98-369, 2363(a)(1)(B), added par. (44).
Pub. L. 98-369, 2303(g)(1)(C), redesignated former par. (44) as
(43).
Subsec. (a)(45). Pub. L. 98-369, 2367(a), added par. (45).
Subsec. (a)(46). Pub. L. 98-369, 2651(c), added par. (46).
Subsec. (a), foll. par. (46). Pub. L. 98-369, 2373(b)(9),
substituted ''The provisions of paragraph (9)(A), (31), and (33) and of
section 1396b(i)(4) of this title shall not apply to'' for ''For
purposes of paragraph (9)(A), (26), (31), and (33), and of section
1396b(i)(4) of this title, the term 'skilled nursing facility' and
'nursing home' do not include''.
Subsec. (e)(4). Pub. L. 98-369, 2362(a), added par. (4).
Subsec. (f). Pub. L. 98-369, 2373(b)(10), substituted ''paragraph
(10)(A)'' and ''paragraph (10)(C)'' for ''clause (10)(A)'' and ''clause
(10)(C)'', respectively, wherever appearing.
1982 -- Subsec. (a)(10)(A). Pub. L. 97-248, 137(b)(7), redesignated
existing provisions as provisions preceding cl. (i) and cl. (i), and
added cl. (ii).
Subsec. (a)(10)(C), (D). Pub. L. 97-248, 137(a)(3), amended
directory language of Pub. L. 97-35, 2171(a)(3), to correct an error,
and did not involve any change in text. See 1981 Amendment note below.
Subsec. (a)(10)(C)(i). Pub. L. 97-248, 137(b)(8), substituted '',
(II)'' for ''and (II)'', and added subcl. (III).
Subsec. (a)(10)(C)(ii)(I). Pub. L. 97-248, 137(b)(9), substituted
''under the age of 18 who (but for income and resources) would be
eligible for medical assistance as an individual described in
subparagraph (A)(i)'' for ''described in section 1396d(a)(i) of this
title''.
Subsec. (a)(10). Pub. L. 97-248, 131(c), formerly 131(b), as
redesignated by Pub. L. 97-448, 309(a)(8), in provisions following
subpar. (D) added cl. (IV).
Subsec. (a)(14). Pub. L. 97-248, 131(a), substituted provisions that
a State plan for medical assistance must provide that enrollment fees,
premiums, or similar charges, and deductions, cost sharing, or similar
charges, may be imposed only as provided in section 1396o of this title
for provisions that such plan must provide that, with respect to
individuals receiving assistance, no enrollment fee, premium, or similar
charge, and no deduction, cost sharing, or similar charge with respect
to the care and services listed in pars. (1) through (5), (7), and (17)
of section 1396d(a) of this title, would be imposed under the plan, and
any deduction, cost sharing, or similar charge imposed under the plan
with respect to other care and services would be nominal in amount (as
determined in accordance with standards approved by the Secretary and
included in the plan), and with respect to individuals not receiving
assistance, there could be imposed an enrollment fee, premium, or
similar charge (as determined in accordance with standards prescribed by
the Secretary) related to the individual's income, and any deductible,
cost-sharing, or similar charge imposed under the plan would be nominal.
Subsec. (a)(18). Pub. L. 97-248, 132(a), substituted provisions that
a State plan for medical assistance must comply with the provisions of
section 1396p of this title with respect to liens, adjustments and
recoveries of medical assistance correctly paid, and transfers of assets
for provisions that such plan must provide that no lien could be imposed
against the property of any individual prior to his death on account of
medical assistance paid or to be paid on his behalf under the plan
(except pursuant to the judgment of a court on account of benefits
incorrectly paid on behalf of such individual), and that there would be
no adjustment or recovery (except, in the case of an individual who was
65 years of age or older when he received such assistance, from his
estate, and then only after the death of his surviving spouse, if any,
and only at a time when he had no surviving child who was under age 21
or (with respect to States eligible to participate in the State program
established under subchapter XVI of this chapter), was blind or
permanently and totally disabled, or was blind or disabled as defined in
section 1382c of this title with respect to States which were not
eligible to participate in such program) of any medical assistance
correctly paid on behalf of such individual under the plan.
Subsec. (a). Pub. L. 97-248, 137(e), inserted '', (26)'' after
''(9)(A)'' in provisions following par. (44).
Subsec. (b)(2) to (4). Pub. L. 97-248, 137(b)(10), struck out par.
(2) which provided that the Secretary would not approve any plan which
imposed any age requirement which excluded any individual who had not
attained the age of 19 and was a dependent child under part A of
subchapter IV of this chapter, and redesignated pars. (3) and (4) as
(2) and (3), respectively.
Subsec. (d). Pub. L. 97-248, 146(a), substituted references to
utilization and quality control peer review organizations having a
contract with the Secretary, for references to conditionally or
otherwise designated Professional Standards Review Organizations,
wherever appearing.
Subsec. (e)(3). Pub. L. 97-248, 134(a), added par. (3).
Subsec. (j). Pub. L. 97-248, 132(c), 136(d), struck out subsec.
(j) which related to the denial of medical assistance under a State plan
because of an individual's disposal of resources for less than fair
market value, the period of ineligibility, and the eligibility of
certain individuals for medical assistance under a State plan who would
otherwise be ineligible because of the provisions of section 1382b(c) of
this title, and added a new subsec. (j) relating to waiver or
modification of requirements with respect to American Samoa medical
assistance program.
1981 -- Subsec. (a)(9)(C). Pub. L. 97-35, 2175(d)(1)(C), added
subpar. (C).
Subsec. (a)(10)(A). Pub. L. 97-35, 2171(a)(1), substituted
''including at least the care and services listed in paragraphs (1)
through (5) and (17) of section 1396d(a) of this title, to all
individuals receiving aid or assistance under any plan of the State
approved under subchapter I, X, XIV, or XVI of this chapter, or part A
or part E of subchapter IV of this chapter (including pregnant women
deemed by the State to be receiving such aid as authorized by section
606(g) of this title and individuals considered by the State to be
receiving such aid as authorized under section 614(g) of this title)''
for ''to all individuals receiving aid or assistance under any plan of
the State approved under subchapters I, X, XIV, or XVI, or part A of
subchapter IV of this chapter''.
Subsec. (a)(10)(B). Pub. L. 97-35, 2171(a)(2), substituted reference
to subparagraph for reference to clause in two places.
Subsec. (a)(10)(C). Pub. L. 97-35, 2171(a)(3), as amended by Pub.
L. 97-248, 137(a)(3), substituted provisions relating to plans for
medical assistance included for any group of individuals described in
section 1396d(a) of this title who are not described in subpar. (A) for
provisions relating to medical assistance for any group of individuals
not described in subpar. (A) and who do not meet the income and
resources requirements of the appropriate State plan, or the
supplementary security income program under subchapter XVI of this
chapter, as the case may be, as determined in accordance with standards
prescribed by the Secretary.
Subsec. (a)(10)(D). Pub. L. 97-35, 2171(a)(3), as amended by Pub.
L. 97-248, 137(a)(3), added subpar. (D).
Subsec. (a)(11). Pub. L. 97-35, 2193(c)(9), substituted ''under or
through an allotment under) subchapter V of this chapter, (i) providing
for utilizing such agency, institution, or organization in furnishing
care and services which are available under such subchapter or
allotment'' for ''for part or all of the cost of plans or projects under
subchapter V of this chapter, (i) providing for utilizing such agency,
institution, or organization in furnishing care and services which are
available under such plan or project under subchapter V of this
chapter''.
Subsec. (a)(13)(A). Pub. L. 97-35, 2171(b), 2173(a)(1)(B), (C),
struck out subpar. (A) which provided that a State plan must provide
for the inclusion of some institutional and some noninstitutional care
and services and for the inclusion of home health services for any
individual who is entitled to skilled nursing facility services,
redesignated subpar. (E) as (A), and in subpar. (A), as so
redesignated, made the subsection applicable to hospital facilities,
inserted reference to rates which take into account the situation of
hospitals which serve a disproportionate number of low income patients
with special needs and provide, in the case of hospital patients
receiving services at an inappropriate level of care under conditions
similar to those described in section 1395x(v)(1)(G) of this title, for
lower reimbursement rates reflecting the level of care actually received
in a manner consistent with such section, and substituted ''safety
standards and to assure that individuals eligible for medical assistance
have reasonable access (taking into account geographic location and
reasonable travel time) to inpatient hospital services of adequate
quality'' for ''safety standards''.
Subsec. (a)(13)(B). Pub. L. 97-35, 2171(b), 2173(a)(1)(C), struck
out subpar. (B) which provided that a State plan must provide in the
case of individuals receiving aid or assistance under any plan of the
State approved under subchapter I, X, XIV, or XVI, or part A of
subchapter IV of this chapter, or with respect to whom supplemental
security income benefits are being paid under subchapter XVI of this
chapter, for the inclusion of at least the care and services listed in
paragraphs (1) through (5) and (17) of section 1396d(a) of this title,
and redesignated subpar. (F) as (B).
Subsec. (a)(13)(C). Pub. L. 97-35, 2171(b), struck out subpar. (C)
which provided for care and services of individuals not included in
former subpar. (B).
Subsec. (a)(13)(D). Pub. L. 97-35, 2173(a)(1)(A), struck out subpar.
(D) which provided for payment of reasonable cost of inpatient hospital
services provided under the plan with provisions for determination of
such costs with certain maximum limitations and for payment of
reasonable cost of inappropriate inpatient services described in subsec.
(h)(1) of this section.
Subsec. (a)(13)(E), (F). Pub. L. 97-35, 2173(a)(1)(C), redesignated
subpars. (E) and (F) as (A) and (B), respectively.
Subsec. (a)(20)(D). Pub. L. 97-35, 2173(a)(2), struck out subpar.
(D) which required provision for methods of determining reasonable cost
of institutional care of such patients.
Subsec. (a)(23). Pub. L. 97-35, 2175(a), substituted ''except as
provided in section 1396n and except in the case of'' for ''except in
the case of'', and struck out provision that a State plan shall not be
deemed to be out of compliance with the requirements of this paragraph
or pars. (1) and (10) of this subsection solely by reason of the fact
that the State or any political subdivision thereof has entered into a
contract with an organization which has agreed to provide care and
services in addition to those offered under the State plan to
individuals eligible for medical assistance who reside in the geographic
area served by such organization and who elect to obtain such care and
services from such organization, or by reason of the fact that the plan
provides for payment for rural health clinic services only if those
services are provided by a rural health clinic.
Subsec. (a)(25)(C). Pub. L. 97-35, 2182, substituted ''of the
individual and where the amount of reimbursement the State can
reasonably expect to recover exceeds the costs of such recovery, the
State'' for ''of the individual, the State''.
Subsec. (a)(30). Pub. L. 97-35, 2174(a), substituted ''that payments
are consistent'' for ''that payments (including payments for any drugs
provided under the plan) are not in excess of reasonable charges
consistent''.
Subsec. (a)(39). Pub. L. 97-35, 2105(c), substituted ''person'' for
''individual'' in two places.
Subsec. (a)(44). Pub. L. 97-35, 2181(a)(2)(C), added par. (44).
Subsec. (b)(2). Pub. L. 97-35, 2172(a), substituted ''any age
requirement which excludes any individual who has not attained the age
of 19 and is a dependent child under part A of subchapter IV of this
chapter;'' for ''effective July 1, 1967, any age requirement which
excludes any individual who has not attained the age of 21 and is or
would, except for the provisions of section 606(a)(2) of this title, be
a dependent child under part A of subchapter IV of this chapter; or''.
Subsec. (d). Pub. L. 97-35, 2113(m), added subsec. (d).
Subsec. (e). Pub. L. 97-35, 2178(b), designated existing provisions
as par. (1) and added par. (2).
Subsec. (h). Pub. L. 97-35, 2173(b)(1), (d), as amended by Pub. L.
99-509, 9433(a), added a new subsec. (h) and repealed former subsec.
(h) which related to skilled nursing and intermediate care facility
services.
1980 -- Subsec. (a)(13)(B). Pub. L. 96-499, 965(b)(1), substituted
''paragraphs (1) through (5) and (17)'' for ''clauses (1) through (5)''.
Subsec. (a)(13)(C)(i). Pub. L. 96-499, 965(b)(2), substituted
''paragraphs (1) through (5) and (17)'' for ''clauses (1) through (5)''.
Subsec. (a)(13)(C)(ii). Pub. L. 96-499, 965(b)(3), substituted
''paragraphs numbered (1) through (17)'' for ''clauses numbered (1)
through (16)''.
Subsec. (a)(13)(D). Pub. L. 96-499, 902(b)(1), designated existing
provisions as cl. (i) and added cl. (ii).
Subsec. (a)(13)(D)(i). Pub. L. 96-499, 903(b), 905(a), inserted
''(except where the State agency is subject to an order under section
1396m of this title)'' after ''payment'' and '', except that in the case
of hospitals reimbursed for services under part A of subchapter XVIII of
this chapter in accordance with section 1395f(b)(3) of this title, the
plan must provide for payment of inpatient hospital services provided in
such hospitals under the plan in accordance with the reimbursement
system used under such section'' after ''subchapter XVIII of this
chapter''.
Subsec. (a)(13)(E). Pub. L. 96-499, 905(a), inserted ''(except where
the State agency is subject to an order under section 1396m of this
title)''.
Pub. L. 96-499, 962(a), substituted provisions which required a
State plan for medical assistance to provide for payment of skilled
nursing facility and intermediate care facility services provided under
such plan through the use of rates determined in accordance with methods
and standards developed by the State rather than on a reasonable cost
related basis, required the filing of uniform cost reports by each
facility, and required periodic audits of such reports by the State.
Subsec. (a)(14)(A)(i). Pub. L. 96-499, 965(b)(4), substituted
''paragraphs (1) through (5), (7), and (17)'' for ''clauses (1) through
(5) and (7)''.
Subsec. (a)(33)(B). Pub. L. 96-499, 916(b)(1)(B), inserted exception
authorizing the Secretary where there was cause to question the adequacy
of participation determinations to make independent determinations
concerning the extent to which individual institutions and agencies met
the requirements for participation.
Subsec. (a)(35). Pub. L. 96-499, 912(b), substituted ''disclosing
entity (as defined in section 1320a-3(a)(2) of this title)'' for
''intermediate care facility''.
Subsec. (a)(39). Pub. L. 96-499, 913(c), substituted provisions
requiring that State plans for medical assistance authorize the State
agency to bar specified individuals from participation in the program
under the State plan when required by the Secretary to do so pursuant to
section 1320a-7 of this title for provisions requiring that State plans
for medical assistance provide for the suspension of physicians or other
individuals from participation in the State plan upon notification by
the Secretary that such physician or other individual had been suspended
from participation in the plan under subchapter XVIII of this chapter.
Subsec. (a)(41). Pub. L. 96-272 added par. (41).
Subsec. (a)(42). Pub. L. 96-499, 914(b)(1), added par. (42).
Subsec. (a)(43). Pub. L. 96-499, 918(b)(1)(C), added par. (43).
Subsec. (g). Pub. L. 96-499, 913(d), struck out subsec. (g) which
related to waiver of suspension of payments to physicians or
practitioners suspended from participation in approved State plans.
Subsec. (h). Pub. L. 96-499, 902(b)(2), added subsec. (h).
Subsec. (i). Pub. L. 96-499, 916(b)(1)(A), added subsec. (i).
Subsec. (j). Pub. L. 96-611 added subsec. (j).
1978 -- Subsec. (a)(4)(C). Pub. L. 95-559 added cl. (C).
1977 -- Subsec. (a)(13)(F). Pub. L. 95-210, 2(c)(1), added subpar.
(F).
Subsec. (a)(23). Pub. L. 95-210, 2(c)(2), inserted '', or by reason
of the fact that the plan provides for payment for rural health clinic
services only if those services are provided by a rural health clinic''
after ''who elect to obtain such care and services from such
organization''.
Subsec. (a)(26). Pub. L. 95-142, 20(b), inserted provision relating
to staff of skilled nursing facilities.
Subsec. (a)(27)(B). Pub. L. 95-142, 9, inserted ''or the Secretary''
after ''State agency'' wherever appearing.
Subsec. (a)(32). Pub. L. 95-142, 2(a)(3), substituted provisions
relating to terms, conditions, etc., for payments under an assignment or
power of attorney, for provisions relating to terms, conditions, etc.,
for payments to anyone other than the individual receiving any care or
service provided by a physician, dentist, or other individual
practitioner, or such physician, dentist, or practitioner.
Subsec. (a)(35). Pub. L. 95-142, 3(c)(1)(A), substituted provisions
relating to requirements for intermediate care facilities to comply with
section 1320a-3 of this title for provisions relating to disclosure
requirements, effective Jan. 1, 1973, applicable to intermediate care
facilities with respect to ownership, corporate, status, etc.
Subsec. (a)(37). Pub. L. 95-142, 2(b)(1)(C), 3(c)(1)(C), 7(b)(1),
added subsec. (a)(37) and made and struck out minor changes in
phraseology, necessitating no changes in text.
Subsec. (a)(38). Pub. L. 95-142, 3(c)(1)(D), 7(b)(2), 19(b)(2)(A),
added par. (38) and made and struck out minor changes in phraseology
necessitating no changes in text.
Subsec. (a)(39). Pub. L. 95-142, 7(b)(3), 19(b)(2)(B), added par.
(39).
Subsec. (a)(40). Pub. L. 95-142, 19(b)(2)(C), added par. (40).
Subsec. (a), foll. par. (40). Pub. L. 95-142, 2(b)(1)(D), added
paragraph relating to waiver of requirement of cl. (A) of par. (37).
Subsec. (g). Pub. L. 95-142, 7(c), added subsec. (g).
1976 -- Subsec. (g). Pub. L. 94-552 struck out provisions for
consent to suit and waiver of immunity by State.
1975 -- Subsec. (a). Pub. L. 94-48, 1, added undesignated paragraph
at end of subsec. (a) relating to eligibility under this subchapter of
any individual who was eligible for the month of August 1972, under a
State plan approved under subchapters I, X, XIV, XVI, or part A of
subchapter IV of this chapter if such individual would have been
eligible for such month had the increase in monthly insurance benefits
under subchapter II of this chapter resulting from enactment of Pub. L.
92-336 not been applicable to such individual.
Subsec. (a)(23). Pub. L. 94-48, 2, inserted ''except in the case of
Puerto Rico, the Virgin Islands, and Guam,''.
Subsec. (g). Pub. L. 94-182 added subsec. (g).
1974 -- Subsec. (a)(14)(B)(i). Pub. L. 93-368 substituted ''may''
for ''shall''.
1973 -- Subsec. (a)(5). Pub. L. 93-233, 13(a)(2)(A), (B),
substituted ''to administer or to supervise the administration of the
plan'' for ''to administer the plan'' and ''to supervise the
administration of the plan'' in that order and inserted after the
parenthetical phrase the conditional provision ''if the State is
eligible to participate in the State plan program established under
subchapter XVI of this chapter, or by the agency or agencies
administering the supplemental security income program established under
subchapter XVI of this chapter or the State plan approved under part A
of subchapter IV of this chapter if the State is not eligible to
participate in the State plan program established under subchapter XVI
of this chapter''.
Subsec. (a)(10). Pub. L. 93-233, 13(a)(3), incorporated existing
text in provisions designated as cl. (A), providing therein for medical
assistance to individuals with respect to whom supplemental security
income benefits are paid; incorporated existing par. (A) in provisions
designated as cl. (B); incorporated existing par. (B) in provisions
designated as cl. (C), providing therein for individuals not meeting
income and resources requirements of the supplemental security income
program; substituted in cls. (B)(ii), (C), (C)(i)(ii) and ''medical
assistance'' for ''medical or remedial care and services'' appearing in
predecessor provisions and in cl. (C)(i) ''except for income and
resources'' for ''if needy'' appearing in predecessor provision; and in
the exception provisions included reference to par. (16) of section
1396(a) of this title in item (I), substituted ''deductibles'' for ''the
deductibles'' in item (II), and added item (III).
Subsec. (a)(13)(B). Pub. L. 93-233, 13(a)(4), substituted ''any plan
of the State approved'' for ''the State's plan approved'' and inserted
after ''part A of subchapter IV of this chapter'' text reading '', or
with respect to whom supplemental security income benefits are being
paid under subchapter XVI of this chapter''.
Subsec. (a)(13)(C)(ii)(I). Pub. L. 93-233, 18(x)(1), substituted
reference to cl. ''16'' for ''14''.
Subsec. (a)(14)(A). Pub. L. 93-233, 13(a)(5), substituted ''any plan
of the State approved'' for ''a State plan approved'' and ''with respect
to whom supplemental security income benefits are being paid under
subchapter XVI of this chapter, or who meet the income and resources
requirements of the appropriate State plan, or the supplemental security
income program under subchapter XVI of this chapter, as the case may be,
and individuals with respect to whom there is being paid, or who are
eligible, or would be eligible if they were not in a medical
institution, to have paid with respect to them, a State supplementary
payment and are eligible for medical assistance equal in amount,
duration, and scope to the medical assistance made available to
individuals described in paragraph (10)(A)'' for ''who meet the income
and resources requirements of the one of such State plans which is
appropriate''.
Subsec. (a)(14)(B). Pub. L. 93-233, 13(a)(6)(A)-(D), inserted after
''with respect to individuals'' the parenthetical provision ''(other
than individuals with respect to whom there is being paid, or who are
eligible or would be eligible if they were not in a medical institution,
to have paid with respect to them, a State supplementary payment and are
eligible for medical assistance equal in amount, duration, and scope to
the medical assistance made available to individuals described in
paragraph (10)(A))''; inserted after ''any such State plan'' the clause
''and with respect to whom supplemental security income benefits are not
being paid under subchapter XVI of this chapter''; substituted ''the
appropriate State plan, or the supplemental security income program
under subchapter XVI of this chapter, as the case may be,'' for ''the
one of such State plans which is appropriate''; and struck out ''or
who, after December 31, 1973, are included under the State plan for
medical assistance pursuant to subsection (a)(10)(B) of this section
approved under this subchapter'' preceding the hyphen and cl. (i),
respectively.
Subsec. (a)(17). Pub. L. 93-233, 13(a)(7)(A)-(D), (8), substituted:
''any plan of the State approved under subchapter I, X, XIV, or XVI, or
part A of subchapter IV of this chapter, and with respect to whom
supplemental security income benefits are not being paid under
subchapter XVI of this chapter'' for ''the State's plan approved under
subchapter I, X, XIV, or XVI, or part A of subchapter IV of this
chapter''; ''except for income and resources'' for ''if he met the
requirements as to need''; ''any plan of the State approved under
subchapter I, X, XIV, or XVI, or part A of subchapter IV of this
chapter, or to have paid with respect to him supplemental security
income benefits under subchapter XVI of this chapter'' for ''a State
plan approved under subchapter I, X, XIV, or XVI, or part A of
subchapter IV of this chapter''; ''such aid, assistance, or benefits''
for ''and amount of such aid or assistance under such plan''; and
''(with respect to States eligible to participate in the State program
established under subchapter XVI of this chapter), is blind or
permanently and totally disabled, or is blind or disabled as defined in
section 1382c of this title (with respect to States which are not
eligible to participate in such program)'' for ''is blind or permanently
and totally disabled''.
Subsec. (a)(18). Pub. L. 93-233, 13(a)(8), substituted ''(with
respect to States eligible to participate in the State program
established under subchapter XVI of this chapter), is blind or
permanently and totally disabled, or is blind or disabled as defined in
section 1382c of this title (with respect to States which are not
eligible to participate in such program)'' for ''is blind or permanently
and totally disabled''.
Subsec. (a)(20)(C). Pub. L. 93-233, 13(a)(9), inserted reference to
section 803(a)(1)(A)(i) and (ii) of this title.
Subsec. (a)(21), (24). Pub. L. 93-233, 18(x)(4), provided for
substitution of ''nursing facilities'' for ''nursing homes''.
Subsec. (a)(26)(B). Pub. L. 93-233, 18(x)(4), provided for
substitution of ''nursing facility'' and ''nursing facilities'' for
''nursing home'' and ''nursing homes'', changes already executed under
1972 Amendment by Pub. L. 92-603, 278(a)(19).
Subsec. (a)(33)(A). Pub. L. 93-233, 18(x)(2), substituted
''penultimate sentence'' for ''last sentence''.
Subsec. (a)(34). Pub. L. 93-233, 18(o), inserted ''(or application
was made on his behalf in the case of a deceased individual)'' after
''he made application''.
Subsec. (a)(35)(A). Pub. L. 93-233, 18(p), required the intermediate
care facility to supply full and complete information respecting the
person who is the owner (in whole or in part) of any mortgage, deed of
trust, note, or other obligation secured (in whole or in part) by the
intermediate care facility or any of the property or assets of the
intermediate care facility.
Subsec. (a)(35) to (37). Pub. L. 93-233, 18(x)(3)(A), (B),
substituted ''; and'' for ''.'' at end of par. (35); and corrected
numerical sequence of paragraphs, redesignating par. (37) as (36), the
original subsec. (a) having been enacted without a par. (36).
Subsec. (e). Pub. L. 93-233, 18(q), substituted ''each family which
was receiving aid pursuant to a plan of the State approved under part
A'' for ''each family which was eligible for assistance pursuant to part
A'', ''for such aid because of increased hours of, or increased income
from, employment'' for ''for such assistance because of increased income
from employment'', and ''remain eligible for assistance under the plan
approved under this subchapter (as though the family was receiving aid
under the plan approved under part A of subchapter IV of this chapter)
for 4 calendar months beginning with the month in which such family
became ineligible for aid under the plan approved under part A of
subchapter IV of this chapter because of income and resources or hours
of work limitations'' for ''remain eligible for such assistance for 4
calendar months following the month in which such family would otherwise
be determined to be ineligible for such assistance because of the income
and resources limitations''.
Subsec. (f). Pub. L. 93-233, 13(a)(10)(A)-(D) substituted: ''no
State not eligible to participate in the State plan program established
under subchapter XVI of this chapter'' for ''no State'' and ''any
supplemental security income payment and State supplementary payment
made with respect to such individual'' for ''such individual's payment
under subchapter XVI of this chapter'' and ''as recognized under State
law'' for ''as defined in section 213 of Title 26'' in parenthetical
text; and inserted two end sentences for consideration of certain
individuals as eligible for medical assistance under cl. (10)(A) or (C)
of subsec. (a) of this section or as eligible for such assistance under
cl. (10)(A) in States not providing such assistance under cl. (10)(C),
respectively.
1972 -- Subsec. (a). Pub. L. 92-603, 268(a), 278(b)(14), inserted
provisions exempting Christian Science sanatoriums from certain nursing
facility and nursing home requirements.
Subsec. (a)(9). Pub. L. 92-603, 239(a), inserted provisions to
utilize State health agency for establishing and maintaining health
standards for private or public institutions in which recipients of
medical assistance under the plan may receive care or services.
Subsec. (a)(13)(A)(ii), (C). Pub. L. 92-603, 278(a)(18), (b)(14),
substituted ''skilled nursing facility'' for ''skilled nursing home''.
Subsec. (a)(13)(D). Pub. L. 92-603, 221(c)(5), 232(a), inserted
provisions that the reasonable cost of inpatient hospital services shall
not exceed the amount determined under section 1395x(v) of this title
and inserted reference to the consistency of methods and standards with
section 1320a-1 of this title for determining the reasonable cost of
inpatient hospital services.
Subsec. (a)(13)(E). Pub. L. 92-603, 249(a), added subpar. (E).
Subsec. (a)(14). Pub. L. 92-603, 208(a), substituted a nominal
amount for an amount reasonably related to the recipient's income as the
amount of the deduction, cost sharing, or similar charge imposed under
the plan and inserted provisions covering individuals who are not
receiving aid or assistance under any state plan and who do not meet the
income and resources requirements and covering individuals who are
included under the state plan for medical assistance pursuant to subsec.
(a)(10)(B) of this section approved under this subchapter.
Subsec. (a)(23). Pub. L. 92-603, 240, inserted provisions allowing
States to adopt comprehensive health care programs while still complying
with medicaid requirements.
Subsec. (a)(26). Pub. L. 92-603, 274(a), 278(a)(19), (b)(14),
substituted ''evaluation)'' for ''evaluation'' and ''care'' for
''care)'' and substituted ''skilled nursing facility'' and ''skilled
nursing facilities'' for ''skilled nursing home'' and ''skilled nursing
homes''.
Subsec. (a)(28). Pub. L. 92-603, 246(a), 278(a)(20), substituted
''skilled nursing facility'' for ''skilled nursing home'' and
substituted a simple reference to the requirements contained in section
1395x(j) of this title with a specified exception for provisions
spelling out in detail the requirements for skilled nursing homes
receiving payments.
Subsec. (a)(30). Pub. L. 92-603, 237(a)(2), substituted ''under the
plan (including but not limited to utilization review plans as provided
for in section 1396b(i)(4) of this title)'' for ''under the plan''.
Subsec. (a)(31)(A). Pub. L. 92-603, 298, struck out ''which provides
more than a minimum level of health care services'' after ''intermediate
care facility''.
Subsec. (a)(32). Pub. L. 92-603, 236(b)(3), added par. (32).
Subsec. (a)(33). Pub. L. 92-603, 239(b)(3), added par. (33).
Subsec. (a)(34). Pub. L. 92-603, 255(a)(3), added par. (34).
Subsec. (a)(35). Pub. L. 92-603, 299A(3), added par. (35).
Subsec. (a)(37). Pub. L. 92-603, 299D(b)(3), added par. (37).
Subsec. (d). Pub. L. 92-603, 231, repealed subsec. (d) which
related to modification of state plans for medical assistance under
certain circumstances.
Subsec. (e). Pub. L. 92-603, 209(a), added subsec. (e).
Subsec. (f). Pub. L. 92-603, 209(b)(1), added subsec. (f).
1971 -- Subsec. (a)(31). Pub. L. 92-223 added par. (31).
1969 -- Subsec. (c). Pub. L. 91-56, 2(c), substituted ''aid or
assistance in the form of money payments (other than so much, if any, of
the aid or assistance in such form as was, immediately prior to the
effective date of the State plan under this subchapter, attributable to
medical needs)'' for ''aid or assistance (other than so much of the aid
or assistance as is provided for under the plan of the State approved
under this subchapter)''.
Subsec. (d). Pub. L. 91-56, 2(d), added subsec. (d).
1968 -- Subsec. (a)(2). Pub. L. 90-248, 231, changed the date on
which State plans must meet certain financial participation requirements
by substituting ''July 1, 1969'' for ''July 1, 1970''.
Subsec. (a)(4). Pub. L. 90-248, 210(a)(6), designated existing
provisions as subpar. (A) and added subpar. (B).
Subsec. (a)(10). Pub. L. 90-248, 223(a), 241(f)(1), struck out
''IV,'' after ''I,'' and inserted '', and part A of subchapter IV of
this chapter'' after ''XVI of this chapter'', and designated existing
provisions as item I and added item II.
Subsec. (a)(11). Pub. L. 90-248, 302(b), designated existing
provisions as cl. (A) and added cl. (B).
Subsec. (a)(13). Pub. L. 90-248, 224(a), designated existing
provisions as subpar. (A), incorporated existing cl. (A) in provisions
designated as subpars. (B) and (C)(i), making subpar. (B) and (C)
applicable to individuals receiving aid or assistance under an approved
State plan and to individuals not covered under subpar. (B),
respectively, added cl. (ii) of subpar. (C), redesignated former cl.
(B) as subpar. (D), and deleted effective date of July 1, 1967, for
former cls. (A) and (B).
Subsec. (a)(13)(A). Pub. L. 90-248, 224(c)(1), designated existing
provisions as cl. (i) and added cl. (ii).
Subsec. (a)(14)(A). Pub. L. 90-248, 235(a)(1), inserted ''in the
case of individuals receiving aid or assistance under State plans
approved under subchapters I, X, XIV, XVI, and part A of subchapter IV
of this chapter,''.
Subsec. (a)(14)(B). Pub. L. 90-248, 235(a)(2), inserted ''inpatient
hospital services or'' after ''respect to'' and substituted ''to an
individual'' for ''him''.
Subsec. (a)(15). Pub. L. 90-248, 235(a)(3), struck out subpar. (B)
provision for meeting the full cost of any deductible imposed with
respect to any such individual under the insurance program established
by part A of such subchapter, deleted subpar. (B) designation preceding
''where, under the plan'', and substituted therein ''established by such
subchapter'' for ''established by part B of such subchapter''.
Subsec. (a)(17). Pub. L. 90-248, 238, inserted in parenthetical
expression ''and may, in accordance with standards prescribed by the
Secretary, differ with respect to income levels, but only in the case of
applicants or recipients of assistance under the plan who are not
receiving aid or assistance under the State's plan approved under
subchapter I, X, XIV, or XVI of this chapter, or part A of subchapter IV
of this chapter, based on the variations between shelter costs in urban
areas and in rural areas'' after ''all groups''.
Pub. L. 90-248, 241(f)(2), in cl. (B) struck out ''IV,'' after
''I,'' and inserted '', or part A of subchapter IV of this chapter''
after ''XVI of this chapter''.
Subsec. (a)(23) to (30). Pub. L. 90-248, 227(a), 228(a), 229(a),
234(a), 236(a), 237, added pars. (23), (24), (25), (26) to (28), (29),
(30), respectively.
Subsec. (b)(2). Pub. L. 90-248, 241(f)(3), inserted ''part A of''
before ''subchapter IV''.
Subsec. (c). Pub. L. 90-248, 241(f)(4), struck out ''IV,'' after
''I,'' and inserted '', or part A of subchapter IV of this chapter''
after ''XVI of this chapter''.
Section 2(c)(1) of Pub. L. 102-234 provided that: ''The amendments
made by this section (amending this section and section 1396b of this
title) shall take effect January 1, 1992, without regard to whether or
not regulations have been promulgated to carry out such amendments by
such date.''
Section 3(e)(1) of Pub. L. 102-234 provided that: ''The amendments
made by this section (amending this section and sections 1396b and
1396r-4 of this title) shall take effect January 1, 1992.''
Section 4402(e) of Pub. L. 101-508 provided that:
''(1) The amendments made by this section (enacting section 1396e of
this title and amending this section and sections 1396b and 1396d of
this title) apply (except as provided under paragraph (2)) to payments
under title XIX of the Social Security Act (this subchapter) for
calendar quarters beginning on or after January 1, 1991, without regard
to whether or not final regulations to carry out such amendments have
been promulgated by such date.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than legislation
authorizing or appropriating funds) in order for the plan to meet the
additional requirements imposed by the amendments made by subsection (a)
(enacting section 1396e of this title and amending this section), the
State plan shall not be regarded as failing to comply with the
requirements of such title solely on the basis of its failure to meet
this additional requirement before the first day of the first calendar
quarter beginning after the close of the first regular session of the
State legislature that begins after the date of the enactment of this
Act (Nov. 5, 1990). For purposes of the previous sentence, in the case
of a State that has a 2-year legislative session, each year of such
session shall be deemed to be a separate regular session of the State
legislature.''
Section 4501(f) of Pub. L. 101-508 provided that: ''The amendments
made by this section (amending this section and sections 1395v and 1396d
of this title) shall apply to calendar quarters beginning on or after
January 1, 1991, without regard to whether or not regulations to
implement such amendments are promulgated by such date; except that the
amendments made by subsection (e) (amending this section and section
1396d of this title) shall apply to determinations of income for months
beginning with January 1991.''
Section 4601(b) of Pub. L. 101-508 provided that:
''(1) The amendments made by this subsection (probably should be
''section'', which amended this section and sections 1396b, 1396d, and
1396r-6 of this title) apply (except as otherwise provided in this
subsection) to payments under title XIX of the Social Security Act (this
subchapter) for calendar quarters beginning on or after July 1, 1991,
without regard to whether or not final regulations to carry out such
amendments have been promulgated by such date.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than legislation
authorizing or appropriating funds) in order for the plan to meet the
additional requirements imposed by the amendments made by this
subsection (section), the State plan shall not be regarded as failing to
comply with the requirements of such title solely on the basis of its
failure to meet these additional requirements before the first day of
the first calendar quarter beginning after the close of the first
regular session of the State legislature that begins after the date of
the enactment of this Act (Nov. 5, 1990). For purposes of the previous
sentence, in the case of a State that has a 2-year legislative session,
each year of such session shall be deemed to be a separate regular
session of the State legislature.''
Section 4602(b) of Pub. L. 101-508 provided that: ''The amendments
made by subsection (a) (amending this section) apply to payments under
title XIX of the Social Security Act (this subchapter) for calenar (sic)
quarters beginning on or after July 1, 1991, without regard to whether
or not final regulations to carry out such amendments have been
promulgated by such date.''
Section 4603(b) of Pub. L. 101-508 provided that:
''(1) Infants. -- The amendment made by subsection (a)(1) (amending
this section) shall apply to individuals born on or after January 1,
1991, without regard to whether or not final regulations to carry out
such amendment have been promulgated by such date.
''(2) Pregnant women. -- The amendments made by subsection (a)(2)
(amending this section) shall apply with respect to determinations to
terminate the eligibility of women, based on change of income, made on
or after January 1, 1991, without regard to whether or not final
regulations to carry out such amendments have been promulgated by such
date.''
Section 4604(d) of Pub. L. 101-508 provided that:
''(1) The amendments made by this subsection (probably should be
''section'', which amended this section and section 1396n of this title)
shall become effective with respect to payments under title XIX of the
Social Security Act (this subchapter) for calendar quarters beginning on
or after July 1, 1991, without regard to whether or not final
regulations to carry out such amendments have been promulgated by such
date.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than legislation
authorizing or appropriating funds) in order for the plan to meet the
additional requirements imposed by the amendments made by this
subsection (section), the State plan shall not be regarded as failing to
comply with the requirements of such title solely on the basis of its
failure to meet these additional requirements before the first day of
the first calendar quarter beginning after the close of the first
regular session of the State legislature that begins after the date of
the enactment of this Act (Nov. 5, 1990). For purposes of the previous
sentence, in the case of a State that has a 2-year legislative session,
each year of such session shall be deemed to be a separate regular
session of the State legislature.''
Amendment by section 4701(b)(1) of Pub. L. 101-508 effective Jan.
1, 1991, see section 4701(c) of Pub. L. 101-508, set out as a note
under section 1396b of this title.
Section 4704(f) of Pub. L. 101-508 provided that: ''The amendments
made by this section (amending this section and sections 1396b, 1396d,
and 1396n of this title) shall be effective as if included in the
enactment of the Omnibus Budget Reconciliation Act of 1989 (Pub. L.
101-239).''
Section 4708(b) of Pub. L. 101-508 provided that: ''The amendments
made by this section (amending this section) shall apply to services
furnished on or after the date of the enactment of this Act (Nov. 5,
1990).''
Section 4711(e) of Pub. L. 101-508 provided that:
''(1) Except as provided in this subsection, the amendments made by
this section (enacting section 1396t of this title and amending this
section and sections 1396b and 1396d of this title) shall apply to home
and community care furnished on or after July 1, 1991, without regard to
whether or not final regulations to carry out such amendments have been
promulgated by such date.
''(2)(A) The amendments made by subsection (c)(1) (amending this
section) shall apply to home and community care furnished on or after
July 1, 1991, or, if later, 30 days after the date of publication of
interim regulations under section 1929(k)(1) (section 1396t(k)(1) of
this title).
''(B) The amendment made by subsection (c)(2) (amending section 1396b
of this title) shall apply to civil money penalties imposed after the
date of the enactment of this Act (Nov. 5, 1990).''
Section 4713(c) of Pub. L. 101-508 provided that: ''The amendments
made by this section (amending this section and section 1396d of this
title) shall apply to medical assistance furnished on or after January
1, 1991.''
Section 4715(b) of Pub. L. 101-508 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply to treatment
of income for months beginning more than 30 days after the date of the
enactment of this Act (Nov. 5, 1990).''
Section 4732(e) of Pub. L. 101-508 provided that: ''The amendments
made by this section (amending this section and section 1396b of this
title) shall take effect on the date of the enactment of this Act (Nov.
5, 1990).''
Section 4751(c) of Pub. L. 101-508 provided that: ''The amendments
made by this section (amending this section and sections 1396b and 1396r
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).''
Section 4752(c)(2) of Pub. L. 101-508 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
medical assistance for calendar quarters beginning more than 60 days
after the date of establishment of the physician identifier system under
section 1902(x) of the Social Security Act (subsec. (x) of this
section).''
Section 4754(b) of Pub. L. 101-508 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply to sanctions
effected more than 60 days after the date of the enactment of this Act
(Nov. 5, 1990).''
Section 4755(c)(1) of Pub. L. 101-508 provided that the amendment
made by that section is effective July 1, 1990.
Section 4801(e)(11) of Pub. L. 101-508 provided that the amendment
made by that section is effective on the date on which the Secretary
promulgates standards regarding the qualifications of nursing facility
administrators under section 1396r(f)(4) of this title.
Section 4801(e)(19) of Pub. L. 101-508 provided that: ''Except as
provided in paragraphs (7), (11), and (16), the amendments made by this
subsection (amending this section and sections 1396b and 1396r of this
title, repealing section 1396g of this title, and amending provisions
set out as a note under 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).''
Amendment by section 6115(c) of Pub. L. 101-239 applicable to
screening pap smears performed on or after July 1, 1990, see section
6115(d) of Pub. L. 101-239, set out as a note under section 1395x of
this title.
Section 6401(c) of Pub. L. 101-239 provided that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (amending this section and section 1396b of this title)
shall apply to payments under title XIX of the Social Security Act (this
subchapter) for calendar quarters beginning on or after April 1, 1990,
with respect to eligibility for medical assistance on or after such
date, without regard to whether or not final regulations to carry out
such amendments have been promulgated by such date.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than legislation
appropriating funds) in order for the plan to meet the additional
requirements imposed by the amendments made by this section, the State
plan shall not be regarded as failing to comply with the requirements of
such title solely on the basis of its failure to meet these additional
requirements before the first day of the first calendar quarter
beginning after the close of the first regular session of the State
legislature that begins after the date of the enactment of this Act
(Dec. 19, 1989). For purposes of the previous sentence, in the case of
a State that has a 2-year legislative session, each year of such session
shall be deemed to be a separate regular session of the State
legislature.''
Section 6402(c), formerly 6402(d), of Pub. L. 101-239, as
renumbered and amended by Pub. L. 101-508, title IV, 4704(e)(2), Nov.
5, 1990, 104 Stat. 1388-172, provided that: ''The amendments made by
this section (enacting section 1396r-7 of this title and amending this
section) (except as otherwise provided in such amendments) shall take
effect on the date of the enactment of this Act (Dec. 19, 1989).''
Section 6403(e) of Pub. L. 101-239 provided that: ''The amendments
made by this section (amending this section and section 1396d of this
title) shall take effect on April 1, 1990, without regard to whether or
not final regulations to carry out such amendments have been promulgated
by such date.''
Section 6404(d) of Pub. L. 101-239 provided that:
''(1) The amendments made by this section (amending this section and
section 1396d of this title) apply (except as provided under paragraph
(2)) to payments under title XIX of the Social Security Act (this
subchapter) for calendar quarters beginning on or after April 1, 1990,
without regard to whether or not final regulations to carry out such
amendments have been promulgated by such date.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than legislation
appropriating funds) in order for the plan to meet the additional
requirements imposed by the amendments made by this section, the State
plan shall not be regarded as failing to comply with the requirements of
such title solely on the basis of its failure to meet these additional
requirements before the first day of the first calendar quarter
beginning after the close of the first regular session of the State
legislature that begins after the date of the enactment of this Act
(Dec. 19, 1989). For purposes of the previous sentence, in the case of
a State that has a 2-year legislative session, each year of such session
shall be deemed to be a separate regular session of the State
legislature.''
Section 6405(c) of Pub. L. 101-239 provided that: ''The amendments
made by this section (amending this section and section 1396d of this
title) shall become effective with respect to services furnished by a
certified pediatric nurse practitioner or certified family nurse
practitioner on or after July 1, 1990.''
Section 6406(b) of Pub. L. 101-239 provided that: ''The amendments
made by subsection (a) (amending this section) shall take effect on July
1, 1990, without regard to whether regulations to carry out such
amendments have been promulgated by such date.''
Section 6408(c)(2) of Pub. L. 101-239 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
services furnished on or after April 1, 1990, without regard to whether
or not final regulations have been promulgated by such date to implement
such amendments.''
Section 6408(d)(5) of Pub. L. 101-239 provided that:
''(A) The amendments made by this subsection (amending this section
and sections 1396d and 1396o of this title) apply (except as provided
under subparagraph (B)) to payments under title XIX of the Social
Security Act (this subchapter) for calendar quarters beginning on or
after July 1, 1990, without regard to whether or not final regulations
to carry out such amendments have been promulgated by such date.
''(B) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than legislation
appropriating funds) in order for the plan to meet the additional
requirements imposed by the amendments made by this subsection, the
State plan shall not be regarded as failing to comply with the
requirements of such title solely on the basis of its failure to meet
these additional requirements before the first day of the first calendar
quarter beginning after the close of the first regular session of the
State legislature that begins after the date of the enactment of this
Act (Dec. 19, 1989). For purposes of the previous sentence, in the case
of a State that has a 2-year legislative session, each year of such
session shall be deemed to be a separate regular session of the State
legislature.''
Section 6411(a)(2) of Pub. L. 101-239 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply as
if it had been included in the enactment of the Medicare Catastrophic
Coverage Act of 1988 (Pub. L. 100-360).''
Amendment by section 6411(d)(3)(B) of Pub. L. 101-239 applicable to
employment and contracts as of 90 days after Dec. 19, 1989, see section
6411(d)(4)(B) of Pub. L. 101-239, set out as a note under section
1395mm of this title.
Section 6411(e)(4) of Pub. L. 101-239 provided that:
''(A) Spousal transfers. -- The amendments made by paragraph (1)
(amending section 1396p of this title) shall apply to transfers
occurring after the date of the enactment of this Act (Dec. 19, 1989).
''(B) Other amendments. -- Except as provided in subparagraph (A),
the amendments made by this subsection (amending this section and
sections 1396p and 1396r-5 of this title) shall apply as if included in
the enactment of section 303 of the Medicare Catastrophic Coverage Act
of 1988 (Pub. L. 100-360).''
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.
Section 8434(c) of Pub. L. 100-647 provided that: ''The amendment
made by this section (amending this section and section 1396d of this
title) shall be effective as if included in the enactment of section 301
of the Medicare Catastrophic Coverage Act of 1988 (Pub. L. 100-360).''
Amendment by section 202(c)(4) of Pub. L. 100-485 effective Oct. 1,
1990, with provision for earlier effective dates in case of States
making certain changes in their State plans and formally notifying the
Secretary of Health and Human Services of their desire to become subject
to the amendments by title II of Pub. L. 100-485 at such earlier
effective dates, see section 204(a), (b)(1)(A) of Pub. L. 100-485, set
out as a note under section 681 of this title.
Amendments by section 303(a)(2), (b)(1) of Pub. L. 100-485
applicable to payments under this subchapter for calendar quarters
beginning on or after Apr. 1, 1990 (or, in the case of the Commonwealth
of Kentucky, Oct. 1, 1990) (without regard to whether regulations to
implement such amendments are promulgated by that date), with respect to
families that cease to be eligible for aid under part A of subchapter IV
of this chapter on or after that date, see section 303(f)(1) of Pub. L.
100-485, set out as an Effective and Termination Dates of 1988 Amendment
note under section 602 of this title.
Amendment by section 303(d) of Pub. L. 100-485 effective on first
day of first calendar quarter to begin one year or more after Oct. 13,
1988, see sections 303(f)(3) and 403(b) of Pub. L. 100-485, set out as
Effective and Termination Dates of 1988 Amendment notes under section
602 of this title.
Amendment by section 401(d)(1) of Pub. L. 100-485, effective Oct.
1, 1990, except as provided in section 1396d(m)(2) of this title and not
effective for Puerto Rico, Guam, American Samoa, and the Virgin Islands,
until Oct. 1, 1992, see section 401(g) of Pub. L. 100-485, set out as
an Effective and Termination Dates of 1988 Amendment note under section
602 of this title.
Amendment by section 608(d)(14)(I), (15)(A), (B), (16)(C),
(27)(F)-(H), (28) of Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 204(d)(3) of Pub. L. 100-360 applicable to
screening mammography performed on or after Jan. 1, 1990, see section
204(e) of Pub. L. 100-360, set out as a note under section 1395m of
this title.
Amendment by section 301(e)(2) of Pub. L. 100-360 effective July 1,
1989, see section 301(e)(3) of Pub. L. 100-360, set out as a note under
section 1395v of this title.
Section 301(h) of Pub. L. 100-360, as amended by Pub. L. 100-485,
title VI, 608(d)(14)(K), Oct. 13, 1988, 102 Stat. 2416, provided
that:
''(1) The amendments made by this section (amending this section and
sections 1395v, 1396b, and 1396d of this title) apply (except as
provided in subsections (e) and (f) (set out as notes under section
1395v and 1396b of this title) and under paragraph (2)) to payments
under title XIX of the Social Security Act (this subchapter) for
calendar quarters beginning on or after January 1, 1989, without regard
to whether or not final regulations to carry out such amendments have
been promulgated by such date, with respect to medical assistance for --
''(A) monthly premiums under title XVIII of such Act (subchapter
XVIII of this chapter) for months beginning with January 1989, and
''(B) items and services furnished on and after January 1, 1989.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary of
Health and Human Services determines requires State legislation (other
than legislation appropriating funds) in order for the plan to meet the
additional requirements imposed by the amendments made by this section,
the State plan shall not be regarded as failing to comply with the
requirements of such title solely on the basis of its failure to meet
these additional requirements before the first day of the first calendar
quarter beginning after the close of the first session of the State
legislature that begins after the date of the enactment of this Act
(July 1, 1988). For purposes of the previous sentence, in the case of a
State that has a 2-year legislative session, each year of such session
shall be deemed to be a separate regular session of the State
legislature.''
Section 302(f) of Pub. L. 100-360 provided that:
''(1) In general. -- The amendments made by this section (amending
this section and sections 1396b and 1396r-4 of this title) apply (except
as provided in this subsection) to payments under title XIX of the
Social Security Act (this subchapter) for calendar quarters beginning on
or after July 1, 1989, with respect to eligibility for medical
assistance on or after such date, without regard to whether or not final
regulations to carry out such amendments have been promulgated by such
date.
''(2) Payment adjustment. -- The amendments made by subsection (b)(2)
(amending section 1396r-4 of this title) shall take effect on the date
of the enactment of this Act (July 1, 1988).
''(3) Delay for state legislation. -- In the case of a State plan for
medical assistance under title XIX of the Social Security Act (this
subchapter) which the Secretary of Health and Human Services determines
requires State legislation (other than legislation appropriating funds)
in order for the plan to meet the additional requirements imposed by the
amendments made by this section (other than subsection (b)(2)), the
State plan shall not be regarded as failing to comply with the
requirements of such title solely on the basis of its failure to meet
these additional requirements before the first day of the first calendar
quarter beginning after the close of the first regular session of the
State legislature that begins after the date of the enactment of this
Act. For purposes of the previous sentence, in the case of a State that
has a regular legislative session of 2 years, each year of such session
shall be deemed to be a separate regular session of the State
legislature.''
Amendment by section 303(d) of Pub. L. 100-360 effective on and
after Apr. 8, 1988, with additional provision for supersedure of
certain administrative regulations, see section 303(g)(4) of Pub. L.
100-360, set out as an Effective Date note under section 1396r-5 of this
title.
Amendment by section 303(e)(1), (5) of Pub. L. 100-360 applicable to
medical assistance furnished on or after Oct. 1, 1982, see section
303(g)(6) of Pub. L. 100-360, set out as an Effective Date note under
section 1396r-5 of this title.
Subsec. (a)(51)(A), as enacted by section 303(e)(2)-(4) of Pub. L.
100-360, applicable to payments under this subchapter for calendar
quarters beginning on or after Sept. 30, 1989, without regard to
whether or not final regulations to carry out that paragraph have been
promulgated by that date, see section 303(g)(1)(A) of Pub. L. 100-360,
set out as an Effective Date note under section 1396r-5 of this title.
Subsec. (a)(51)(B), as enacted by section 303(e)(2)-(4) of Pub. L.
100-360, applicable to payments under this subchapter for calendar
quarters beginning on or after July 1, 1988 (except in certain
situations requiring State legislative action), without regard to
whether or not final regulations to carry out that paragraph have been
promulgated by that date, with an exception for resources disposed of
before July 1, 1988, see section 303(g)(2)(A), (C), (5) of Pub. L.
100-360, set out as an Effective Date note under section 1396r-5 of this
title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(k)(5), (7)(B)-(D), (10)(G)(ii), (iv), (17)(B),
(l)(3)(E), (H), (J), (6)(C), (D), (8)(C), and (n)(2), (4) 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.
For contingent effective date of amendment by section 4072(d) of Pub.
L. 100-203, see section 4072(e) of Pub. L. 100-203, set out as a note
under section 1395x of this title.
Section 4101(a)(3) of Pub. L. 100-203 provided that: ''The
amendments made by this subsection (amending this section) shall apply
to medical assistance furnished on or after July 1, 1988.''
Section 4101(b)(3) of Pub. L. 100-203 provided that: ''The
amendments made by this subsection (amending this section and provisions
set out below) shall apply with respect to medical assistance furnished
on or after July 1, 1988.''
Amendment by section 4101(c)(2) of Pub. L. 100-203 applicable to
medical assistance furnished on or after Oct. 1, 1988, see section
4101(c)(3) of Pub. L. 100-203, set out as a note under section 1396d of
this title.
Section 4101(e)(6) of Pub. L. 100-203 provided that:
''(A) The amendment made by paragraph (1) (amending this section)
shall become effective on the date of enactment of this Act (Dec. 22,
1987).
''(B) The amendments made by paragraphs (2) and (3) (amending this
section) shall be effective as if they had been included in the
enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985
(Pub. L. 99-272).
''(C) The amendment made by paragraph (4) (amending this section)
shall apply to elections made on or after the enactment of this Act.
''(D) The amendment made by paragraph (5) (amending this section)
shall apply as if included in the enactment of section 9401 of the
Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99-509).''
Section 4113(c)(3) of Pub. L. 100-203 provided that: ''The
amendments made by this subsection (amending this section) shall apply
to services furnished on and after July 1, 1988.''
Section 4118(c)(2) of Pub. L. 100-203 provided that: ''The
amendment made by paragraph (1) (amending this section) shall be
effective as if it were included in section 134 of the Tax Equity and
Fiscal Responsibility Act of 1982 (Pub. L. 97-248).''
Section 4118(h)(3), formerly 4118(h)(2), of Pub. L. 100-203, as
renumbered and amended by Pub. L. 100-360, title IV,
411(k)(10)(G)(iii), July 1, 1988, 102 Stat. 796, provided that: ''The
amendments made by this subsection (amending this section and section
1396b of this title) shall apply to costs incurred after the date of the
enactment of this Act (Dec. 22, 1987).''
Section 4118(m)(2) of Pub. L. 100-203 provided that: ''The
amendments made by paragraph (1) (amending this section and repealing
section 1320a-8 of this title) shall apply to audits conducted after the
date of the enactment of this Act (Dec. 22, 1987).''
Amendments by sections 4211(b)(1), (h)(1)-(5), 4212(d)(2), (3),
(e)(1) of Pub. L. 100-203 applicable to nursing facility services
furnished on or after Oct. 1, 1990, without regard to whether
regulations implementing such amendments are promulgated by such date,
except as otherwise specifically provided in section 1396r of this
title, and except that subsec. (a)(28)(B) of this section as amended by
section 4211(b) of Pub. L. 100-203 applicable to calendar quarters
beginning more than 6 months after Dec. 22, 1987, with transitional
rule, see section 4214(a), (b)(2) of Pub. L. 100-203, as amended, set
out as an Effective Date note under section 1396r of this title.
Section 4212(d)(4) of Pub. L. 100-203 provided that: ''The
amendments made by this subsection (amending this section and section
1396b of this title) shall not apply to a State until such date (not
earlier than October 1, 1990) as of which the Secretary determines that
--
''(A) the State has specified the resident assessment instrument
under section 1919(e)(5) of the Social Security Act (section 1396r(e)(5)
of this title), and
''(B) the State has begun conducting surveys under section 1919(g)(2)
of such Act.''
Amendment by section 4213(b)(1) of Pub. L. 100-203 applicable to
payments under this subchapter for calendar quarters beginning on or
after Dec. 22, 1987, without regard to whether regulations implementing
such amendments are promulgated by such date, except as otherwise
specifically provided in section 1396r of this title, with transitional
rule, see section 4214(b) of Pub. L. 100-203, as amended, set out as an
Effective Date note under section 1396r of this title.
Section 4218(b) of Pub. L. 100-203 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply with respect
to certifications or recertifications during the period beginning on
July 1, 1988, and ending on October 1, 1990.''
Amendment by section 9115(b) of Pub. L. 100-203 effective July 1,
1988, see section 9115(c) of Pub. L. 100-203, set out as a note under
section 1382 of this title.
Section 9119(d)(2) of Pub. L. 100-203, as added by Pub. L.
100-360, title IV, 411(n)(4), formerly 411(n)(3), July 1, 1988, 102
Stat. 807, and renumbered by Pub. L. 100-485, title VI, 608(d)(28),
Oct. 13, 1988, 102 Stat. 2423, provided that: ''The amendments made
by paragraph (1) (amending this section) apply to payments under title
XIX of the Social Security Act (this subchapter) for calendar quarters
beginning on or after July 1, 1988, without regard to whether or not
final regulations to carry out such amendments have been promulgated by
such date.''
Amendment by sections 5(a) and 8(f) of Pub. L. 100-93, applicable,
with certain exception, to payments under subchapter XIX of this chapter
for calendar quarters beginning more than thirty days after Aug. 18,
1987, without regard to whether or not final regulations to carry out
such amendments have been published by such date, see section 15(c) of
Pub. L. 100-93, set out as a note under section 1320a-7 of this title.
Amendment by section 7 of Pub. L. 100-93 effective at end of
fourteen-day period beginning Aug. 18, 1987, and inapplicable to
administrative proceedings commenced before end of such period, see
section 15(a) of Pub. L. 100-93, set out as a note under section
1320a-7 of this title.
Section 10(b) of Pub. L. 99-643 provided that:
''(1) Except as provided in paragraph (2), the amendments made by
sections 3, 4, 5, 6, and 7 (amending this section and sections 1382,
1382c, 1382h, 1383, and 1396s of this title) shall become effective on
July 1, 1987.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary of
Health and Human Services determines requires State legislation in order
for the plan to meet the requirements imposed by the amendments made by
section 3(b) (amending this section) and section 7 of this Act (amending
this section and section 1382h of this title), the State plan shall not
be regarded as failing to comply with the requirements of such title
solely on the basis of its failure to meet such additional requirements
until 60 days after the close of the first regular session of the State
legislature that begins after the date of the enactment of this Act
(Nov. 10, 1986).''
Section 11005(c)(2) of Pub. L. 99-570 provided that: ''The
amendments made by subsection (b) (amending this section) shall become
effective on January 1, 1987, without regard to whether or not final
regulations to carry out such amendments have been promulgated by such
date.''
Amendment by Pub. L. 99-514 effective, except as otherwise provided,
as if included in enactment of the Consolidated Omnibus Budget
Reconciliation Act of 1985, Pub. L. 99-272, see section 1895(e) of Pub.
L. 99-514, set out as a note under section 162 of Title 26, Internal
Revenue Code.
Amendment by section 9320(h)(3) of Pub. L. 99-509 applicable to
services furnished on or after Jan. 1, 1989, with exceptions for
hospitals located in rural areas which meet certain requirements related
to certified registered nurse anesthetists, see section 9320(i), (k) of
Pub. L. 99-509, as amended, set out as notes under section 1395k of
this title.
Section 9401(f) of Pub. L. 99-509, as amended by Pub. L. 100-203,
title IV, 4101(b)(2)(C), Dec. 22, 1987, 101 Stat. 1330-141, provided
that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (amending this section and section 1396b of this title)
shall apply to medical assistance furnished in calendar quarters
beginning on or after April 1, 1987.
''(2) Subparagraph (C) of section 1902(l)(1) of the Social Security
Act (subsec. (l)(1)(C) of this section), as added by subsection (b) of
this section, shall apply to medical assistance furnished in calendar
quarters beginning on or after October 1, 1987.
''(3) An amendment made by this section shall become effective as
provided in paragraph (1) or (2) without regard to whether or not final
regulations to carry out such amendment have been promulgated by the
applicable date.''
Section 9402(c) of Pub. L. 99-509 provided that: ''The amendments
made by this section (amending this section) shall apply to payments to
States for calendar quarters beginning on or after July 1, 1987, without
regard to whether or not final regulations to carry out such amendments
have been promulgated by such date.''
Section 9403(h) of Pub. L. 99-509 provided that: ''The amendments
made by this section (amending this section and sections 1396b, 1396d,
and 1396o of this title) apply to payments under title XIX of the Social
Security Act (this subchapter) for calendar quarters beginning on or
after July 1, 1987, without regard to whether or not final regulations
to carry out such amendments have been promulgated by such date.''
Section 9404(c) of Pub. L. 99-509 provided that:
''(1) The amendments made by this section (amending this section and
section 1396d of this title) apply (except as provided under paragraph
(2)) to payments under title XIX of the Social Security Act (this
subchapter) for calendar quarters beginning on or after July 1, 1987,
without regard to whether regulations to implement such amendments are
promulgated by such date.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than legislation
appropriating funds) in order for the plan to meet the additional
requirements imposed by the amendments made by this section, the State
plan shall not be regarded as failing to comply with the requirements of
such title solely on the basis of its failure to meet these additional
requirements before the first day of the first calendar quarter
beginning after the close of the first regular session of the State
legislature that begins after the date of the enactment of this Act
(Oct. 21, 1986).''
Section 9406(c) of Pub. L. 99-509 provided that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (amending this section and section 1396b of this title)
shall apply to medical assistance furnished to aliens on or after
January 1, 1987, without regard to whether or not final regulations to
carry out such amendments have been promulgated by such date.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary of
Health and Human Services determines requires State legislation (other
than legislation appropriating funds) in order for the plan to meet the
additional requirement imposed by the amendment made in subsection (b)
(amending this section), the State plan shall not be regarded as failing
to comply with the requirements of such title solely on the basis of its
failure to meet such additional requirement before the first day of the
first calendar quarter beginning after the close of the first regular
session of the State legislature that begins after the date of the
enactment of this Act (Oct. 21, 1986).''
Section 9407(d) of Pub. L. 99-509 provided that: ''The amendments
made by this section (enacting section 1396r-1 of this title and
amending this section and sections 1396b and 1396s of this title) shall
apply to ambulatory prenatal care furnished in calendar quarters
beginning on or after April 1, 1987, without regard to whether or not
final regulations to carry out such amendments have been promulgated by
such date.''
Section 9408(d) of Pub. L. 99-509 provided that: ''The amendments
made by this section (amending this section and section 1396d of this
title) shall apply to services furnished on or after the date of the
enactment of this Act (Oct. 21, 1986).''
Section 9431(c) of Pub. L. 99-509 provided that: ''The amendments
made by this section (amending this section and section 1396b of this
title) apply to payments under title XIX of the Social Security Act
(this subchapter) for calendar quarters beginning on or after July 1,
1987, without regard to whether or not final regulations to carry out
such amendments have been promulgated by such date.''
Section 9433(b) of Pub. L. 99-509 provided that: ''The amendment
made by subsection (a) (amending section 2173 of Pub. L. 97-35, which
amended this section) shall apply as though it was included in the
enactment of the Omnibus Budget Reconciliation Act of 1981 (Public Law
97-35).''
Section 9435(f) of Pub. L. 99-509 provided that: ''The amendments
made by this section (amending this section and section 1396d of this
title and provisions set out as notes under this section and sections
1396d and 1396n of this title) shall be effective as if included in the
enactment of the Consolidated Omnibus Budget Reconciliation Act of 1985
(Pub. L. 99-272).''
Section 9501(d)(2), (3) of Pub. L. 99-272 provided that:
''(2) Optional services. -- The amendments made by subsection (b)
(amending this section) shall become effective on the date of the
enactment of this Act (Apr. 7, 1986).
''(3) Continued coverage. -- The amendment made by subsection (c)
(amending this section) shall apply to medical assistance furnished to a
woman on or after the date of the enactment of this Act.''
Section 9503(g) of Pub. L. 99-272 provided that:
''(1) Except as otherwise provided, the amendments made by this
section (amending this section and sections 1396b and 1396k of this
title and section 1144 of Title 29, Labor, and enacting provisions set
out as notes under this section and section 1144 of Title 29) shall
apply to calendar quarters beginning on or after the date of the
enactment of this Act (Apr. 7, 1986).
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary of
Health and Human Services determines requires State legislation (other
than legislation appropriating funds) in order for the plan to meet the
additional requirements imposed by the amendments made by this section,
the State plan shall not be regarded as failing to comply with the
requirements of such title solely on the basis of its failure to meet
these additional requirements before the first day of the first calendar
quarter beginning after the close of the first regular session of the
State legislature that begins after the date of the enactment of this
Act.
''(3) No penalty may be applied against any State for a violation of
section 1902(a)(25) of the Social Security Act (subsec. (a)(25) of this
section) occurring prior to the effective date of the amendments made by
this section.
''(4) The amendment made by subsection (c) (enacting provisions set
out below) shall become effective on the date of the enactment of this
Act (Apr. 7, 1986).''
Section 9505(e) of Pub. L. 99-272, as amended by Pub. L. 99-509,
title IX, 9435(d)(1), Oct. 21, 1986, 100 Stat. 2070, provided that:
''The amendments made by this section (amending this section and
sections 1396d and 1396o of this title) shall apply to medical
assistance provided for hospice care furnished on or after the date of
the enactment of this Act (Apr. 7, 1986), without regard to whether or
not regulations to carry out the amendments have been promulgated by
that date.''
Section 9506(b), (c) of Pub. L. 99-272, as amended by Pub. L.
99-509, title IX, 9435(c), Oct. 21, 1986, 100 Stat. 2070, provided
that:
''(b) Effective Date. -- The amendment made by subsection (a)
(amending this section) shall apply to medical assistance furnished on
or after the first day of the second month beginning after the date of
the enactment of this Act (Apr. 7, 1986).
''(c) Exception. -- The amendment made by subsection (a) (amending
this section) shall not apply to any trust or initial trust decree
established prior to April 7, 1986, solely for the benefit of a mentally
retarded individual who resides in an intermediate care facility for the
mentally retarded.''
Section 9509(b) of Pub. L. 99-272 provided that:
''(1) Except as provided in paragraphs (2) and (3), the amendments
made by this section (amending this section and enacting provisions set
out below) shall apply to medical assistance furnished on or after
October 1, 1985, but only with respect to changes of ownership occurring
on or after such date.
''(2) The amendments made by this section shall not apply with
respect to a change of ownership pursuant to an enforceable agreement
entered into prior to October 1, 1985.
''(3) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary of
Health and Human Services determines requires State legislation (other
than legislation appropriating funds) in order for the plan to meet the
requirements imposed by the amendments made by this section, the State
plan shall not be regarded as failing to comply with the requirements of
such title solely on the basis of its failure to meet the requirements
imposed by the amendments made by this section before the first day of
the first calendar quarter beginning after the close of the first
regular session of the State legislature that begins after the date of
the enactment of this Act (Apr. 7, 1986).''
Section 9510(b) of Pub. L. 99-272, as amended by Pub. L. 99-509,
title IX, 9435(d)(2), Oct. 21, 1986, 100 Stat. 2070, provided that:
''The amendment made by this section (amending this section) shall apply
with respect to payment for services furnished on or after October 1,
1985, without regard to whether or not regulations to carry out the
amendment have been promulgated by that date.''
Section 9529(a)(2) of Pub. L. 99-272 provided that: ''The amendment
made by paragraph (1) (amending this section) shall apply to medical
assistance furnished on or after the first calendar quarter that begins
more than 90 days after the date of the enactment of this Act (Apr. 7,
1986).''
Section 9529(b)(3) of Pub. L. 99-272 provided that: ''This
subsection, and the amendments made by this subsection (amending this
section and enacting provisions set out below), shall apply to adoption
assistance agreements entered into before, on, or after the date of the
enactment of this Act (Apr. 7, 1986).''
Amendment by section 12305(b)(3) of Pub. L. 99-272 applicable to
medical assistance furnished in or after first calendar quarter
beginning more than 90 days after Apr. 7, 1986, see section 12305(c) of
Pub. L. 99-272, set out as a note under section 673 of this title.
Amendment by Pub. L. 98-617 effective as if originally included in
the Deficit Reduction Act of 1984, Pub. L. 98-369, see section 3(c) of
Pub. L. 98-617, set out as a note under section 1395f of this title.
Amendment by section 2303(g)(1) of Pub. L. 98-369 applicable to
clinical diagnostic laboratory tests furnished on or after July 1, 1984,
but not applicable to clinical diagnostic laboratory tests furnished to
inpatients of a provider operating under a waiver granted pursuant to
section 602(k) of Pub. L. 98-21, set out as a note under section 1395y
of this title, see section 2303(j)(1) and (3) of Pub. L. 98-369, set
out as a note under section 1395l of this title.
Section 2314(c)(3) of Pub. L. 98-369 provided that:
''(A) Except as provided in subparagraph (B), the amendments made by
subsection (b) (amending this section) shall apply to medical assistance
furnished on or after October 1, 1984.
''(B) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary of
Health and Human Services determines requires State legislation in order
for the plan to meet the additional requirement imposed by the
amendments made by this section (amending this section and section 1395x
of this title and enacting provisions set out as a note under section
1395x of this title), the State plan shall not be regarded as failing to
comply with the requirements of such title solely on the basis of its
failure to meet this additional requirement before the first day of the
first calendar quarter beginning after the close of the first regular
session of the State legislature that begins after the date of the
enactment of this Act (July 18, 1984).''
Amendment by section 2335(e) of Pub. L. 98-369 effective July 18,
1984, see section 2335(g) of Pub. L. 98-369, set out as a note under
section 1395f of this title.
Section 2361(d) of Pub. L. 98-369 provided that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (amending this section and sections 606 and 1396d of this
title) shall apply to calendar quarters beginning on or after October 1,
1984, without regard to whether or not final regulations to carry out
such amendments have been promulgated by such date.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary of
Health and Human Services determines requires State legislation in order
for the plan to meet the additional requirements imposed by the
amendments made by this section, the State plan shall not be regarded as
failing to comply with the requirements of such title solely on the
basis of its failure to meet these additional requirements before the
first day of the first calendar quarter beginning after the close of the
first regular session of the State legislature that begins after the
date of the enactment of this Act (July 18, 1984).''
Section 2362(b) of Pub. L. 98-369 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply to children
born on or after October 1, 1984.''
Amendment by section 2363(a)(1) of Pub. L. 98-369 applicable to
calendar quarters beginning on or after July 18, 1984, except that, in
the case of individuals admitted to skilled nursing facilities before
that date, the amendment shall not require recertifications sooner or
more frequently than were required under the law in effect before that
date, see section 2363(c) of Pub. L. 98-369, set out as a note under
section 1396b of this title.
Section 2367(c) of Pub. L. 98-369 provided that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (amending this section and section 1396k of this title)
shall become effective on October 1, 1984.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary of
Health and Human Services determines requires State legislation in order
for the plan to meet the additional requirement imposed by the
amendments made by this section, the State plan shall not be regarded as
failing to comply with the requirements of such title solely on the
basis of its failure to meet this additional requirement before the
first day of the first calendar quarter beginning after the close of the
first regular session of the State legislature that begins after the
date of the enactment of this Act (July 18, 1984).''
Section 2368(c) of Pub. L. 98-369 provided that: ''The amendments
made by this section (amending this section) shall become effective on
the date of the enactment of this Act (July 18, 1984).''
Amendment by section 2651(c) of Pub. L. 98-369 effective Apr. 1,
1985, except as otherwise provided, see section 2651(l)(2) of Pub. L.
98-369, set out as an Effective Date note under section 1320b-7 of this
title.
Amendment by section 131(a), (c) of Pub. L. 97-248 effective Oct.
1, 1982, see section 131(d) of Pub. L. 97-248, formerly 131(c),
redesignated Pub. L. 97-448, title III, 309(a)(8), Jan. 12, 1983, 96
Stat. 2408, set out as an Effective Date note under section 1396o of
this title.
Amendment by section 132(a), (c) of Pub. L. 97-248 effective Sept.
3, 1982, see section 132(d) of Pub. L. 97-248, set out as an Effective
Date note under section 1396p of this title.
Section 134(b) of Pub. L. 97-248 provided that: ''The amendment
made by subsection (a) (amending this section) shall become effective on
October 1, 1982.''
Amendment by section 136(d) of Pub. L. 97-248 effective Oct. 1,
1982, see section 136(e) of Pub. L. 97-248, set out as a note under
section 1301 of this title.
Section 137(d) of Pub. L. 97-248 provided that:
''(1) Except as otherwise provided in this section, any amendment to
the Omnibus Budget Reconciliation Act of 1981 (Pub. L. 97-35) made by
this section (amending this section and sections 1320a-1 and 1396b of
this title and provisions set out as a note under section 603 of this
title) shall be effective as if it had been originally included in the
provision of the Omnibus Budget Reconciliation Act of 1981 to which such
amendment relates.
''(2) Except as otherwise provided in this section, any amendment to
the Social Security Act (this chapter) made by the preceding provisions
of this section (amending this section and sections 701, 705, 1320a-7a,
1320b-4, 1396b, 1396d, and 1396n of this title) shall be effective as if
it had been originally included as a part of that provision of the
Social Security Act to which it relates, as such provision of the Social
Security Act was amended by the Omnibus Budget Reconciliation Act of
1981 (Pub. L. 97-35).''
Amendment by section 146(a) 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.
Section 2113(o) of Pub. L. 97-35 provided that: ''The amendments
made by this section (amending this section and sections 1320c, 1320c-1,
1320c-3, 1320c-4, 1320c-7, 1320c-8, 1320c-9, 1320c-11, 1320c-17,
1320c-21, and 1396b of this title and repealing sections 1320c-13 and
1320c-20 of this title) apply to agreements with Professional Standards
Review Organizations entered into on or after October 1, 1981.''
Section 2171(c) of Pub. L. 97-35 provided that: ''The amendments
made by this section (amending this section) shall become effective on
the date of the enactment of this Act (Aug. 13, 1981).''
Section 2172(c) of Pub. L. 97-35 provided that: ''The amendments
made by this section (amending this section and section 1396d of this
title) shall become effective on the date of the enactment of this Act
(Aug. 13, 1981).''
Section 2173(b)(2) of Pub. L. 97-35 provided that: ''The amendment
made by paragraph (1) (amending this section) shall not apply with
respect to services furnished before the date the Secretary of Health
and Human Services first promulgates and has in effect final regulations
(on an interim or other basis) to carry out section 1902(a)(13)(A) of
the Social Security Act (subsec. (a)(13)(A) of this section) (as amended
by this subtitle).''
Section 2174(c) of Pub. L. 97-35 provided that: ''The amendments
made by this section (amending this section and section 1396b of this
title) shall apply to services furnished on or after October 1, 1981.''
Section 2175(d)(2) of Pub. L. 97-35 provided that:
''(A) The amendments made by paragraph (1) (amending this section)
shall (except as provided under subparagraph (B)) be effective with
respect to payments under title XIX of the Social Security Act (this
subchapter) for calendar quarters beginning on or after October 1, 1981.
''(B) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary of
Health and Human Services determines requires State legislation in order
for the plan to meet the additional requirement imposed by the amendment
made by paragraph (1)(C), the State plan shall not be regarded as
failing to comply with the requirements of such title solely on the
basis of its failure to meet this additional requirement before the
first day of the first calendar year beginning after the close of the
first regular session of the State legislature that begins after the
date of the enactment of this Act (Aug. 13, 1981).''
Section 2178(c) of Pub. L. 97-35 provided that: ''The amendments
made by this section (amending this section and section 1396b of this
title) shall apply with respect to services furnished, under a State
plan approved under title XIX of the Social Security Act (this
subchapter), on or after October 1, 1981; except that such amendments
shall not apply with respect to services furnished by a health
maintenance organization under a contract with a State entered into
under such title before October 1, 1981 unless the organization requests
that such amendments apply and the Secretary of Health and Human
Services and the single State agency (administering or supervising the
administration of the State plan under such title) agree to such
request.''
Amendment by section 2181(a)(2) of Pub. L. 97-35 effective Oct. 1,
1981, see section 2181(b) of Pub. L. 97-35, set out as a note under
section 603 of this title.
For effective date, savings, and transitional provisions relating to
amendment by section 2193(c)(9) of Pub. L. 97-35, see section 2194 of
Pub. L. 97-35, set out as a note under section 701 of this title.
Amendment by section 902(b) of Pub. L. 96-499 effective on date on
which final regulations to implement the amendment are first issued, see
section 902(c) of Pub. L. 96-499, set out as a note under section 1395x
of this title.
Section 914(b)(2) of Pub. L. 96-499, as amended by Pub. L. 97-248,
title I, 137(c)(1), Sept. 3, 1982, 96 Stat. 381, provided that:
''(A) The amendments made by paragraph (1) (amending this section)
shall (except as provided under subparagraph (B)) apply to cost
reporting periods, beginning on or after April 1, 1981, of an entity
providing services under a State plan approved under title XIX of the
Social Security Act (this subchapter).''
''(B) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary determines requires
State legislation in order for the plan to meet the additional
requirements imposed by the amendments made by paragraph (1), the State
plan shall not be regarded as failing to comply with the requirements of
such title solely on the basis of its failure to meet these additional
requirements before the first day of the first calendar quarter
beginning after the close of the first regular session of the State
legislature that begins after the date of the enactment of this Act.''
Section 918(b)(2) of Pub. L. 96-499 provided that:
''(A) The amendments made by paragraph (1) (enacting this section)
shall (except as otherwise provided in subparagraph (B)) apply to
medical assistance provided, under a State plan approved under title XIX
of the Social Security Act (this subchapter), on and after the first day
of the first calendar quarter that begins more than six months after the
date of the enactment of this Act (Dec. 5, 1980).
''(B) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation in order for the plan to
meet the additional requirements imposed by the amendments made by
paragraph (1), the State plan shall not be regarded as failing to comply
with the requirements of such title solely on the basis of its failure
to meet these additional requirements before the first day of the first
calendar quarter beginning after the close of the first regular session
of the State legislature that begins after the date of the enactment of
this Act.''
Section 962(b) of Pub. L. 96-499 provided that: ''The amendment
made by subsection (a) (amending this section) shall become effective on
October 1, 1980.''
Section 965(c) of Pub. L. 96-499 provided that:
''(1) The amendments made by this section (amending this section and
section 1396d of this title) shall (except as provided under paragraph
(2)) be effective with respect to payments under title XIX of the Social
Security Act (this subchapter) for calendar quarters beginning more than
one hundred and twenty days after the date of the enactment of this Act
(Dec. 5, 1980).
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation in order for the plan to
meet the additional requirements imposed by the amendments made by this
section, the State plan shall not be regarded as failing to comply with
the requirements of such title solely on the basis of its failure to
meet these additional requirements before the first day of the first
calendar quarter beginning after the close of the first regular session
of the State legislature that begins after the date of the enactment of
this Act.''
Section 14(a)(2) of Pub. L. 95-559 provided that:
''(A) Except as provided in subparagraph (B), the amendments made by
paragraph (1) (amending this section) shall take effect one hundred and
eighty days after the date of the enactment of this Act (Nov. 1, 1978).
''(B) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary
determines requires State legislation in order for the plan to meet the
requirement added by the amendments made by paragraph (1), such
amendments shall not apply with respect to such State plan before ninety
days after the close of the first regular session of the State
legislature that begins after the date of the enactment of this Act.''
Amendment by Pub. L. 95-210 applicable to medical assistance
provided, under a State plan approved under subchapter XIX of this
chapter, on and after the first day of the first calendar quarter that
begins more than six months after Dec. 13, 1977, with exception for
plans requiring State legislation, see section 2(f) of Pub. L. 95-210,
set out as a note under section 1395cc of this title.
Amendment by section 2(a)(3) of Pub. L. 95-142 applicable with
respect to care and services furnished on or after Oct. 25, 1977, see
section 2(a)(4) of Pub. L. 95-142, set out as a note under section
1395g of this title.
Section 2(b)(2) of Pub. L. 95-142 provided that: ''The amendments
made by paragraph (1) (amending this section) shall apply to calendar
quarters beginning on and after July 1, 1978, with respect to State
plans approved under title XIX of the Social Security Act (this
subchapter).''
Amendment by section 3(c)(1) of Pub. L. 95-142 effective Jan. 1,
1978, see section 3(e) of Pub. L. 95-142, set out as an Effective Date
note under section 1320a-3 of this title.
Section 7(e)(2) of Pub. L. 95-142 provided that: ''The amendment
made by subsection (b) (amending this section) shall become effective on
January 1, 1978.''
Section 19(c)(2) of Pub. L. 95-142 provided that:
''(A) The amendments made by subsection (b) (amending this section
and section 1395x of this title) shall apply with respect to operations
of a hospital, skilled nursing facility, or intermediate care facility,
on and after the first day of its first fiscal year which begins after
the end of the six-month period beginning on the date a uniform
reporting system is established (under section 1121(a) of the Social
Security Act) (section 1320a(a) of this title) for that type of health
services facility.
''(B) The amendments made by subsection (b) (amending this section
and section 1395x of this title) shall apply, with respect to the
operation of a health services facility or organization which is neither
a hospital, a skilled nursing facility, nor an intermediate care
facility, on and after the first day of its first fiscal year which
begins after such date as the Secretary of Health, Education, and
Welfare (now Health and Human Services) determines to be appropriate for
the implementation of the reporting requirement for that type of
facility or organization.
''(C) Except as provided in subparagraphs (A) and (B), the amendments
made by subsection (b)(2) (amending this section) shall apply, with
respect to State plans approved under title XIX of the Social Security
Act (this subchapter), on and after October 1, 1977.''
Amendment by section 20(b) of Pub. L. 95-142 effective Oct. 1,
1977, and the Secretary to adjust payments made to States under section
1396b of this title to reflect such amendment, see section 20(c) of Pub.
L. 95-142, set out as a note under section 1396b of this title.
Section 2 of Pub. L. 94-552 provided that: ''The amendments made by
the first section (amending this section and section 1396b of this
title) shall take effect as of January 1, 1976.''
Section 111(c) of Pub. L. 94-182 provided that: ''The amendments
made by this section (amending this section and section 1396b of this
title) shall (except as otherwise provided for therein) become effective
January 1, 1976.''
Section 9(b) of Pub. L. 93-368 provided that: ''The amendment made
by subsection (a) (amending this section) shall be effective January 1,
1973.''
Section 13(d) of Pub. L. 93-233 provided that: ''The amendments
made by subsection (a) (amending this section and sections 1396, 1396b,
and 1396d of this title) shall be effective with respect to payments
under section 1903 of the Social Security Act (section 1396b of this
title) for calendar quarters commencing after December 31, 1973.''
Section 18(z-3)(4) of Pub. L. 93-233 provided that: ''The
amendments made by subsections (o) and (u) (amending this section and
section 1396b of this title) shall be effective July 1, 1973''.
Section 208(b) of Pub. L. 92-603 provided that: ''The amendment
made by subsection (a) (amending this section) shall be effective
January 1, 1973 (or earlier if the State plan so provided).''
Section 209(b)(2) of Pub. L. 92-603 provided that: ''The amendment
made by this subsection (amending this section) shall become effective
on January 1, 1974.''
Section 232(c) of Pub. L. 92-603 provided that: ''The amendments
made by this section (amending this section and section 705 of this
title) shall be effective July 1, 1972 (or earlier if the State plan so
provides).''
Amendment by section 236(b) of Pub. L. 92-603 effective Jan. 1,
1973, or earlier if the State plan so provides, see section 236(c) of
Pub. L. 92-603, set out as a note under section 1395u of this title.
Section 237(d)(2) of Pub. L. 92-603 provided that: ''The amendment
made by subsection (a)(2) (amending this section) shall be effective
July 1, 1973.''
Section 239(d) of Pub. L. 92-603 provided that: ''The amendments
made by this section (amending this section and section 705 of this
title) shall be effective January 1, 1973 (or earlier if the State plan
so provides).''
Amendment by section 246(a) of Pub. L. 92-603 to be effective July
1, 1973, see section 246(c) of Pub. L. 92-603, set out as a note under
section 1395x of this title.
Section 255(b) of Pub. L. 92-603 provided that: ''The amendments
made by subsection (a) (amending this section) shall be effective July
1, 1973.''
Section 268(c) of Pub. L. 92-603 provided that: ''The amendments
made by this section (amending this section and section 1396g of this
title) shall be effective on the date of the enactment of this Act (Oct.
30, 1972).''
Amendment by section 299D(b) of Pub. L. 92-603 effective beginning
Jan. 1, 1973, or within 6 months following Oct. 30, 1972, whichever is
later, see section 299D(c) of Pub. L. 92-603, set out as a note under
section 1395aa of this title.
Section 4(d) of Pub. L. 92-223, as amended by section 292 of Pub.
L. 92-603, provided that: ''The amendments made by this section
(amending this section and section 1396d of this title and repealing
section 1320a of this title) shall become effective January 1, 1972;
except that the repeal made by subsection (c) (repealing section 1320a
of this title), shall not become effective in the case of any State,
which on January 1, 1972 did not have in effect a State plan approved
under title XIX of the Social Security Act (this subchapter), until the
first day of the first month (occurring after such date) that such State
does have in effect a State plan approved under such title (this
subchapter).''
Amendment by section 210(a)(6) of Pub. L. 90-248 effective July 1,
1969, or, if earlier (with respect to a State's plan approved under this
subchapter) on the date as of which the modification of the State plan
to comply with such amendment is approved, see section 210(b) of Pub.
L. 90-248, set out as a note under section 302 of this title.
Section 223(b) of Pub. L. 90-248 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply with respect
to calendar quarters beginning after June 30, 1967.''
Section 224(b) of Pub. L. 90-248 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply with respect
to calendar quarters beginning after December 31, 1967.''
Section 224(c)(2) of Pub. L. 90-248 provided that: ''The amendment
made by paragraph (1) of this subsection (amending this section) shall
apply with respect to calendar quarters beginning after June 30, 1970.''
Section 227(b) of Pub. L. 90-248, as amended by section 271A of Pub.
L. 92-603, effective from and after July 1, 1972, provided that: ''The
amendments made by this section (amending this section) shall apply with
respect to calendar quarters beginning after June 30, 1969; except that
such amendments shall apply in the case of Puerto Rico, the Virgin
Islands, and Guam only with respect to calendar quarters beginning after
June 30, 1975.''
Section 229(b) of Pub. L. 90-248 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply with respect
to legal liabilities of third parties arising after March 31, 1968.''
Section 234(b) of Pub. L. 90-248 provided that: ''The amendments
made by subsection (a) of this section (amending this section) (unless
otherwise specified in the body of such amendments) shall take effect on
January 1, 1969.''
Section 235(b) of Pub. L. 90-248 provided that: ''The amendments
made by subsection (a) (amending this section) shall be effective in the
case of calendar quarters beginning after December 31, 1967.''
Enactment by section 236(a) of Pub. L. 90-248 effective July 1,
1970, except as otherwise specified in the text thereof, see section
236(c) of Pub. L. 90-248, set out as an Effective Date note under
section 1396g of this title.
Section 237 of Pub. L. 90-248 provided that the amendment made by
that section is effective Apr. 1, 1968.
Section 238 of Pub. L. 90-248 provided that the amendment made by
that section is effective July 1, 1969.
Functions, powers, and duties of Secretary of Health and Human
Services under subsec. (a)(4)(A) of this section, insofar as relates to
the prescription of personnel standards on a merit basis, transferred to
Office of Personnel Management, see section 4728(a)(3)(D) of this title.
Section 4745 of Pub. L. 101-508 provided that:
''(a) Demonstration Projects. --
''(1) In general. -- (A) The Secretary of Health and Human Services
(hereafter in this section referred to as the 'Secretary') shall enter
into agreements with 3 and no more than 4 States submitting applications
under this section for the purpose of conducting demonstration projects
to study the effect on access to, and costs of, health care of
eliminating the categorical eligibility requirement for medicaid
benefits for certain low-income individuals.
''(B) In entering into agreements with States under this section the
Secretary shall provide that at least 1 and no more than 2 of the
projects are conducted on a substate basis.
''(2) Requirements. -- (A) The Secretary may not enter into an
agreement with a State to conduct a project unless the Secretary
determines that --
''(i) the project can reasonably be expected to improve access to
health insurance coverage for the uninsured;
''(ii) with respect to projects for which the statewideness
requirement has not been waived, the State provides, under its plan
under title XIX of the Social Security Act (this subchapter), for
eligibility for medical assistance for all individuals described in
subparagraphs (A), (B), (C), and (D) of paragraph (1) of section 1902(l)
of such Act (subsec. (l)(1)(A), (B), (C), (D) of this section) (based on
the State's election of certain eligibility options the highest income
standards and, based on the State's waiver of the application of any
resource standard);
''(iii) eligibility for benefits under the project is limited to
individuals in families with income below 150 percent of the income
official poverty line and who are not individuals receiving benefits
under title XIX of the Social Security Act;
''(iv) if the Secretary determines that it is cost-effective for the
project to utilize employer coverage (as described in section
1925(b)(4)(D) of the Social Security Act (section 1396r-6(b)(4)(D) of
this title)), the project must require an employer contribution and
benefits under the State plan under title XIX of such Act will continue
to be made available to the extent they are not available under the
employer coverage;
''(v) the project provides for coverage of benefits consistent with
subsection (b); and
''(vi) the project only imposes premiums, coinsurance, and other
cost-sharing consistent with subsection (c).
''(B) The Secretary may waive the requirements of clause (ii) of this
paragraph (probably means subparagraph (A)) with respect to those
projects described in subparagraph (B) of paragraph (1).
''(3) Permissible restrictions. -- A project may limit eligibility to
individuals whose assets are valued below a level specified by the
State. For this purpose, any evaluation of such assets shall be made in
a manner consistent with the standards for valuation of assets under the
State plan under title XIX of the Social Security Act for individuals
entitled to assistance under part A of title IV of such Act (part A of
subchapter IV of this chapter). Nothing in this section shall be
construed as requiring a State to provide for eligibility for
individuals for months before the month in which such eligibility is
first established.
''(4) Extension of eligibility. -- A project may provide for
extension of eligibility for medical assistance for individuals covered
under the project in a manner similar to that provided under section
1925 of the Social Security Act to certain families receiving aid
pursuant to a plan of the State approved under part A of title IV of
such Act.
''(5) Waiver of requirements. --
''(A) In general. -- Subject to subparagraph (B), the Secretary may
waive such requirements of title XIX of the Social Security Act (except
section 1903(m) of the Social Security Act (section 1396b(m) of this
title)) as may be required to provide for additional coverage of
individuals under projects under this section.
''(B) Nonwaivable provisions. -- Except with respect to those
projects described in subparagraph (B) of paragraph (1), the Secretary
may not waive, under subparagraph (A), the statewideness requirement of
section 1902(a)(1) of the Social Security Act (subsec. (a)(1) of this
section) or the Federal medical assistance percentage specified in
section 1905(b) of such Act (section 1396d(b) of this title).
''(b) Benefits. --
''(1) In general. -- Except as provided in this subsection, the
amount, duration, and scope of medical assistance made available under a
project shall be the same as the amount, duration, and scope of such
assistance made available to individuals entitled to medical assistance
under the State plan under section 1902(a)(10)(A)(i) of the Social
Security Act (subsec. (a)(10)(A)(i) of this section).
''(2) Limits on benefits. --
''(A) Required. -- Except with respect to those projects described in
subparagraph (B) of paragraph (1), no medical assistance shall be made
available under a project for nursing facility services or
community-based long-term care services (as defined by the Secretary) or
for pregnancy-related services. No medical assistance shall be made
available under a project to individuals confined to a State
correctional facility, county jail, local or county detention center, or
other State institution.
''(B) Permissible. -- A State, with the approval of the Secretary,
may limit or otherwise deny eligibility for medical assistance under the
project and may limit coverage of items and services under the project,
other than early and periodic screening, diagnostic, and treatment
services for children under 18 years of age.
''(3) Use of utilization controls. -- Nothing in this subsection
shall be construed as limiting a State's authority to impose controls
over utilization of services, including preadmission requirements,
managed care provisions, use of preferred providers, and use of second
opinions before surgical procedures.
''(c) Premiums and Cost-Sharing. --
''(1) None for those with income below the poverty line. -- Under a
project, there shall be no premiums, coinsurance, or other cost-sharing
for individuals whose family income level does not exceed 100 percent of
the income official poverty line (as defined in subsection (g)(1))
applicable to a family of the size involved.
''(2) Limit for those with income above the poverty line. -- Under a
project, for individuals whose family income level exceeds 100 percent,
but is less than 150 percent, of the income official poverty line
applicable to a family of the size involved, the monthly average amount
of premiums, coinsurance, and other cost-sharing for covered items and
services shall not exceed 3 percent of the family's average gross
monthly earnings.
''(3) Income determination. -- Each project shall provide for
determinations of income in a manner consistent with the methodology
used for determinations of income under title XIX of the Social Security
Act (this subchapter) for individuals entitled to benefits under part A
of title IV of such Act (part A of subchapter IV of this chapter).
''(d) Duration. -- Each project under this section shall commence not
later than July 1, 1991 and shall be conducted for a 3-year period;
except that the Secretary may terminate such a project if the Secretary
determines that the project is not in substantial compliance with the
requirements of this section.
''(e) Limits on Expenditures and Funding. --
''(1) In general. -- (A) The Secretary in conducting projects shall
limit the total amount of the Federal share of benefits paid and
expenses incurred under title XIX of the Social Security Act (this
subchapter) to no more than $12,000,000 in each of fiscal years 1991,
1992, and 1993, and to no more than $4,000,000 in fiscal year 1994.
''(B) Of the amounts appropriated under subparagraph (A), the
Secretary shall provide that no more than one-third of such amounts
shall be used to carry out the projects described in paragraph (1)(B) of
subsection (a) (for which the statewideness requirement has been
waived).
''(2) No funding of current beneficiaries. -- No funding shall be
available under a project with respect to medical assistance provided to
individuals who are otherwise eligible for medical assistance under the
plan without regard to the project.
''(3) No increase in federal medical assistance percentage. --
Payments to a State under a project with respect to expenditures made
for medical assistance made available under the project may not exceed
the Federal medical assistance percentage (as defined in section 1905(b)
of the Social Security Act (section 1396d(b) of this title)) of such
expenditures.
''(f) Evaluation and Report. --
''(1) Evaluations. -- For each project the Secretary shall provide
for an evaluation to determine the effect of the project with respect to
--
''(A) access to, and costs of, health care,
''(B) private health care insurance coverage, and
''(C) premiums and cost-sharing.
''(2) Reports. -- The Secretary shall prepare and submit to Congress
an interim report on the status of the projects not later than January
1, 1993, and a final report containing such summary together with such
further recommendations as the Secretary may determine appropriate not
later than January 1, 1995.
''(g) Definitions. -- In this section:
''(1) The term 'income official poverty line' means such line as
defined by the Office of Management and Budget and revised annually in
accordance with section 673(2) of the Omnibus Budget Reconciliation Act
of 1981 (section 9902(2) of this title).
''(2) The term 'project' refers to a demonstration project under
subsection (a).''
Section 4747 of Pub. L. 101-508 provided that:
''(a) In General. -- Not later than 3 months after the date of the
enactment of this Act (Nov. 5, 1990), the Secretary of Health and Human
Services (hereafter in this section referred to as the 'Secretary')
shall provide for 2 demonstration projects to be administered by States
that submit an application under this section, through programs
administered by the States under title XIX of the Social Security Act
(this subchapter). Such demonstration projects shall provide coverage
for the services described in subsection (c) to individuals whose income
and resources do not exceed the maximum allowable amount for eligibility
for any individual in any category of disability under the State plan
under section 1902 of the Social Security Act (this section), and who
have tested positive for the presence of HIV virus (without regard to
the presence of any symptoms of AIDS or opportunistic diseases related
to AIDS).
''(b) Services Available Under a Demonstration Project. -- (1) The
medical assistance made available to individuals described in section
1902(a)(10)(A) of the Social Security Act (subsec. (a)(10)(A) of this
section) shall be made available to individuals described in subsection
(a) who receive services under a demonstration project under such
paragraph.
''(2) A demonstration project under subsection (a) shall provide
services in addition to the services described in paragraph (1) which
shall be limited only on the basis of medical necessity or the
appropriateness of such services. To the extent not provided as
described in paragraph (1), such additional services shall include --
''(A) general and preventative medical care services (including
inpatient, outpatient, residential care, physician visits, clinic
visits, and hospice care);
''(B) prescription drugs, including drugs for the purposes of
preventative health care services;
''(C) counseling and social services;
''(D) substance abuse treatment services (including services for
multiple substances abusers);
''(E) home care services (including assistance in carrying out
activities of daily living);
''(F) case management;
''(G) health education services;
''(H) respite care for caregivers;
''(I) dental services; and
''(J) diagnostic and laboratory services(.)
''(c) Agreements With States. -- (1) Each State conducting a
demonstration project under subsection (a) shall enter into an agreement
with a hospital and at least one other nonprofit organization submitting
applications to the State. The State shall require that such hospital
and other entity have a demonstrated record of case management of
patients who have tested positive for the presence of HIV virus and have
access to a control group of such type of patients who are not receiving
State or Federal payments for medical services (or other payments from
private insurance coverage) before developing symptoms of AIDS. Under
such agreement, the State shall agree to pay each such entity for the
services provided under subsection (b) and not later than 12 months
after the commencement of a demonstration project, institute a system of
monthly payment to each such entity based on the average per capita cost
of the services described in subsection (c) provided to individuals
described in paragraphs (1) and (2) of subsection (a).
''(2) A demonstration project described in subsection (a) shall be
limited to an enrollment of not more than 200 individuals.
''(3) A demonstration project conducted under subsection (a) shall
commence not later than 9 months after the date of the enactment of this
Act (Nov. 5, 1990) and shall terminate on the date that is 3 years after
the date of commencement.
''(4)(A) The Secretary shall provide for an evaluation of the
comparative costs of providing services to individuals who have tested
positive for the presence of HIV virus at an early stage after detection
of such virus and those that are treated at a later stage after such
detection.
''(B) The Secretary shall report to Congress on the results of the
evaluation conducted under subparagraph (A) no later than 6 months after
the date of termination of the demonstration projects described in this
section.
''(d) Federal Share of Costs. -- The Federal share of the cost of
services described in paragraph (3) furnished under a demonstration
project conducted under paragraph (1) shall be determined by the
otherwise applicable Federal matching assistance percentage pursuant to
section 1905(b) of the Social Security Act (section 1396d(b) of this
title).
''(e) Waiver of Requirements of the Social Security Act. -- The
Secretary may waive such requirements of the Social Security Act (this
chapter) as the Secretary determines to be necessary to carry out the
purposes of this section.
''(f) Limitation on Amount of Expenditures. -- The amount of funds
that may be expended as medical assistance to carry out the purposes of
this section shall be $5,000,000 for fiscal year 1991, $12,000,000 for
fiscal year 1992, and $13,000,000 for fiscal year 1993.''
Section 4751(d) of Pub. L. 101-508 provided that:
''(1) In general. -- The Secretary, no later than 6 months after the
date of enactment of this section (Nov. 5, 1990), shall develop and
implement a national campaign to inform the public of the option to
execute advance directives and of a patient's right to participate and
direct health care decisions.
''(2) Development and distribution of information. -- The Secretary
shall develop or approve nationwide informational materials that would
be distributed by providers under the requirements of this section
(amending this section and sections 1396b and 1396r of this title and
enacting provisions set out above), to inform the public and the medical
and legal profession of each person's right to make decisions concerning
medical care, including the right to accept or refuse medical or
surgical treatment, and the existence of advance directives.
''(3) Providing assistance to states. -- The Secretary shall assist
appropriate State agencies, associations, or other private entities in
developing the State-specific documents that would be distributed by
providers under the requirements of this section. The Secretary shall
further assist appropriate State agencies, associations, or other
private entities in ensuring that providers are provided a copy of the
documents that are to be distributed under the requirements of the
section.
''(4) Duties of secretary. -- The Secretary shall mail information to
Social Security recipients, (and) add a page to the medicare handbook
with respect to the provisions of this section.''
Section 4752(a)(1)(B) of Pub. L. 101-508 provided that: ''The
system established under the amendment made by subparagraph (A)
(amending this section) may be the same as, or different from, the
system established under section 9202(g) of the Consolidated Omnibus
Budget Reconciliation Act of 1985 (Pub. L. 99-272, formerly set out in a
note under section 1395ww of this title).''
Section 4752(d) of Pub. L. 101-508 provided that:
''(1) Passage of fmgems examination in order to obtain identifier.
-- The Secretary of Health and Human Service(s) shall provide, in the
identifier system established under section 1902(x) of the Social
Security Act (subsec. (x) of this section), that no foreign medical
graduate (as defined in section 1886(h)(5)(D) of such Act (section
1395ww(h)(5)(D) of this title)) shall be issued an identifier under such
system unless the individual --
''(A) has passed the FMGEMS examination (as defined in section
1886(h)(5)(E) of such Act);
''(B) has previously received certification from, or has previously
passed the examination of, the Educational Commission for Foreign
Medical Graduates; or
''(C) has held a license from 1 or more States continuously since
1958.
''(2) Effective date. -- Paragraph (1) shall apply with respect to
issuance of an identifier applicable to services furnished on or after
January 1, 1992.''
Section 11115(c) of Pub. L. 101-508 provided that: ''Pursuant to
section 1902(a)(17) of the Social Security Act (42 U.S.C.
1396a(a)(17)), the Secretary of Health and Human Services shall
promulgate regulations to exempt from any determination of income and
resources (for the month of receipt and the following month) under title
XIX of the Social Security Act (this subchapter) any refund of Federal
income taxes made to an individual by reason of section 32 of the
Internal Revenue Code of 1986 (26 U.S.C. 32) (relating to earned income
tax credit), and any payment made to an individual by an employer under
section 3507 of such Code (26 U.S.C. 3507) (relating to advance payment
of earned income credit).''
Section 6506(b) of Pub. L. 101-239 provided that:
''(1) In general. -- The Secretary of Health and Human Services
shall, by not later than 1 year after the date of the enactment of this
Act (Dec. 19, 1989), develop a model application form for use in
applying for benefits under title XIX of the Social Security Act (this
subchapter) for individuals who are not receiving cash assistance under
part A of title IV of the Social Security Act (part A of subchapter IV
of this chapter), and who are not institutionalized. In developing such
model application form, the Secretary is not authorized to require that
such form be adopted by States as part of their State medicaid plan.
''(2) Dissemination of model form. -- The Secretary shall provide for
publication in the Federal Register of the model application form
developed under paragraph (1), and shall send a copy of such form to
each State agency responsible for administering a State medicaid plan.''
Section 8435 of Pub. L. 100-647 provided that: ''The Secretary of
Health and Human Services may not fail or refuse to approve an amendment
to a State plan under title XIX of the Social Security Act (this
subchapter) that provides for coverage of case-management services
described in section 1915(g)(2) of such Act (section 1396n(g)(2) of this
title), or to deny payment to a State for such services under section
1903(a)(1) of such Act (section 1396b(a)(1) of this title) on the basis
that a State is required to provide such services under State law or on
the basis that the State had paid or is paying for such services from
non-Federal funds before or after April 7, 1986. Nothing in this
section shall be construed as requiring the Secretary to make payment to
a State under section 1903(a)(1) of such Act for such case-management
services which are provided without charge to the users of such
services.''
Section 301(g)(1) of Pub. L. 100-360 provided that: ''In the case
of any State which is providing medical assistance to its residents
under a waiver granted under section 1115(a) of the Social Security Act
(section 1315(a) of this title), the Secretary of Health and Human
Services shall require the State to meet the requirement of section
1902(a)(10)(E) of the Social Security Act (subsec. (a)(10)(E) of this
section) in the same manner as the State would be required to meet such
requirement if the State had in effect a plan approved under title XIX
of such Act (this subchapter).''
Pub. L. 100-203, title IV, 4112, Dec. 22, 1987, 101 Stat.
1330-148, which related to adjustment in medicaid payment for inpatient
hospital services furnished by disproportionate share hospitals was
amended by Pub. L. 100-360, title IV, 411(k)(6)(A)-(B)(i), July 1,
1988, 102 Stat. 792, 793, and so amended, 4112 enacts the provisions
of former section 4112 as section 1396r-4 of this title and amends
sections 1396b and 1396s of this title.
Section 4211(b)(2) of Pub. L. 100-203, as amended by Pub. L.
101-508, title IV, 4801(e)(1)(B), Nov. 5, 1990, 104 Stat. 1388-215,
provided that: ''A plan of a State under title XIX of the Social
Security Act (this subchapter) shall not be considered to have met the
requirement of section 1902(a)(13)(A) of the Social Security Act
(subsec. (a)(13)(A) of this section) (as amended by paragraph (1)(A) of
this subsection), as of the first day of a Federal fiscal year
(beginning on or after October 1, 1990), unless the State has submitted
to the Secretary of Health and Human Services, as of April 1 before the
fiscal year, an amendment to such State plan to provide for an
appropriate adjustment in payment amounts for nursing facility services
furnished during the Federal fiscal year. Each such amendment shall
include a detailed description of the specific methodology to be used in
determining the appropriate adjustment in payment amounts for nursing
facility services. The Secretary shall, not later than September 30
before the fiscal year concerned, review each such plan amendment for
compliance with such requirement and by such date shall approve or
disapprove each such amendment. If the Secretary disapproves such an
amendment, the State shall immediately submit a revised amendment which
meets such requirement. The absence of approval of such a plan
amendment does not relieve the State or any nursing facility of any
obligation or requirement under title XIX of the Social Security Act (as
amended by this Act).''
Section 4211(j) of Pub. L. 100-203 provided that: ''The Secretary
of Health and Human Services shall, upon request by a State, furnish
technical assistance with respect to the development and implementation
of reimbursement methods for nursing facilities that take into account
the case mix of residents in the different facilities.''
Section 9432 of Pub. L. 99-509, as amended by Pub. L. 100-203,
title IV, 4118(p)(11), as added by Pub. L. 100-360, title IV,
411(k)(10)(M), July 1, 1988, 102 Stat. 797; Pub. L. 101-508, title IV,
4755(b), Nov. 5, 1990, 104 Stat. 1388-210, provided that:
''(a) In General. -- (1) The Secretary of Health and Human Services
(in this section referred to as the 'Secretary') may not publish final
or interim final regulations requiring a State plan approved under title
XIX of the Social Security Act (this subchapter) to include a program
requiring second surgical opinions or a program of inpatient hospital
preadmission review.
''(2) The Secretary may not, during the period beginning on the date
of the enactment of the Omnibus Budget Reconciliation Act of 1990 (Nov.
5, 1990) and ending on the date that is 180 days after the date on which
the report required by subsection (d) is submitted to the Congress,
publish final or interim final regulations requiring a State plan
approved under title XIX of the Social Security Act (this subchapter) to
include a program for ambulatory surgery, preadmission testing, or
same-day surgery.
''(b) Report. --
''(1) The Secretary shall report to Congress, by not later than
October 1, 1988, for each State in a representative sample of States --
''(A) the identity of those procedures which are high volume or high
cost procedures among patients who are covered under the State medicaid
plan,
''(B) the payment rates under those plans for such procedures, and
the aggregate annual payment amounts made under such plans for such
procedures (including the Federal share of such payment amounts),
''(C) the rate at which each such procedure is performed on medicaid
patients and (to the extent that data are available) comparisons to the
rate at which such procedure is performed on patients of comparable age
who are not medicaid patients,
''(D) with respect to each such procedure --
''(i) the number of board certified or board eligible physicians in
the State who provide care and services to medicaid patients and who
perform the procedure, and
''(ii) in the case of a State with a mandatory second surgical
opinion program in operation, the number of physicians described in
clause (i) who provide second opinions (of the type described in section
1164 of the Social Security Act (section 1320c-13 of this title)) for
the procedure at prevailing payment rates under the State medicaid plan,
and
''(E) in the case of a State with a mandatory second surgical opinion
program or a program of inpatient hospital preadmission review in
operation, a description of --
''(i) the extent to which such program impedes access to necessary
care and services, and
''(ii) the measures that the State has taken to address such
impediments, particularly in rural areas.
''(2) Such report shall also include a list of those surgical
procedures which the Secretary believes meet the following criteria and
for which a mandatory second opinion program under medicaid plans may be
appropriate:
''(A) The procedure is one which generally can be postponed without
undue risk to the patient.
''(B) The procedure is a high volume procedure among patients who are
covered under State medicaid plans or is a high cost procedure.
''(C) The procedure has a comparatively high rate of nonconfirmation
upon examination by another qualified physician, there is substantial
geographic variation in the rates of performance of the procedure, or
there are other reasons why requiring second opinions for 100 percent of
such procedures would be cost effective.
''(3) The representative sample of States required to be included in
the report shall include States with mandatory second surgical opinion
programs in operation, States with programs of inpatient hospital
preadmission review in operation, and States with neither such program
in operation.
''(4) In this subsection and subsection (d), the term 'medicaid plan'
means a State plan approved under title XIX of the Social Security Act
(this subchapter).
''(c) Study. --
''(1) The Secretary shall conduct a study of the utilization of
selected medical treatments and surgical procedures by medicaid
beneficiaries in order to assess the appropriateness, necessity, and
effectiveness of such treatments and procedures.
''(2) The study shall analyze the extent to which there is
significant variation in the rate of utilization by medicaid
beneficiaries of selected treatments and procedures for different
geographic areas within States and among States.
''(3) The study shall also identify underutilized, medically
necessary treatments and procedures for which --
''(A) a failure to furnish could have an adverse effect on health
status, and
''(B) the rate of utilization by medicaid beneficiaries is
significantly less than the rate for comparable, age-adjusted
populations.
''(4) The study shall be coordinated, to the extent practicable, with
the research program established pursuant to section 1875(c) of the
Social Security Act (section 1395ll(c) of this title), with particular
regard to the relationship of the variations described in paragraph (2)
to patient outcomes.
''(5) The Secretary shall submit an interim report on the results of
the study, including an analysis of the geographic variations under
paragraph (2), to the Congress not later than January 1, 1990, and shall
report the final results of the study to the Congress not later than
January 1, 1992.
''(d) Report. -- The Secretary shall report to Congress, by not later
than January 1, 1993, for each State in a representative sample of
States --
''(1) an analysis of the procedures for which programs for ambulatory
surgery, preadmission testing, and same-day surgery are appropriate for
patients who are covered under the State medicaid plan, and
''(2) the effects of such programs on access of such patients to
necessary care, quality of care, and costs of care.
In selecting such a sample of States, the Secretary shall include
some States with medicaid plans that include such programs.''
Section 9503(c) of Pub. L. 99-272 provided that: ''The Secretary of
Health and Human Services shall promulgate final regulations necessary
to carry out sections 1902(a)(25) and 1903(r)(6)(J) of the Social
Security Act (subsec. (a)(25) of this section and section 1396b(r)(6)(J)
of this title) within 6 months after the date of the enactment of this
Act (Apr. 7, 1986).''
Section 9509(c) of Pub. L. 99-272 directed Comptroller General to
conduct a study of effects of the amendments made by this section and
report results of such study to Congress two years after Apr. 7, 1986.
Section 9520 of Pub. L. 99-272 directed Secretary of Health and
Human Services, within six months after Apr. 7, 1986, to establish a
task force concerning alternatives to institutional care for
technology-dependent children, such task force to (1) include
representatives of Federal and State agencies with responsibilities
relating to child health, health insurers, large employers (including
those that self-insure for health care costs), providers of health care
to technology-dependent children, and parents of technology-dependent
children, (2) identify barriers that prevent the provision of
appropriate care in a home or community setting to meet special needs of
technology-dependent children, (3) recommend changes in the provision
and financing of health care in private and public health care programs
(including appropriate joint public-private initiatives) so as to
provide home and community-based alternatives to the
institutionalization of technology-dependent children, and (4) make a
final report to Secretary and to Congress on its activities not later
than two years after Apr. 7, 1986.
Section 9529(b)(2) of Pub. L. 99-272 provided that: ''In the case
of an adoption assistance agreement (other than an agreement under part
E of title IV of the Social Security Act (part E of subchapter IV of
this chapter)) entered into before the date of the enactment of this Act
(Apr. 7, 1986) --
''(A) the requirements of subdivisions (aa) and (bb) of section
1902(a)(10)(A)(ii)(VIII) of the Social Security Act (subsec.
(a)(10)(A)(ii)(VIII)(aa), (bb) of this section) shall be deemed to be
met if the State agency responsible for adoption assistance agreements
determines that --
''(i) at the time of adoptive placement the child had special needs
for medical or rehabilitative care that made the child difficult to
place; and
''(ii) there is in effect with respect to such child an adoption
assistance agreement between the State and an adoptive parent or
parents; and
''(B) the requirement of subdivision (cc) of such section shall be
deemed to be met if the child was found by the State to be eligible for
medical assistance prior to such agreement being entered into.''
Section 2366 of Pub. L. 98-369 provided that: ''The provisions of
section 1902(a)(13) of the Social Security Act (subsec. (a)(13) of this
section), in so far as they require a reduction of the amount of payment
otherwise to be made to a public psychiatric hospital due to the level
of care received in such hospital, shall not apply to payments to
hospitals before July 1, 1985, and such a reduction made for payments
during the 12-month period ending June 30, 1986, and during the 12-month
period ending June 30, 1987, shall be one-third and two-thirds,
respectively, of the amount of the reduction which would have been made
without regard to this section.''
Section 2373(c) of Pub. L. 98-369, as amended by Pub. L. 100-93,
9, Aug. 18, 1987, 101 Stat. 695, provided that:
''(1) The Secretary of Health and Human Services shall not take any
compliance, disallowance, penalty, or other regulatory action against a
State with respect to the moratorium period described in paragraph (2)
by reason of such State's plan described in paragraph (5) under title
XIX of the Social Security Act (this subchapter) (including any part of
the plan operating pursuant to section 1902(f) of such Act (subsec. (f)
of this section)), or the operation thereunder, being determined to be
in violation of clause (IV), (V), or (VI) of section 1902(a)(10)(A)(ii)
or section 1902(a)(10)(C)(i)(III) of such Act on account of such plan's
(or its operation) having a standard or methodology which the Secretary
interprets as being less restrictive than the standard or methodology
required under such section, provided that such plan (or its operation)
does not make ineligible any individual who would be eligible but for
the provisions of this subsection.
''(2) The moratorium period is the period beginning on October 1,
1981, and ending 18 months after the date on which the Secretary submits
the report required under paragraph (3).
''(3) The Secretary shall report to the Congress within 12 months
after the date of the enactment of this Act (July 18, 1984) with respect
to the appropriateness, and impact on States and recipients of medical
assistance, of applying standards and methodologies utilized in cash
assistance programs to those recipients of medical assistance who do not
receive cash assistance, and any recommendations for changes in such
requirements.
''(4) No provision of law shall repeal or suspend the moratorium
imposed by this subsection unless such provision specifically amends or
repeals this subsection.
''(5) In this subsection, a State plan is considered to include --
''(A) any amendment or other change in the plan which is submitted by
a State, or
''(B) any policy or guideline delineated in the Medicaid operation or
program manuals of the State which are submitted by the State to the
Secretary,
whether before or after the date of enactment of this Act (July 18,
1984) and whether or not the amendment or change, or the operating or
program manual was approved, disapproved, acted upon, or not acted upon
by the Secretary.
''(6) During the moratorium period, the Secretary shall implement
(and shall not change by any administrative action) the policy in effect
at the beginning of such moratorium period with respect to --
''(A) the point in time at which an institutionalized individual must
sell his home (in order that it not be counted as a resource); and
''(B) the time period allowed for sale of a home of any such
individual,
who is an applicant for or recipient of medical assistance under the
State plan as a medically needy individual (described in section
1902(a)(10)(C) of the Social Security Act (subsec. (a)(10)(C) of this
section)) or as an optional categorically needy individual (described in
section 1902(a)(10)(A)(ii) of such Act).''
(Amendment of section 2373(c) of Pub. L. 98-369, set out above, by
section 9 of Pub. L. 100-93 applicable as though originally included in
Pub. L. 98-369, 2373(c), see section 15(e) of Pub. L. 100-93, set out
as an Effective Date of 1987 Amendment note under section 1320a-7 of
this title.)
Section 2178(d) of Pub. L. 97-35 directed Secretary of Health and
Human Services to conduct a study evaluating extent of, and reasons for,
termination by medicaid beneficiaries of their memberships in health
maintenance organizations, placing special emphasis on quantity and
quality of medical care provided in health maintenance organizations and
quality of such care when provided on a fee-for-service basis, with
Secretary to submit an interim report to Congress, within two years
after Aug. 13, 1981, and a final report within five years from such
date containing, respectively, the interim and final findings and
conclusions made as a result of such study.
Section 310(b)(1) of Pub. L. 96-272 provided that:
''(A) For purposes of section 1902(a)(10)(A) of the Social Security
Act (subsec. (a)(10)(A) of this section), any individual who, prior to
the date of enactment of this Act (June 17, 1980) and for the month of
December 1978, was eligible for and received aid or assistance under a
State plan approved under title I, X, XIV, or XVI, or part A of title IV
of such Act (subchapter I, X, XIV, or XVI, or part A of subchapter IV of
this chapter), or was eligible for and received supplemental security
income benefits under title XVI of such Act (subchapter XVI of this
chapter) (or a supplementary payment described in section 13(c) of
Public Law 93-233) (set out as a note under this section), and was also
in receipt of (or was a dependent, for purposes of chapter 15 of title
38, United States Code, as in effect on December 31, 1978, of an
individual in receipt of) pension from the Veterans' Administration for
the month of December 1978 shall (subject to subparagraph (B)) be deemed
to have been receiving such aid, assistance, supplemental security
income, or supplementary payment, for each calendar month thereafter
(prior to the month in which the provisions of this subparagraph cease
to be effective with respect to him as determined under subparagraph
(B)), if such individual would have been eligible therefor in December
1978 and in the month in which the provisions of this subparagraph cease
to be effective with respect to him as determined under subparagraph (B)
had the increase in income of such individual (or of the family of which
such individual is a member), attributable to an election (made by such
individual or another member of such individual's family) under section
306 of the Veterans' and Survivors' Pension Improvement Act of 1978
(section 306 of Pub. L. 95-588, set out as a note under section 521 of
Title 38, Veterans' Benefits), not occurred.
''(B)(i) The provisions of subparagraph (A) shall take effect on
January 1, 1979, and shall cease to be effective, in the case of any
individual, for and after the first calendar month beginning more than
10 days after an 'informed election' (as defined in subdivision (ii) of
this subparagraph) has been made by such individual (or, if such
individual is not eligible to make such an election, by a member of such
individual's family who is eligible to make such an election which
affects such individual's eligibility for aid, assistance, or benefits
under a plan or program referred to in subparagraph (A)).
''(ii) The term 'informed election' means an election made under
section 306 of the Veterans' and Survivors' Pension Improvement Act of
1978 (section 306 of Pub. L. 95-588, set out as a note under section 521
of Title 38) (or a reaffirmation of such an election which previously
was made under such section 306) after the date of compliance by the
Administrator of Veterans' Affairs (hereinafter in this section referred
to as the 'Administrator') with the provisions of paragraph (2)(A) with
respect to the individual concerned. An individual who fails, within
the time limits prescribed in paragraph (2)(B), to disaffirm an election
previously made by such individual under such section 306 shall be
deemed, for purposes of this section and such section 306, to have
reaffirmed such election.''
Pub. L. 94-566, title V, 503, Oct. 20, 1976, 90 Stat. 2685,
provided that: ''In addition to other requirements imposed by law as a
condition for the approval of any State plan under title XIX of the
Social Security Act (this subchapter), there is hereby imposed the
requirement (and each such State plan shall be deemed to require) that
medical assistance under such plan shall be provided to any individual,
for any month after June 1977 for which such individual is entitled to a
monthly insurance benefit under title II of such Act (subchapter II of
this chapter) but is not eligible for benefits under title XVI of such
Act (subchapter XVI of this chapter), in like manner and subject to the
same terms and conditions as are applicable under such State plan in the
case of individuals who are eligible for and receiving benefits under
such title XVI (subchapter XVI of this chapter) for such month, if for
such month such individual would be (or could become) eligible for
benefits under such title XVI (subchapter XVI of this chapter) except
for amounts of income received by such individual and his spouse (if
any) which are attributable to increases in the level of monthly
insurance benefits payable under title II of such Act (subchapter II of
this chapter) which have occurred pursuant to section 215(i) of such Act
(section 415(i) of this title), in the case of such individual, since
the last month after April 1977 for which such individual was both
eligible for (and received) benefits under such title XVI (subchapter
XVI of this chapter) and was entitled to a monthly insurance benefit
under such title II (subchapter II of this chapter), and, in the case of
such individual's spouse (if any), since the last such month for which
such spouse was both eligible for (and received) benefits under such
title XVI (subchapter XVI of this chapter) and was entitled to a monthly
insurance benefit under such title II (subchapter II of this chapter).
Solely for purposes of this section, payments of the type described in
section 1616(a) of the Social Security Act (section 1382e(a) of this
title) or of the type described in section 212(a) of Public Law 93-66
(set out as note under section 1382 of this title) shall be deemed to be
benefits under title XVI of the Social Security Act (subchapter XVI of
this chapter).''
Section 13(c) of Pub. L. 93-233 provided that: ''In addition to
other requirements imposed by law as conditions for the approval of any
State plan under title XIX of the Social Security Act (this subchapter),
there is hereby imposed (effective January 1, 1974) the requirement (and
each such State plan shall be deemed to require) that medical assistance
under such plan shall be provided to any individual --
''(1) for any month for which there (A) is payable with respect to
such individual a supplementary payment pursuant to an agreement entered
into between the State and the Secretary of Health, Education, and
Welfare (now Health and Human Services) under section 212(a) of Public
Law 93-66 (set out as note under section 1382 of this title), and (B)
would be payable with respect to such individual such a supplementary
payment, if the amount of the supplementary payments payable pursuant to
such agreement were established without regard to paragraph (3)(A)(ii)
of such section 212(a) (set out as note under section 1382 of this
title), and
''(2) in like manner, and subject to the same terms and conditions,
as medical assistance is provided under such plan to individuals with
respect to whom benefits are payable for such month under the
supplementary security income program established by title XVI of the
Social Security Act (subchapter XVI of this chapter).
Federal matching under title XIX of the Social Security Act (this
subchapter) shall be available for the medical assistance furnished to
individuals who are eligible for such assistance under this
subsection.''
Section 230 of Pub. L. 93-66, title II, July 9, 1973, 87 Stat. 159,
provided that: ''In the case of any State plan (approved under title
XIX of the Social Security Act (this subchapter)) which for December
1973 provided medical assistance to persons described in section
1905(a)(vi) of such Act (section 1396d(a)(vi) of this title), there is
hereby imposed the requirement (and such State plan shall be deemed to
require) that medical assistance under such plan be provided to each
such person (who for December 1973 was eligible for medical assistance
under such plan) for each month (after December 1973) that --
''(1) the individual (referred to in the last sentence of section
1905(a) of such Act (section 1396d(a) of this title)) with whom such
person is living continues to meet the criteria (as in effect for
December 1973) for aid or assistance under a State plan (referred to in
such sentence), and
''(2) such person continues to have the relationship with such
individual described in such sentence and meets the other criteria
(referred to in such sentence) with respect to a State plan (so referred
to) as such plan was in effect for December 1973.
Federal matching under title XIX of the Social Security Act (this
subchapter) shall be available for the medical assistance furnished to
individuals eligible for such assistance under this section.''
Section 231 of Pub. L. 93-66, title II, July 9, 1973, 87 Stat. 159,
as amended by Pub. L. 93-233, 13(b)(1), Dec. 31, 1973, 87 Stat. 964,
provided that: ''For purposes of section 1902(a)(10) of the Social
Security Act (subsec. (a)(10) of this section), any individual who, for
all (or any part of) the month of December 1973 --
''(1) was an inpatient in an institution qualified for reimbursement
under title XIX of the Social Security Act (this subchapter), and
''(2)(A) received or would (except for his being an inpatient in such
institution) have been eligible to receive aid or assistance under a
State plan approved under title I, X, XIV, or XVI of such Act
(subchapter I, X, XIV, or XVI of this chapter), and
''(B), (sic) on the basis of his status as described in subparagraph
(A), was included as an individual eligible for medical assistance under
a State plan approved under title XIX of such Act (this subchapter)
(whether or not such individual actually received aid or assistance
under a State plan referred to in subparagraph (A)),
shall be deemed to be receiving such aid or assistance for such month
and for each succeeding month in a continuous period of months if, for
each month in such period --
''(3) such individual continues to be (for all of such month) an
inpatient in such an institution and would (except for his being an
inpatient in such institution) continue to meet the conditions of
eligibility to receive aid or assistance under such plan (as such plan
was in effect for December 1973), and
''(4) such individual is determined (under the utilization review and
other professional audit procedures applicable to State plans approved
under title XIX of the Social Security Act (this subchapter)) to be in
need of care in such an institution.
Federal matching under title XIX of the Social Security Act (this
subchapter) shall be available for the medical assistance furnished to
individuals eligible for such assistance under this section.''
Section 232 of Pub. L. 93-66, title II, July 9, 1973, 87 Stat. 160,
as amended by Pub. L. 93-233, 13(b)(2), Dec. 31, 1973, 87 Stat. 964,
provided that: ''For purposes of section 1902(a)(10) of the Social
Security Act (subsec. (a)(10) of this section), any individual who, for
the month of December 1973 was eligible (subsec. (a)(10) of this
section) for medical assistance by reason of his having been determined
to meet the criteria for blindness or disability (established by a State
plan approved under title I, X, XIV, or XVI of such Act (subchapter I,
X, XIV, or XVI of this chapter)), shall be deemed for purposes of title
XIX (this subchapter) to be an individual who is blind or disabled
within the meaning of section 1614(a) of the Social Security Act
(section 1382c(a) of this title) for each month in a continuous period
of months (beginning with the month of January 1974), if, for each month
in such period, such individual continues to meet the criteria for
blindness or disability so established by such a State plan (as it was
in effect for December 1973), and the other conditions of eligibility
contained in the plan of the State approved under title XIX (this
subchapter) (as it was in effect in December 1973). Federal matching
under title XIX of the Social Security Act (this subchapter) shall be
available for the medical assistance furnished to individuals eligible
for such assistance under this section.''
This Subchapter
Section 249E of Pub. L. 92-603, as amended by section 233 of Pub.
L. 93-66, title II, July 9, 1973, 87 Stat. 160, provided that: ''For
purposes of section 1902(a)(10) of the Social Security Act (subsec.
(a)(10) of this section) any individual who, for the month of August
1972, was eligible for or receiving aid or assistance under a State plan
approved under title I, X, XIV, or XVI, or part A of title IV of such
Act (subchapter I, X, XIV, or XVI, or part A of subchapter IV of this
chapter) and who for such month was entitled to monthly insurance
benefits under title II of such Act (subchapter II of this chapter)
shall be deemed to be eligible for such aid or assistance for any month
thereafter prior to July 1975 if such individual would have been
eligible for such aid or assistance for such month had the increase in
monthly insurance benefits under title II of such Act (subchapter II of
this chapter) resulting from enactment of Pub. L. 92-336 (see Tables)
not been applicable to such individual.''
Section 234(c) of Pub. L. 90-248 provided that: ''Notwithstanding
any other provision of law, after June 30, 1968, no Federal funds shall
be paid to any State as Federal matching under title I, X, XIV, XVI, or
XIX of the Social Security Act (subchapter I, X, XIV, XVI, or XIX of
this chapter) for payments made to any nursing home for or on account of
any nursing home services provided by such nursing home for any period
during which such nursing home is determined not to meet fully all
requirements of the State for licensure as a nursing home, except that
the Secretary may prescribe a reasonable period or periods of time
during which a nursing home which has formerly met such requirements
will be eligible for payments which include Federal participation if
during such period or periods such home promptly takes all necessary
steps to again meet such requirements.''
Pub. L. 90-227, 1, Dec. 27, 1967, 81 Stat. 744, provided: ''That
(a) the Commissioner of the District of Columbia (now Mayor) (hereafter
in this Act (enacting this note and provisions set out as a note under
section 1395v of this title) referred to as the 'Commissioner') may
submit under title XIX of the Social Security Act (this subchapter) to
the Secretary of Health, Education, and Welfare (now Health and Human
Services) (hereafter in this Act referred to as the 'Secretary') a plan
for medical assistance (and any modifications of such plan) to enable
the District of Columbia to receive Federal financial assistance under
such title for a medical assistance program established by the
Commissioner under such plan.
''(b)(1) Notwithstanding any other provision of law, the Commissioner
may take such action as may be necessary to submit such plan to the
Secretary and to establish and carry out such medical assistance
program, except that in prescribing the standards for determining
eligibility for and the extent of medical assistance under the District
of Columbia's plan for medical assistance, the Commissioner may not
(except to the extent required by title XIX of the Social Security Act
(this subchapter)) --
''(A) prescribe maximum income levels for recipients of medical
assistance under such plan which exceed (i) the title XIX maximum income
levels if such levels are in effect, or (ii) the Commissioner's maximum
income levels for the local medical assistance program if there are no
title XIX maximum income levels in effect; or
''(B) prescribe criteria which would permit an individual or family
to be eligible for such assistance if such individual or family would be
ineligible, solely by reason of his or its resources, for medical
assistance both under the plan of the State of Maryland approved under
title XIX of the Social Security Act (this subchapter) and under the
plan of the State of Virginia approved under such title.
''(2) For purposes of subparagraph (A) of paragraph (1) of this
subsection --
''(A) the term 'title XIX maximum income levels' means any maximum
income levels which may be specified by title XIX of the Social Security
Act (this subchapter) for recipients of medical assistance under State
plans approved under that title;
''(B) the term 'the Commissioner's maximum income levels for the
local medical assistance program' means the maximum income levels
prescribed for recipients of medical assistance under the District of
Columbia's medical assistance program in effect in the fiscal year
ending June 30, 1967; and
''(C) during any of the first four calendar quarters in which medical
assistance is provided under such plan there shall be deemed to be no
title XIX maximum income levels in effect if the title XIX maximum
income levels in effect during such quarter are higher than the
Commissioner's maximum income levels for the local medical assistance
program.''
1255a; title 38 section 5503.
/1/ So in original. The semicolon probably should be a comma.
/2/ So in original. Probably should be followed by ''and''.
/3/ So in original. The semicolon probably should be a comma.
/4/ So in original. The ''; and'' probably should be a comma.
/5/ So in original. Two subdivs. (XI) have been enacted.
/6/ So in original. The period probably should be a semicolon.
/7/ So in original. Probably should be ''section''.
/8/ So in original. The word ''and'' probably should not appear.
/9/ So in original. Probably should be section ''1396d(l)(2)(B)''.
/10/ So in original. The period probably should be a semicolon.
/11/ So in original. Probably should be ''(56)''.
/12/ So in original. The period probably should be ''; and''.
/13/ So in original. Probably should be ''(59)''.
/14/ So in original. Probably should be subsection ''(x)''.
/15/ So in original. Probably should be ''an''.
/16/ So in original.
/17/ So in original. Probably should be followed by a comma.
/18/ So in original. Probably should be ''this subsection''.
/19/ So in original. Probably should be followed by a comma.
/20/ So in original. The comma probably should not appear.
/21/ See References in Text note below.
/22/ See References in Text note below.
/23/ So in original. There is no par. (2).
42 USC 1396b. Payment to States
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Computation of amount
From the sums appropriated therefor, the Secretary (except as
otherwise provided in this section) shall pay to each State which has a
plan approved under this subchapter, for each quarter, beginning with
the quarter commencing January 1, 1966 --
(1) an amount equal to the Federal medical assistance percentage (as
defined in section 1396d(b) of this title, subject to subsections (g)
and (j) of this section and section 1396r-4(f) of this title) of the
total amount expended during such quarter as medical assistance under
the State plan; plus
(2)(A) an amount equal to 75 per centum of so much of the sums
expended during such quarter (as found necessary by the Secretary for
the proper and efficient administration of the State plan) as are
attributable to compensation or training of skilled professional medical
personnel, and staff directly supporting such personnel, of the State
agency or any other public agency; plus
(B) notwithstanding paragraph (1) or subparagraph (A), with respect
to amounts expended for nursing aide training and competency evaluation
programs, and competency evaluation programs, described in section
1396r(e)(1) of this title (including the costs for nurse aides to
complete such competency evaluation programs), regardless of whether the
programs are provided in or outside nursing facilities or of the skill
of the personnel involved in such programs, an amount equal to 50
percent (or, for calendar quarters beginning on or after July 1, 1988,
and before October 1, 1990, the lesser of 90 percent or the Federal
medical assistance percentage plus 25 percentage points) of so much of
the sums expended during such quarter (as found necessary by the
Secretary for the proper and efficient administration of the State plan)
as are attributable to such programs; plus
(C) an amount equal to 75 percent of so much of the sums expended
during such quarter (as found necessary by the Secretary for the proper
and efficient administration of the State plan) as are attributable to
preadmission screening and resident review activities conducted by the
State under section 1396r(e)(7) of this title; plus
(D) for each calendar quarter during --
(i) fiscal year 1991, an amount equal to 90 percent,
(ii) fiscal year 1992, an amount equal to 85 percent,
(iii) fiscal year 1993, an amount equal to 80 percent, and
(iv) fiscal year 1994 and thereafter, an amount equal to 75 percent,
of so much of the sums expended during such quarter (as found
necessary by the Secretary for the proper and efficient administration
of the State plan) as are attributable to State activities under section
1396r(g) of this title; plus
(3) an amount equal to --
(A)(i) 90 per centum of so much of the sums expended during such
quarter as are attributable to the design, development, or installation
of such mechanized claims processing and information retrieval systems
as the Secretary determines are likely to provide more efficient,
economical, and effective administration of the plan and to be
compatible with the claims processing and information retrieval systems
utilized in the administration of subchapter XVIII of this chapter,
including the State's share of the cost of installing such a system to
be used jointly in the administration of such State's plan and the plan
of any other State approved under this chapter, and
(ii) 90 per centum of so much of the sums expended during any such
quarter in the fiscal year ending June 30, 1972, or the fiscal year
ending June 30, 1973, as are attributable to the design, development, or
installation of cost determination systems for State-owned general
hospitals (except that the total amount paid to all States under this
clause for either such fiscal year shall not exceed $150,000), and
(B) 75 per centum of so much of the sums expended during such quarter
as are attributable to the operation of systems (whether such systems
are operated directly by the State or by another person under a contract
with the State) of the type described in subparagraph (A)(i) (whether or
not designed, developed, or installed with assistance under such
subparagraph) which are approved by the Secretary and which include
provision for prompt written notice to each individual who is furnished
services covered by the plan, or to each individual in a sample group of
individuals who are furnished such services, of the specific services
(other than confidential services) so covered, the name of the person or
persons furnishing the services, the date or dates on which the services
were furnished, and the amount of the payment or payments made under the
plan on account of the services; and
(C) 75 per centum of the sums expended with respect to costs incurred
during such quarter (as found necessary by the Secretary for the proper
and efficient administration of the State plan) as are attributable to
the performance of medical and utilization review or quality review by a
utilization and quality control peer review organization or by an entity
which meets the requirements of section 1320c-1 of this title, as
determined by the Secretary, under a contract entered into under section
1396a(d) of this title; and
(D) 75 percent of so much of the sums expended by the State plan
during a quarter in 1991, 1992, or 1993, as the Secretary determines is
attributable to the statewide adoption of a drug use review program
which conforms to the requirements of section 1396r-8(g) of this title;
plus
(4) an amount equal to 100 percent of the sums expended during the
quarter which are attributable to the costs of the implementation and
operation of the immigration status verification system described in
section 1320b-7(d) of this title; plus
(5) an amount equal to 90 per centum of the sums expended during such
quarter which are attributable to the offering, arranging, and
furnishing (directly or on a contract basis) of family planning services
and supplies;
(6) subject to subsection (b)(3) of this section, an amount equal to
--
(A) 90 per centum of the sums expended during such a quarter within
the twelve-quarter period beginning with the first quarter in which a
payment is made to the State pursuant to this paragraph, and
(B) 75 per centum of the sums expended during each succeeding
calendar quarter,
with respect to costs incurred during such quarter (as found
necessary by the Secretary for the elimination of fraud in the provision
and administration of medical assistance provided under the State plan)
which are attributable to the establishment and operation of (including
the training of personnel employed by) a State medicaid fraud control
unit (described in subsection (q) of this section); plus
(7) subject to section 1396r(g)(3)(B) of this title, an amount equal
to 50 per centum of the remainder of the amounts expended during such
quarter as found necessary by the Secretary for the proper and efficient
administration of the State plan.
(b) Quarterly expenditures beginning after December 31, 1969
(1) Notwithstanding the preceding provisions of this section, the
amount determined under subsection (a)(1) of this section for any State
for any quarter beginning after December 31, 1969, shall not take into
account any amounts expended as medical assistance with respect to
individuals aged 65 or over and disabled individuals entitled to
hospital insurance benefits under subchapter XVIII of this chapter which
would not have been so expended if the individuals involved had been
enrolled in the insurance program established by part B of subchapter
XVIII of this chapter, other than amounts expended under provisions of
the plan of such State required by section 1396a(a)(34) of this title.
(2) For limitation on Federal participation for capital expenditures
which are out of conformity with a comprehensive plan of a State or
areawide planning agency, see section 1320a-1 of this title.
(3) The amount of funds which the Secretary is otherwise obligated to
pay a State during a quarter under subsection (a)(6) of this section may
not exceed the higher of --
(A) $125,000, or
(B) one-quarter of 1 per centum of the sums expended by the Federal,
State, and local governments during the previous quarter in carrying out
the State's plan under this subchapter.
(c) Treatment of educationally-related services
Nothing in this subchapter shall be construed as prohibiting or
restricting, or authorizing the Secretary to prohibit or restrict,
payment under subsection (a) of this section for medical assistance for
covered services furnished to a child with a disability because such
services are included in the child's individualized education program
established pursuant to part B of the Individuals with Disabilities
Education Act (20 U.S.C. 1411 et seq.) or furnished to an infant or
toddler with a disability because such services are included in the
child's individualized family service plan adopted pursuant to part H of
such Act (20 U.S.C. 1471 et seq.).
(d) Estimates of State entitlement; installments; adjustments to
reflect overpayments or underpayments; time for recovery or adjustment;
uncollectable or discharged debts; obligated appropriations; disputed
claims
(1) Prior to the beginning of each quarter, the Secretary shall
estimate the amount to which a State will be entitled under subsections
(a) and (b) of this section for such quarter, such estimates to be based
on (A) a report filed by the State containing its estimate of the total
sum to be expended in such quarter in accordance with the provisions of
such subsections, and stating the amount appropriated or made available
by the State and its political subdivisions for such expenditures in
such quarter, and if such amount is less than the State's proportionate
share of the total sum of such estimated expenditures, the source or
sources from which the difference is expected to be derived, and (B)
such other investigation as the Secretary may find necessary.
(2)(A) The Secretary shall then pay to the State, in such
installments as he may determine, the amount so estimated, reduced or
increased to the extent of any overpayment or underpayment which the
Secretary determines was made under this section to such State for any
prior quarter and with respect to which adjustment has not already been
made under this subsection.
(B) Expenditures for which payments were made to the State under
subsection (a) of this section shall be treated as an overpayment to the
extent that the State or local agency administering such plan has been
reimbursed for such expenditures by a third party pursuant to the
provisions of its plan in compliance with section 1396a(a)(25) of this
title.
(C) For purposes of this subsection, when an overpayment is
discovered, which was made by a State to a person or other entity, the
State shall have a period of 60 days in which to recover or attempt to
recover such overpayment before adjustment is made in the Federal
payment to such State on account of such overpayment. Except as
otherwise provided in subparagraph (D), the adjustment in the Federal
payment shall be made at the end of the 60 days, whether or not recovery
was made.
(D) In any case where the State is unable to recover a debt which
represents an overpayment (or any portion thereof) made to a person or
other entity on account of such debt having been discharged in
bankruptcy or otherwise being uncollectable, no adjustment shall be made
in the Federal payment to such State on account of such overpayment (or
portion thereof).
(3) The pro rata share to which the United States is equitably
entitled, as determined by the Secretary, of the net amount recovered
during any quarter by the State or any political subdivision thereof
with respect to medical assistance furnished under the State plan shall
be considered an overpayment to be adjusted under this subsection.
(4) Upon the making of any estimate by the Secretary under this
subsection, any appropriations available for payments under this section
shall be deemed obligated.
(5) In any case in which the Secretary estimates that there has been
an overpayment under this section to a State on the basis of a claim by
such State that has been disallowed by the Secretary under section
1316(d) of this title, and such State disputes such disallowance, the
amount of the Federal payment in controversy shall, at the option of the
State, be retained by such State or recovered by the Secretary pending a
final determination with respect to such payment amount. If such final
determination is to the effect that any amount was properly disallowed,
and the State chose to retain payment of the amount in controversy, the
Secretary shall offset, from any subsequent payments made to such State
under this subchapter, an amount equal to the proper amount of the
disallowance plus interest on such amount disallowed for the period
beginning on the date such amount was disallowed and ending on the date
of such final determination at a rate (determined by the Secretary)
based on the average of the bond equivalent of the weekly 90-day
treasury bill auction rates during such period.
(6)(A) Each State (as defined in subsection (w)(7)(D) of this
section) shall include, in the first report submitted under paragraph
(1) after the end of each fiscal year, information related to --
(i) provider-related donations made to the State or units of local
government during such fiscal year, and
(ii) health care related taxes collected by the State or such units
during such fiscal year.
(B) Each State shall include, in the first report submitted under
paragraph (1) after the end of each fiscal year, information related to
the total amount of payment adjustments made, and the amount of payment
adjustments made to individual providers (by provider), under section
1396r-4(c) of this title during such fiscal year.
(e) Transition costs of closures or conversions permitted
A State plan approved under this subchapter may include, as a cost
with respect to hospital services under the plan under this subchapter,
periodic expenditures made to reflect transitional allowances
established with respect to a hospital closure or conversion under
section 1395uu of this title.
(f) Limitation on Federal participation in medical assistance
(1)(A) Except as provided in paragraph (4), payment under the
preceding provisions of this section shall not be made with respect to
any amount expended as medical assistance in a calendar quarter, in any
State, for any member of a family the annual income of which exceeds the
applicable income limitation determined under this paragraph.
(B)(i) Except as provided in clause (ii) of this subparagraph, the
applicable income limitation with respect to any family is the amount
determined, in accordance with standards prescribed by the Secretary, to
be equivalent to 133 1/3 percent of the highest amount which would
ordinarily be paid to a family of the same size without any income or
resources, in the form of money payments, under the plan of the State
approved under part A of subchapter IV of this chapter.
(ii) If the Secretary finds that the operation of a uniform maximum
limits payments to families of more than one size, he may adjust the
amount otherwise determined under clause (i) to take account of families
of different sizes.
(C) The total amount of any applicable income limitation determined
under subparagraph (B) shall, if it is not a multiple of $100 or such
other amount as the Secretary may prescribe, be rounded to the next
higher multiple of $100 or such other amount, as the case may be.
(2)(A) In computing a family's income for purposes of paragraph (1),
there shall be excluded any costs (whether in the form of insurance
premiums or otherwise and regardless of whether such costs are
reimbursed under another public program of the State or political
subdivision thereof) incurred by such family for medical care or for any
other type of remedial care recognized under State law or, (B)
notwithstanding section 1396o of this title at State option, an amount
paid by such family, at the family's option, to the State, provided that
the amount, when combined with costs incurred in prior months, is
sufficient when excluded from the family's income to reduce such
family's income below the applicable income limitation described in
paragraph (1). The amount of State expenditures for which medical
assistance is available under subsection (a)(1) of this section will be
reduced by amounts paid to the State pursuant to this subparagraph.. /1/
(3) For purposes of paragraph (1)(B), in the case of a family
consisting of only one individual, the ''highest amount which would
ordinarily be paid'' to such family under the State's plan approved
under part A of subchapter IV of this chapter shall be the amount
determined by the State agency (on the basis of reasonable relationship
to the amounts payable under such plan to families consisting of two or
more persons) to be the amount of the aid which would ordinarily be
payable under such plan to a family (without any income or resources)
consisting of one person if such plan provided for aid to such a family.
(4) The limitations on payment imposed by the preceding provisions of
this subsection shall not apply with respect to any amount expended by a
State as medical assistance for any individual described in section
1396a(a)(10)(A)(i)(III), 1396a(a)(10)(A)(i)(IV), 1396a(a)(10)(A)(i)(V),
1396a(a)(10)(A)(i)(VI), 1396a(a)(10)(A)(i)(VII),
1396a(a)(10)(A)(ii)(IX), 1396a(a)(10)(A)(ii)(X), or 1396d(p)(1) of this
title or for any individual --
(A) who is receiving aid or assistance under any plan of the State
approved under subchapter I, X, XIV or XVI, or part A of subchapter IV,
or with respect to whom supplemental security income benefits are being
paid under subchapter XVI of this chapter, or
(B) who is not receiving such aid or assistance, and with respect to
whom such benefits are not being paid, but (i) is eligible to receive
such aid or assistance, or to have such benefits paid with respect to
him, or (ii) would be eligible to receive such aid or assistance, or to
have such benefits paid with respect to him if he were not in a medical
institution, or
(C) with respect to whom there is being paid, or who is eligible, or
would be eligible if he were not in a medical institution, to have paid
with respect to him, a State supplementary payment and is eligible for
medical assistance equal in amount, duration, and scope to the medical
assistance made available to individuals described in section
1396a(a)(10)(A) of this title, but only if the income of such individual
(as determined under section 1382a of this title, but without regard to
subsection (b) thereof) does not exceed 300 percent of the supplemental
security income benefit rate established by section 1382(b)(1) of this
title,
at the time of the provision of the medical assistance giving rise to
such expenditure.
(g) Decrease in Federal medical assistance percentage of amounts paid
for services furnished under State plan after June 30, 1973
(1) Subject to paragraph (3), with respect to amounts paid for the
following services furnished under the State plan after June 30, 1973
(other than services furnished pursuant to a contract with a health
maintenance organization as defined in section 1395mm of this title or
which is a qualified health maintenance organization (as defined in
section 300e-9(d) of this title)), the Federal medical assistance
percentage shall be decreased as follows: After an individual has
received inpatient hospital services or services in an intermediate care
facility for the mentally retarded for 60 days or inpatient mental
hospital services for 90 days (whether or not such days are
consecutive), during any fiscal year, the Federal medical assistance
percentage with respect to amounts paid for any such care furnished
thereafter to such individual shall be decreased by a per centum thereof
(determined under paragraph (5)) unless the State agency responsible for
the administration of the plan makes a showing satisfactory to the
Secretary that, with respect to each calendar quarter for which the
State submits a request for payment at the full Federal medical
assistance percentage for amounts paid for inpatient hospital services
or services in an intermediate care facility for the mentally retarded
furnished beyond 60 days (or inpatient mental hospital services
furnished beyond 90 days), such State has an effective program of
medical review of the care of patients in mental hospitals and
intermediate care facilities for the mentally retarded pursuant to
paragraphs (26) and (31) of section 1396a(a) of this title whereby the
professional management of each case is reviewed and evaluated at least
annually by independent professional review teams. In determining the
number of days on which an individual has received services described in
this subsection, there shall not be counted any days with respect to
which such individual is entitled to have payments made (in whole or in
part) on his behalf under section 1395d of this title.
(2) The Secretary shall, as part of his validation procedures under
this subsection, conduct timely sample onsite surveys of private and
public institutions in which recipients of medical assistance may
receive care and services under a State plan approved under this
subchapter, and his findings with respect to such surveys (as well as
the showings of the State agency required under this subsection) shall
be made available for public inspection.
(3)(A) No reduction in the Federal medical assistance percentage of a
State otherwise required to be imposed under this subsection shall take
effect --
(i) if such reduction is due to the State's unsatisfactory or invalid
showing made with respect to a calendar quarter beginning before January
1, 1977;
(ii) before January 1, 1978;
(iii) unless a notice of such reduction has been provided to the
State at least 30 days before the date such reduction takes effect; or
(iv) due to the State's unsatisfactory or invalid showing made with
respect to a calendar quarter beginning after September 30, 1977, unless
notice of such reduction has been provided to the State no later than
the first day of the fourth calendar quarter following the calendar
quarter with respect to which such showing was made.
(B) The Secretary shall waive application of any reduction in the
Federal medical assistance percentage of a State otherwise required to
be imposed under paragraph (1) because a showing by the State, made
under such paragraph with respect to a calendar quarter ending after
January 1, 1977, and before January 1, 1978, is determined to be either
unsatisfactory under such paragraph or invalid under paragraph (2), if
the Secretary determines that the State's showing made under paragraph
(1) with respect to any calendar quarter ending on or before December
31, 1978, is satisfactory under such paragraph and is valid under
paragraph (2).
(4)(A) The Secretary may not find the showing of a State, with
respect to a calendar quarter under paragraph (1), to be satisfactory if
the showing is submitted to the Secretary later than the 30th day after
the last day of the calendar quarter, unless the State demonstrates to
the satisfaction of the Secretary good cause for not meeting such
deadline.
(B) The Secretary shall find a showing of a State, with respect to a
calendar quarter under paragraph (1), to be satisfactory under such
paragraph with respect to the requirement that the State conduct annual
onsite inspections in mental hospitals and intermediate care facilities
for the mentally retarded under paragraphs (26) and (31) of section
1396a(a) of this title, if the showing demonstrates that the State has
conducted such an onsite inspection during the 12-month period ending on
the last date of the calendar quarter --
(i) in each of not less than 98 per centum of the number of such
hospitals and facilities requiring such inspection, and
(ii) in every such hospital or facility which has 200 or more beds,
and that, with respect to such hospitals and facilities not inspected
within such period, the State has exercised good faith and due diligence
in attempting to conduct such inspection, or if the State demonstrates
to the satisfaction of the Secretary that it would have made such a
showing but for failings of a technical nature only.
(5) In the case of a State's unsatisfactory or invalid showing made
with respect to a type of facility or institutional services in a
calendar quarter, the per centum amount of the reduction of the State's
Federal medical assistance percentage for that type of services under
paragraph (1) is equal to 33 1/3 per centum multiplied by a fraction,
the denominator of which is equal to the total number of patients
receiving that type of services in that quarter under the State plan in
facilities or institutions for which a showing was required to be made
under this subsection, and the numerator of which is equal to the number
of such patients receiving such type of services in that quarter in
those facilities or institutions for which a satisfactory and valid
showing was not made for that calendar quarter.
(6)(A) Recertifications required under section 1396a(a)(44) of this
title shall be conducted at least every 60 days in the case of inpatient
hospital services.
(B) Such recertifications in the case of services in an intermediate
care facility for the mentally retarded shall be conducted at least --
(i) 60 days after the date of the initial certification,
(ii) 180 days after the date of the initial certification,
(iii) 12 months after the date of the initial certification,
(iv) 18 months after the date of the initial certification,
(v) 24 months after the date of the initial certification, and
(vi) every 12 months thereafter.
(C) For purposes of determining compliance with the schedule
established by this paragraph, a recertification shall be considered to
have been done on a timely basis if it was performed not later than 10
days after the date the recertification was otherwise required and the
State establishes good cause why the physician or other person making
such recertification did not meet such schedule.
(h) Repealed. Pub. L. 100-203, title IV, 4211(g)(1), Dec. 22,
1987, 101 Stat. 1330-205
(i) Payment for organ transplants; item or service furnished by
excluded individual, entity, or physician; other restrictions
Payment under the preceding provisions of this section shall not be
made --
(1) for organ transplant procedures unless the State plan provides
for written standards respecting the coverage of such procedures and
unless such standards provide that --
(A) similarly situated individuals are treated alike; and
(B) any restriction, on the facilities or practitioners which may
provide such procedures, is consistent with the accessibility of high
quality care to individuals eligible for the procedures under the State
plan; or
(2) with respect to any amount expended for an item or service (other
than an emergency item or service, not including items or services
furnished in an emergency room of a hospital) furnished --
(A) under the plan by any individual or entity during any period when
the individual or entity is excluded from participation under subchapter
V, XVIII, or XX of this chapter or under this subchapter pursuant to
section 1320a-7, 1320a-7a, 1320c-5, or 1395u(j)(2) of this title, or
(B) at the medical direction or on the prescription of a physician,
during the period when such physician is excluded from participation
under subchapter V, XVIII, or XX of this chapter or under this
subchapter pursuant to section 1320a-7, 1320a-7a, 1320c-5, or
1395u(j)(2) of this title and when the person furnishing such item or
service knew or had reason to know of the exclusion (after a reasonable
time period after reasonable notice has been furnished to the person).
/2/
(3) with respect to any amount expended for inpatient hospital
services furnished under the plan (other than amounts attributable to
the special situation of a hospital which serves a disproportionate
number of low income patients with special needs) to the extent that
such amount exceeds the hospital's customary charges with respect to
such services or (if such services are furnished under the plan by a
public institution free of charge or at nominal charges to the public)
exceeds an amount determined on the basis of those items (specified in
regulations prescribed by the Secretary) included in the determination
of such payment which the Secretary finds will provide fair compensation
to such institution for such services; or
(4) with respect to any amount expended for care or services
furnished under the plan by a hospital unless such hospital has in
effect a utilization review plan which meets the requirements imposed by
section 1395x(k) of this title for purposes of subchapter XVIII of this
chapter; and if such hospital has in effect such a utilization review
plan for purposes of subchapter XVIII of this chapter, such plan shall
serve as the plan required by this subsection (with the same standards
and procedures and the same review committee or group) as a condition of
payment under this subchapter; the Secretary is authorized to waive the
requirements of this paragraph if the State agency demonstrates to his
satisfaction that it has in operation utilization review procedures
which are superior in their effectiveness to the procedures required
under section 1395x(k) of this title; or
(5) with respect to any amount expended for any drug product for
which payment may not be made under part B of subchapter XVIII of this
chapter because of section 1395y(c) of this title; or
(6) with respect to any amount expended for inpatient hospital tests
(other than in emergency situations) not specifically ordered by the
attending physician or other responsible practitioner; or
(7) with respect to any amount expended for clinical diagnostic
laboratory tests performed by a physician, independent laboratory, or
hospital, to the extent such amount exceeds the amount that would be
recognized under section 1395l(h) of this title for such tests performed
for an individual enrolled under part B of subchapter XVIII of this
chapter; or
(8) with respect to any amount expended for medical assistance (A)
for nursing facility services to reimburse (or otherwise compensate) a
nursing facility for payment of a civil money penalty imposed under
section 1396r(h) of this title or (B) for home and community care to
reimburse (or otherwise compensate) a provider of such care for payment
of a civil money penalty imposed under this subchapter or subchapter XI
of this chapter or for legal expenses in defense of an exclusion or
civil money penalty under this subchapter or subchapter XI of this
chapter if there is no reasonable legal ground for the provider's case;
or
(9) with respect to any amount of medical assistance for pregnant
women and children described in section 1396a(a)(10)(A)(ii)(IX) of this
title, if the State has in effect, under its plan established under part
A of subchapter IV of this chapter, payment levels that are less than
the payment levels in effect under such plan on July 1, 1987; /2/
(10) with respect to covered outpatient drugs of a manufacturer
dispensed in any State unless, (A) except as provided in section
1396r-8(a)(3) of this title, the manufacturer complies with the rebate
requirements of section 1396r-8(a) of this title with respect to the
drugs so dispensed in all States, and (B) effective January 1, 1993, the
State provides for drug use review in accordance with section 1396r-8(g)
of this title; or
(11) with respect to any amount expended to reimburse (or otherwise
compensate) a nursing facility for payment of legal expenses associated
with any action initiated by the facility that is dismissed on the basis
that no reasonable legal ground existed for the institution of such
action; or
(12) with respect to any amount expended for physicians' services
furnished on or after the first day of the first quarter beginning more
than 60 days after the date of establishment of the physician identifier
system under section 1396a(x) of this title, unless the claim for the
services includes the unique physician identifier provided under such
system. /2/
(14) /3/ with respect to any amount expended for physicians' services
furnished by a physician on or after January 1, 1992, to --
(A) a child under 21 years of age, unless the physician --
(i) is certified in family practice or pediatrics by the medical
specialty board recognized by the American Board of Medical Specialties
for family practice or pediatrics,
(ii) is employed by, or affiliated with, a Federally-qualified health
center (as defined in section 1396d(l)(2)(B) of this title),
(iii) holds admitting privileges at a hospital participating in a
State plan approved under this subchapter,
(iv) is a member of the National Health Service Corps,
(v) documents a current, formal, consultation and referral
arrangement with a pediatrician or family practitioner who has the
certification described in clause (i) for purposes of specialized
treatment and admission to a hospital, or
(vi) has been certified by the Secretary as qualified to provide
physicians' services to a child under 21 years of age; or
(B) to a pregnant woman (or during the 60 day period beginning on the
date of termination of the pregnancy) unless the physician --
(i) is certified in family practice or obstetrics by the medical
specialty board recognized by the American Board of Medical Specialties
for family practice or obstetrics,
(ii) is employed by, or affiliated with, a Federally-qualified health
center (as defined in section 1396d(l)(2)(B) of this title),
(iii) holds admitting privileges at a hospital participating in a
State plan approved under this subchapter,
(iv) is a member of the National Health Service Corps,
(v) documents a current, formal, consultation and referral
arrangement with an obstetrician or family practitioner who has the
certification described in clause (i) for purposes of specialized
treatment and admission to a hospital, or
(vi) has been certified by the Secretary as qualified to provide
physicians' services to pregnant women.
Nothing in paragraph (1) shall be construed as permitting a State to
provide services under its plan under this subchapter that are not
reasonable in amount, duration, and scope to achieve their purpose.
(j) Adjustment of amount
Notwithstanding the preceding provisions of this section, the amount
determined under subsection (a)(1) of this section for any State for any
quarter shall be adjusted in accordance with section 1396m of this
title.
(k) Technical assistance to States
The Secretary is authorized to provide at the request of any State
(and without cost to such State) such technical and actuarial assistance
as may be necessary to assist such State to contract with any health
maintenance organization which meets the requirements of subsection (m)
of this section for the purpose of providing medical care and services
to individuals who are entitled to medical assistance under this
subchapter.
(l) Repealed. Pub. L. 94-552, 1, Oct. 18, 1976, 90 Stat. 2540
(m) ''Health maintenance organization'' defined; duties and
functions of Secretary; payments to States; reporting requirements;
remedies
(1)(A) The term ''health maintenance organization'' means a public or
private organization, organized under the laws of any State, which meets
the requirement of section 1396a(w) of this title is a qualified health
maintenance organization (as defined in section 300e-9(d) of this title)
or which meets the requirement of section 1396a(a) of this title and --
(i) makes services it provides to individuals eligible for benefits
under this subchapter accessible to such individuals, within the area
served by the organization, to the same extent as such services are made
accessible to individuals (eligible for medical assistance under the
State plan) not enrolled with the organization, and
(ii) has made adequate provision against the risk of insolvency,
which provision is satisfactory to the State and which assures that
individuals eligible for benefits under this subchapter are in no case
held liable for debts of the organization in case of the organization's
insolvency.
(B) The duties and functions of the Secretary, insofar as they
involve making determinations as to whether an organization is a health
maintenance organization within the meaning of subparagraph (A), shall
be integrated with the administration of section 300e-11(a) and (b) of
this title.
(2)(A) Except as provided in subparagraphs (B), (C), and (G), no
payment shall be made under this subchapter to a State with respect to
expenditures incurred by it for payment (determined under a prepaid
capitation basis or under any other risk basis) for services provided by
any entity (including a health insuring organization) which is
responsible for the provision (directly or through arrangements with
providers of services) of inpatient hospital services and any other
service described in paragraph (2), (3), (4), (5), or (7) of section
1396d(a) of this title or for the provision of any three or more of the
services described in such paragraphs unless --
(i) the Secretary has determined that the entity is a health
maintenance organization as defined in paragraph (1);
(ii) less than 75 percent of the membership of the entity which is
enrolled on a prepaid basis consists of individuals who (I) are insured
for benefits under part B of subchapter XVIII of this chapter or for
benefits under both parts A and B of such subchapter, or (II) are
eligible to receive benefits under this subchapter;
(iii) such services are provided for the benefit of individuals
eligible for benefits under this subchapter in accordance with a
contract between the State and the entity under which prepaid payments
to the entity are made on an actuarially sound basis and under which the
Secretary must provide prior approval for contracts providing for
expenditures in excess of $100,000;
(iv) such contract provides that the Secretary and the State (or any
person or organization designated by either) shall have the right to
audit and inspect any books and records of the entity (and of any
subcontractor) that pertain (I) to the ability of the entity to bear the
risk of potential financial losses, or (II) to services performed or
determinations of amounts payable under the contract;
(v) such contract provides that in the entity's enrollment,
reenrollment, or disenrollment of individuals who are eligible for
benefits under this subchapter and eligible to enroll, reenroll, or
disenroll with the entity pursuant to the contract, the entity will not
discriminate among such individuals on the basis of their health status
or requirements for health care services;
(vi) such contract (I) except as provided under subparagraph (F),
permits individuals who have elected under the plan to enroll with the
entity for provision of such benefits to terminate such enrollment
without cause as of the beginning of the first calendar month following
a full calendar month after the request is made for such termination,
and (II) provides for notification of each such individual, at the time
of the individual's enrollment, of such right to terminate such
enrollment;
(vii) such contract provides that, in the case of medically necessary
services which were provided (I) to an individual enrolled with the
entity under the contract and entitled to benefits with respect to such
services under the State's plan and (II) other than through the
organization because the services were immediately required due to an
unforeseen illness, injury, or condition, either the entity or the State
provides for reimbursement with respect to those services, /4/
(viii) such contract provides for disclosure of information in
accordance with section 1320a-3 of this title and paragraph (4) of this
subsection;
(ix) such contract provides, in the case of an entity that has
entered into a contract for the provision of services of such center
with a federally qualified health center, that (I) rates of prepayment
from the State are adjusted to reflect fully the rates of payment
specified in section 1396a(a)(13)(E) of this title, and (II) at the
election of such center payments made by the entity to such a center for
services described in 1396d(a)(2)(C) of this title are made at the rates
of payment specified in section 1396a(a)(13)(E) of this title;
(x) any physician incentive plan that it operates meets the
requirements described in section 1395mm(i)(8) of this title; and
(xi) such contract provides for maintenance of sufficient patient
encounter data to identify the physician who delivers services to
patients.
(B) Subparagraph (A) /5/ except with respect to clause (ix) of
subparagraph (A), does not apply with respect to payments under this
subchapter to a State with respect to expenditures incurred by it for
payment for services provided by an entity which --
(i)(I) received a grant of at least $100,000 in the fiscal year
ending June 30, 1976, under section 254b(d)(1)(A) or 254c(d)(1) of this
title, and for the period beginning July 1, 1976, and ending on the
expiration of the period for which payments are to be made under this
subchapter has been the recipient of a grant under either such section;
and
(II) provides to its enrollees, on a prepaid capitation risk basis or
on any other risk basis, all of the services and benefits described in
paragraphs (1), (2), (3), (4)(C), and (5) of section 1396d(a) of this
title and, to the extent required by section 1396a(a)(10)(D) of this
title to be provided under a State plan for medical assistance, the
services and benefits described in paragraph (7) of section 1396d(a) of
this title; or
(ii) is a nonprofit primary health care entity located in a rural
area (as defined by the Appalachian Regional Commission) --
(I) which received in the fiscal year ending June 30, 1976, at least
$100,000 (by grant, subgrant, or subcontract) under the Appalachian
Regional Development Act of 1965, and
(II) for the period beginning July 1, 1976, and ending on the
expiration of the period for which payments are to be made under this
subchapter either has been the recipient of a grant, subgrant, or
subcontract under such Act or has provided services under a contract
(initially entered into during a year in which the entity was the
recipient of such a grant, subgrant, or subcontract) with a State agency
under this subchapter on a prepaid capitation risk basis or on any other
risk basis; or
(iii) which has contracted with the single State agency for the
provision of services (but not including inpatient hospital services) to
persons eligible under this subchapter on a prepaid risk basis prior to
1970.
(C) Subparagraph (A)(ii) shall not apply with respect to payments
under this subchapter to a State with respect to expenditures incurred
by it for payment for services by an entity during the three-year period
beginning on October 8, 1976, or beginning on the date the entity
qualifies as a health maintenance organization (as determined by the
Secretary), whichever occurs later, but only if the entity demonstrates
to the satisfaction of the Secretary by the submission of plans for each
year of such three-year period that it is making continuous efforts and
progress toward achieving compliance with subparagraph (A)(ii).
(D) In the case of a health maintenance organization that is a public
entity, the Secretary may modify or waive the requirement described in
subparagraph (A)(ii) but only if the Secretary determines that the
organization has taken and is taking reasonable efforts to enroll
individuals who are not entitled to benefits under the State plan
approved under this subchapter or under subchapter XVIII of this
chapter.
(E) In the case of a health maintenance organization that --
(i) is a nonprofit organization with at least 25,000 members,
(ii) is and has been a qualified health maintenance organization (as
defined in section 300e-9(d) of this title) for a period of at least
four years,
(iii) provides basic health services through members of the staff of
the organization,
(iv) is located in an area designated as medically underserved under
section 300e-1(7) of this title, and
(v) previously received a waiver of the requirement described in
subparagraph (A)(ii) under section 1315 of this title,
the Secretary may modify or waive the requirement described in
subparagraph (A)(ii) but only if the Secretary determines that special
circumstances warrant such modification or waiver and that the
organization has taken and is taking reasonable efforts to enroll
individuals who are not entitled to benefits under the State plan
approved under this subchapter or under subchapter XVIII of this
chapter.
(F) In the case of --
(i) a contract with an entity described in subparagraph (E) or (G),
with a qualified health maintenance organization (as defined in section
300e-9(d) of this title) which meets the requirement of subparagraph
(A)(ii), or or /6/ with an eligible organization with a contract under
section 1395mm of this title which meets the requirement of subparagraph
(A)(ii), or
(ii) a program pursuant to an undertaking described in paragraph (6)
in which at least 25 percent of the membership enrolled on a prepaid
basis are individuals who (I) are not insured for benefits under part B
of subchapter XVIII of this chapter or eligible for benefits under this
subchapter, and (II) (in the case of such individuals whose prepayments
are made in whole or in part by any government entity) had the
opportunity at the time of enrollment in the program to elect other
coverage of health care costs that would have been paid in whole or in
part by any governmental entity,
a State plan may restrict the period in which requests for
termination of enrollment without cause under subparagraph (A)(vi)(I)
are permitted to the first month of each period of enrollment, each such
period of enrollment not to exceed six months in duration, but only if
the State provides notification, at least twice per year, to individuals
enrolled with such entity or organization of the right to terminate such
enrollment and the restriction on the exercise of this right. Such
restriction shall not apply to requests for termination of enrollment
for cause.
(G) In the case of an entity which is receiving (and has received
during the previous two years) a grant of at least $100,000 under
section 254b(d)(1)(A) or 254c(d)(1) of this title or is receiving (and
has received during the previous two years) at least $100,000 (by grant,
subgrant, or subcontract) under the Appalachian Regional Development Act
of 1965, clauses (i) and (ii) of subparagraph (A) shall not apply.
(H) In the case of an individual who --
(i) in a month is eligible for benefits under this subchapter and
enrolled with a health maintenance organization with a contract under
this paragraph,
(ii) in the next month (or in the next 2 months) is not eligible for
such benefits, but
(iii) in the succeeding month is again eligible for such benefits,
the State plan, subject to subparagraph (A)(vi), may enroll the
individual for that succeeding month with the health maintenance
organization described in clause (i) if the organization continues to
have a contract under this paragraph with the State.
(3) Repealed. Pub. L. 101-508, title IV, 4732(d)(2), Nov. 5, 1990,
104 Stat. 1388-196.
(4)(A) Each health maintenance organization which is not a qualified
health maintenance organization (as defined in section 300e-9(d) of this
title) must report to the State and, upon request, to the Secretary, the
Inspector General of the Department of Health and Human Services, and
the Comptroller General a description of transactions between the
organization and a party in interest (as defined in section 300e-17(b)
of this title), including the following transactions:
(i) Any sale or exchange, or leasing of any property between the
organization and such a party.
(ii) Any furnishing for consideration of goods, services (including
management services), or facilities between the organization and such a
party, but not including salaries paid to employees for services
provided in the normal course of their employment.
(iii) Any lending of money or other extension of credit between the
organization and such a party.
The State or Secretary may require that information reported
respecting an organization which controls, or is controlled by, or is
under common control with, another entity be in the form of a
consolidated financial statement for the organization and such entity.
(B) Each organization shall make the information reported pursuant to
subparagraph (A) available to its enrollees upon reasonable request.
(5)(A) If the Secretary determines that an entity with a contract
under this subsection --
(i) fails substantially to provide medically necessary items and
services that are required (under law or under the contract) to be
provided to an individual covered under the contract, if the failure has
adversely affected (or has substantial likelihood of adversely
affecting) the individual;
(ii) imposes premiums on individuals enrolled under this subsection
in excess of the premiums permitted under this subchapter;
(iii) acts to discriminate among individuals in violation of the
provision of paragraph (2)(A)(v), including expulsion or refusal to
re-enroll an individual or engaging in any practice that would
reasonably be expected to have the effect of denying or discouraging
enrollment (except as permitted by this subsection) by eligible
individuals with the organization whose medical condition or history
indicates a need for substantial future medical services;
(iv) misrepresents or falsifies information that is furnished --
(I) to the Secretary or the State under this subsection, or
(II) to an individual or to any other entity under this subsection,
/7/ or
(v) fails to comply with the requirements of section 1395mm(i)(8) of
this title,
the Secretary may provide, in addition to any other remedies
available under law, for any of the remedies described in subparagraph
(B).
(B) The remedies described in this subparagraph are --
(i) civil money penalties of not more than $25,000 for each
determination under subparagraph (A), or, with respect to a
determination under clause (iii) or (iv)(I) of such subparagraph, of not
more than $100,000 for each such determination, plus, with respect to a
determination under subparagraph (A)(ii), double the excess amount
charged in violation of such subparagraph (and the excess amount charged
shall be deducted from the penalty and returned to the individual
concerned), and plus, with respect to a determination under subparagraph
(A)(iii), $15,000 for each individual not enrolled as a result of a
practice described in such subparagraph, or
(ii) denial of payment to the State for medical assistance furnished
under the contract under this subsection for individuals enrolled after
the date the Secretary notifies the organization of a determination
under subparagraph (A) and until the Secretary is satisfied that the
basis for such determination has been corrected and is not likely to
recur.
The provisions of section 1320a-7a of this title (other than
subsections (a) and (b)) shall apply to a civil money penalty under
clause (i) in the same manner as such provisions apply to a penalty or
proceeding under section 1320a-7a(a) of this title.
(6)(A) For purposes of this subsection and section 1396a(e)(2)(A) of
this title, in the case of the State of New Jersey, the term
''contract'' shall be deemed to include an undertaking by the State
agency, in the State plan under this subchapter, to operate a program
meeting all requirements of this subsection.
(B) The undertaking described in subparagraph (A) must provide --
(i) for the establishment of a separate entity responsible for the
operation of a program meeting the requirements of this subsection,
which entity may be a subdivision of the State agency administering the
State plan under this subchapter;
(ii) for separate accounting for the funds used to operate such
program;
(iii) for setting the capitation rates and any other payment rates
for services provided in accordance with this subsection using a
methodology satisfactory to the Secretary designed to ensure that total
Federal matching payments under this subchapter for such services will
be lower than the matching payments that would be made for the same
services, if provided under the State plan on a fee for service basis to
an actuarially equivalent population; and
(iv) that the State agency will contract, for purposes of meeting the
requirement under section 1396a(a)(30)(C) of this title, with an
organization or entity that under section 1320c-3 of this title reviews
services provided by an eligible organization pursuant to a contract
under section 1395mm of this title for the purpose of determining
whether the quality of services meets professionally recognized
standards of health care.
(C) The undertaking described in subparagraph (A) shall be subject to
approval (and annual re-approval) by the Secretary in the same manner as
a contract under this subsection.
(D) The undertaking described in subparagraph (A) shall not be
eligible for a waiver under section 1396n(b) of this title.
(n) Repealed. Pub. L. 100-93, 8(h)(1), Aug. 18, 1987, 101 Stat.
694
(o) Restrictions on authorized payments to States
Notwithstanding the preceding provisions of this section, no payment
shall be made to a State under the preceding provisions of this section
for expenditures for medical assistance provided for an individual under
its State plan approved under this subchapter to the extent that a
private insurer (as defined by the Secretary by regulation) would have
been obligated to provide such assistance but for a provision of its
insurance contract which has the effect of limiting or excluding such
obligation because the individual is eligible for or is provided medical
assistance under the plan.
(p) Assignment of rights of payment; incentive payments for
enforcement and collection
(1) When a political subdivision of a State makes, for the State of
which it is a political subdivision, or one State makes, for another
State, the enforcement and collection of rights of support or payment
assigned under section 1396k of this title, pursuant to a cooperative
arrangement under such section (either within or outside of such State),
there shall be paid to such political subdivision or such other State
from amounts which would otherwise represent the Federal share of
payments for medical assistance provided to the eligible individuals on
whose behalf such enforcement and collection was made, an amount equal
to 15 percent of any amount collected which is attributable to such
rights of support or payment.
(2) Where more than one jurisdiction is involved in such enforcement
or collection, the amount of the incentive payment determined under
paragraph (1) shall be allocated among the jurisdictions in a manner to
be prescribed by the Secretary.
(q) ''State medicaid fraud control unit'' defined
For the purposes of this section, the term ''State medicaid fraud
control unit'' means a single identifiable entity of the State
government which the Secretary certifies (and annually recertifies) as
meeting the following requirements:
(1) The entity (A) is a unit of the office of the State Attorney
General or of another department of State government which possesses
statewide authority to prosecute individuals for criminal violations,
(B) is in a State the constitution of which does not provide for the
criminal prosecution of individuals by a statewide authority and has
formal procedures, approved by the Secretary, that (i) assure its
referral of suspected criminal violations relating to the program under
this subchapter to the appropriate authority or authorities in the State
for prosecution and (ii) assure its assistance of, and coordination
with, such authority or authorities in such prosecutions, or (C) has a
formal working relationship with the office of the State Attorney
General and has formal procedures (including procedures for its referral
of suspected criminal violations to such office) which are approved by
the Secretary and which provide effective coordination of activities
between the entity and such office with respect to the detection,
investigation, and prosecution of suspected criminal violations relating
to the program under this subchapter.
(2) The entity is separate and distinct from the single State agency
that administers or supervises the administration of the State plan
under this subchapter.
(3) The entity's function is conducting a statewide program for the
investigation and prosecution of violations of all applicable State laws
regarding any and all aspects of fraud in connection with any aspect of
the provision of medical assistance and the activities of providers of
such assistance under the State plan under this subchapter.
(4) The entity has procedures for reviewing complaints of the abuse
and neglect of patients of health care facilities which receive payments
under the State plan under this subchapter, and, where appropriate, for
acting upon such complaints under the criminal laws of the State or for
referring them to other State agencies for action.
(5) The entity provides for the collection, or referral for
collection to a single State agency, of overpayments that are made under
the State plan to health care facilities and that are discovered by the
entity in carrying out its activities.
(6) The entity employs such auditors, attorneys, investigators, and
other necessary personnel and is organized in such a manner as is
necessary to promote the effective and efficient conduct of the entity's
activities.
(7) The entity submits to the Secretary an application and annual
reports containing such information as the Secretary determines, by
regulation, to be necessary to determine whether the entity meets the
other requirements of this subsection.
(r) Mechanized claims processing and information retrieval systems;
operational, etc., requirements
(1)(A) In order to receive payments under paragraphs (2)(A) and (7)
of subsection (a) of this section without being subject to per centum
reductions set forth in subparagraph (C) of this paragraph, a State must
provide that mechanized claims processing and information retrieval
systems of the type described in subsection (a)(3)(B) of this section
and detailed in an advance planning document approved by the Secretary
are operational on or before the deadline established under subparagraph
(B).
(B) The deadline for operation of such systems for a State is
September 30, 1985.
(C) If a State fails to meet the deadline established under
subparagraph (B), the per centums specified in paragraphs (2)(A) and (7)
of subsection (a) of this section with respect to that State shall each
be reduced by 5 percentage points for the first two quarters beginning
on or after such deadline, and shall be further reduced by an additional
5 percentage points after each period consisting of two quarters during
which the Secretary determines the State fails to meet the requirements
of subparagraph (A); except that --
(i) neither such per centum may be reduced by more than 25 percentage
points by reason of this paragraph; and
(ii) no reduction shall be made under this paragraph for any quarter
following the quarter during which such State meets the requirements of
subparagraph (A).
(2)(A) In order to receive payments under paragraphs (2)(A) and (7)
of subsection (a) of this section without being subject to the per
centum reductions set forth in subparagraph (C) of this paragraph, a
State must have its mechanized claims processing and information
retrieval systems, of the type required to be operational under
paragraph (1), initially approved by the Secretary in accordance with
paragraph (5)(A) on or before the deadline established under
subparagraph (B).
(B) The deadline for approval of such systems for a State is the last
day of the fourth quarter that begins after the date on which the
Secretary determines that such systems became operational as required
under paragraph (1).
(C) If a State fails to meet the deadline established under
subparagraph (B), the per centums specified in paragraphs (2)(A) and (7)
of subsection (a) of this section with respect to that State shall each
be reduced by 5 percentage points for the first two quarters beginning
after such deadline, and shall be further reduced by an additional 5
percentage points at the end of each period consisting of two quarters
during which the State fails to meet the requirements of subparagraph
(A); except that --
(i) neither such per centum may be reduced by more than 25 percentage
points by reason of this paragraph, and
(ii) no reduction shall be made under this paragraph for any quarter
following the quarter during which such State's systems are approved by
the Secretary as provided in subparagraph (A).
(D) Any State's systems which are approved by the Secretary for
purposes of subsection (a)(3)(B) of this section on or before October 7,
1980, shall be deemed to be initially approved for purposes of this
subsection.
(3)(A) When a State's systems are initially approved, the 75 per
centum Federal matching provided in subsection (a)(3)(B) of this section
shall become effective with respect to such systems, retroactive to the
first quarter beginning after the date on which such systems became
operational as required under paragraph (1), except as provided in
subparagraph (B).
(B) In the case of any State which was subject to a per centum
reduction under paragraph (2), the per centum specified in subsection
(a)(3)(B) of this section shall be reduced by 5 percentage points for
the first two quarters beginning after the deadline established under
paragraph (2)(B), and shall be further reduced by an additional 5
percentage points at the end of each period consisting of two quarters
beginning after such deadline and before the date on which such systems
are initially approved, except that no reduction shall be made under
this paragraph for any quarter following the quarter during which the
State's systems are initially approved by the Secretary.
(4)(A) The Secretary shall review all approved systems not less often
than once every three years, and shall reapprove or disapprove any such
systems. Systems which fail to meet the current performance standards,
system requirements, and any other conditions for approval developed by
the Secretary under paragraph (6) shall be disapproved. Any State
having systems which are so disapproved shall be subject to a per centum
reduction under subparagraph (B). The Secretary shall make the
determination of reapproval or disapproval and so notify the States not
later than the end of the first quarter following the review period.
Reviews may, at the Secretary's discretion, constitute reviews of the
entire system or of only those standards, systems requirements, and
other conditions which have demonstrated weakness in previous reviews.
(B) If the Secretary disapproves a State's systems under subparagraph
(A), the Secretary shall, with respect to such State for quarters
beginning after the determination of disapproval and before the first
quarter beginning after such systems are reapproved, reduce the per
centum specified in subsection (a)(3)(B) of this section to a per centum
of not less than 50 per centum and not more than 70 per centum as the
Secretary determines to be appropriate and commensurate with the nature
of noncompliance by such State; except that such per centum may not be
reduced by more than 10 percentage points in any 4-quarter period by
reason of this subparagraph. No State shall be subject to a per centum
reduction under this paragraph (i) before the fifth quarter beginning
after such State's systems were initially approved, or (ii) on the basis
of a review conducted before October 1, 1981.
(C) The Secretary may retroactively waive a per centum reduction
imposed under subparagraph (B), if the Secretary determines that the
State's systems meet all current performance standards and other
requirements for reapproval and that such action would improve the
administration of the State's plan under this subchapter, except that no
such waiver may extend beyond the four quarters immediately prior to the
quarter in which the State's systems are reapproved.
(5)(A) In order to be initially approved by the Secretary, mechanized
claims processing and information retrieval systems must be of the type
described in subsection (a)(3)(B) of this section and must meet the
following requirements:
(i) The systems must be capable of developing provider, physician,
and patient profiles which are sufficient to provide specific
information as to the use of covered types of services and items,
including prescribed drugs.
(ii) The State must provide that information on probable fraud or
abuse which is obtained from, or developed by, the systems, is made
available to the State's medicaid fraud control unit (if any) certified
under subsection (q) of this section.
(iii) The systems must meet all performance standards and other
requirements for initial approval developed by the Secretary under
paragraph (6).
(B) In order to be reapproved by the Secretary, mechanized claims
processing and information retrieval systems must meet the requirements
of subparagraphs (A)(i) and (A)(ii) and performance standards and other
requirements for reapproval developed by the Secretary under paragraph
(6).
(6) The Secretary, with respect to State systems, shall --
(A) develop performance standards, system requirements, and other
conditions for approval for use in initially approving such State
systems, and shall further develop written approval procedures for
conducting reviews for initial approval, including specific criteria for
assessing systems in operation to insure that all such performance
standards and other requirements are met;
(B) by not later than October 1, 1980, develop an initial set of
performance standards, system requirements, and other conditions for
reapproval for use in reapproving or disapproving State systems, and
shall further develop written reapproval procedures for conducting
reviews for reapproval, including specific criteria for reassessing
systems operations over a period of at least six months during each
fiscal year to insure that all such performance standards and other
requirements are met on a continuous basis;
(C) provide that reviews for reapproval, conducted before October 1,
1981, shall be for the purpose of developing a systems performance data
base and assisting States to improve their systems, and that no per
centum reduction shall be made under paragraph (4) on the basis of such
a review;
(D) insure that review procedures, performance standards, and other
requirements developed under subparagraph (B) are sufficiently flexible
to allow for differing administrative needs among the States, and that
such procedures, standards, and requirements are of a nature which will
permit their use by the States for self-evaluation;
(E) notify all States of proposed procedures, standards, and other
requirements at least one quarter prior to the fiscal year in which such
procedures, standards, and other requirements will be used for
conducting reviews for reapproval;
(F) periodically update the systems performance standards, system
requirements, review criteria, objectives, regulations, and guides as
the Secretary shall from time to time deem appropriate;
(G) provide technical assistance to States in the development and
improvement of the systems so as to continually improve the capacity of
such systems to effectively detect cases of fraud or abuse;
(H) for the purpose of insuring compatibility between the State
systems and the systems utilized in the administration of subchapter
XVIII of this chapter --
(i) develop a uniform identification coding system (to the extent
feasible) for providers, other persons receiving payments under the
State plans (approved under this subchapter) or under subchapter XVIII
of this chapter, and beneficiaries of medical services under such plans
or subchapter;
(ii) provide liaison between States and carriers and intermediaries
having agreements under subchapter XVIII of this chapter to facilitate
timely exchange of appropriate data; and
(iii) improve the exchange of data between the States and the
Secretary with respect to providers and other persons who have been
terminated, suspended, or otherwise sanctioned under a State plan
(approved under this subchapter) or under subchapter XVIII of this
chapter;
(I) develop and disseminate clear definitions of those types of
reasonable costs relating to State systems which are reimbursable under
the provisions of subsection (a)(3) of this section; and
(J) develop and disseminate performance standards for assessing the
State's third party collection efforts in accordance with section
1396a(a)(25)(A)(ii) of this title.
(7)(A) The Secretary shall waive the provisions of this subsection
with respect to initial operation and approval of mechanized claims
processing and information retrieval systems with respect to any State
which --
(i) had a 1976 population (as reported by the Bureau of the Census)
of less than 1,000,000 and which made total expenditures (including
Federal reimbursement) for which Federal financial participation is
authorized under this subchapter of less than $100,000,000 in fiscal
year 1976 (as reported by such State for such year), or
(ii) is a Commonwealth, or territory or possession, of the United
States,
if such State reasonably demonstrates, and the Secretary does not
formally disagree, that the application of such provisions would not
significantly improve the efficiency of the administration of such
State's plan under this subchapter.
(B) If the Secretary determines that the application of the
provisions described in subparagraph (A) to a State would significantly
improve the efficiency of the administration of the State's plan under
this subchapter, the Secretary may withdraw the State's waiver under
subparagraph (A) and, in such case, the Secretary shall impose a
timetable for such State with respect to compliance with the provisions
of this subsection and the imposition of per centum reductions. Such
timetable shall be comparable to the timetable established under this
subsection as to the amount of time allowed such State to comply and the
timing of per centum reductions.
(8)(A) The per centum reductions provided for under this subsection
shall not apply to a State for any quarter with respect to which the
Secretary determines that such State is unable to comply with the
relevant requirements of this subsection --
(i) for good cause (but such a waiver may not be for a period in
excess of 2 quarters), or
(ii) due to circumstances beyond the control of such State.
(B) If the Secretary determines under subparagraph (A) that such a
reduction will not apply to a State, the Secretary shall report to the
Congress on the basis for each such determination and on the
modification of all time limitations and deadlines as described in
subparagraph (C).
(C) For purposes of determining all time limitations and deadlines
imposed under this subsection, any time period during which a State was
found under subparagraph (A)(ii) to be unable to comply with
requirements of this subsection due to circumstances beyond its control
shall not be taken into account, and the Secretary shall modify all such
time limitations and deadlines with respect to such State accordingly.
(s) Repealed. Pub. L. 97-35, title XXI, 2161(c)(1), Aug. 13, 1981,
95 Stat. 805, as amended by Pub. L. 97-248, title I, 137(a)(2), Sept.
3, 1982, 96 Stat. 376
(t) Repealed. Pub. L. 97-35, title XXI, 2161(c)(2), Aug. 13, 1981,
95 Stat. 805, as amended by Pub. L. 97-248, title I, 137(a)(2), Sept.
3, 1982, 96 Stat. 376
(u) Limitation of Federal financial participation in erroneous
medical assistance expenditures
(1)(A) Notwithstanding subsection (a)(1) of this section, if the
ratio of a State's erroneous excess payments for medical assistance (as
defined in subparagraph (D)) to its total expenditures for medical
assistance under the State plan approved under this subchapter exceeds
0.03, for the period consisting of the third and fourth quarters of
fiscal year 1983, or for any full fiscal year thereafter, then the
Secretary shall make no payment for such period or fiscal year with
respect to so much of such erroneous excess payments as exceeds such
allowable error rate of 0.03.
(B) The Secretary may waive, in certain limited cases, all or part of
the reduction required under subparagraph (A) with respect to any State
if such State is unable to reach the allowable error rate for a period
or fiscal year despite a good faith effort by such State.
(C) In estimating the amount to be paid to a State under subsection
(d) of this section, the Secretary shall take into consideration the
limitation on Federal financial participation imposed by subparagraph
(A) and shall reduce the estimate he makes under subsection (d)(1) of
this section, for purposes of payment to the State under subsection
(d)(3) of this section, in light of any expected erroneous excess
payments for medical assistance (estimated in accordance with such
criteria, including sampling procedures, as he may prescribe and subject
to subsequent adjustment, if necessary, under subsection (d)(2) of this
section).
(D)(i) For purposes of this subsection, the term ''erroneous excess
payments for medical assistance'' means the total of --
(I) payments under the State plan with respect to ineligible
individuals and families, and
(II) overpayments on behalf of eligible individuals and families by
reason of error in determining the amount of expenditures for medical
care required of an individual or family as a condition of eligibility.
(ii) In determining the amount of erroneous excess payments for
medical assistance to an ineligible individual or family under clause
(i)(I), if such ineligibility is the result of an error in determining
the amount of the resources of such individual or family, the amount of
the erroneous excess payment shall be the smaller of (I) the amount of
the payment with respect to such individual or family, or (II) the
difference between the actual amount of such resources and the allowable
resource level established under the State plan.
(iii) In determining the amount of erroneous excess payments for
medical assistance to an individual or family under clause (i)(II), the
amount of the erroneous excess payment shall be the smaller of (I) the
amount of the payment on behalf of the individual or family, or (II) the
difference between the actual amount incurred for medical care by the
individual or family and the amount which should have been incurred in
order to establish eligibility for medical assistance.
(iv) In determining the amount of erroneous excess payments, there
shall not be included any error resulting from a failure of an
individual to cooperate or give correct information with respect to
third-party liability as required under section 1396k(a)(1)(C) or
602(a)(26)(C) of this title or with respect to payments made in
violation of section 1396e of this title.
(v) In determining the amount of erroneous excess payments, there
shall not be included any erroneous payments made for ambulatory
prenatal care provided during a presumptive eligibility period (as
defined in section 1396r-1(b)(1) of this title).
(E) For purposes of subparagraph (D), there shall be excluded, in
determining both erroneous excess payments for medical assistance and
total expenditures for medical assistance --
(i) payments with respect to any individual whose eligibility
therefor was determined exclusively by the Secretary under an agreement
pursuant to section 1383c of this title and such other classes of
individuals as the Secretary may by regulation prescribe whose
eligibility was determined in part under such an agreement; and
(ii) payments made as the result of a technical error.
(2) The State agency administering the plan approved under this
subchapter shall, at such times and in such form as the Secretary may
specify, provide information on the rates of erroneous excess payments
made (or expected, with respect to future periods specified by the
Secretary) in connection with its administration of such plan, together
with any other data he requests that are reasonably necessary for him to
carry out the provisions of this subsection.
(3)(A) If a State fails to cooperate with the Secretary in providing
information necessary to carry out this subsection, the Secretary,
directly or through contractual or such other arrangements as he may
find appropriate, shall establish the error rates for that State on the
basis of the best data reasonably available to him and in accordance
with such techniques for sampling and estimating as he finds
appropriate.
(B) In any case in which it is necessary for the Secretary to
exercise his authority under subparagraph (A) to determine a State's
error rates for a fiscal year, the amount that would otherwise be
payable to such State under this subchapter for quarters in such year
shall be reduced by the costs incurred by the Secretary in making
(directly or otherwise) such determination.
(4) This subsection shall not apply with respect to Puerto Rico,
Guam, the Virgin Islands, the Northern Mariana Islands, or American
Samoa.
(v) Medical assistance to aliens not lawfully admitted for permanent
residence
(1) Notwithstanding the preceding provisions of this section, except
as provided in paragraph (2), no payment may be made to a State under
this section for medical assistance furnished to an alien who is not
lawfully admitted for permanent residence or otherwise permanently
residing in the United States under color of law.
(2) Payment shall be made under this section for care and services
that are furnished to an alien described in paragraph (1) only if --
(A) such care and services are necessary for the treatment of an
emergency medical condition of the alien, and
(B) such alien otherwise meets the eligibility requirements for
medical assistance under the State plan approved under this subchapter
(other than the requirement of the receipt of aid or assistance under
subchapter IV of this chapter, supplemental security income benefits
under subchapter XVI of this chapter, or a State supplementary payment).
(3) For purposes of this subsection, the term ''emergency medical
condition'' means a medical condition (including emergency labor and
delivery) manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of immediate medical
attention could reasonably be expected to result in --
(A) placing the patient's health in serious jeopardy,
(B) serious impairment to bodily functions, or
(C) serious dysfunction of any bodily organ or part.
(w) Prohibition on use of voluntary contributions, and limitation on
use of provider-specific taxes to obtain Federal financial participation
under medicaid
(1)(A) Notwithstanding the previous provisions of this section, for
purposes of determining the amount to be paid to a State (as defined in
paragraph (7)(D)) under subsection (a)(1) of this section for quarters
in any fiscal year, the total amount expended during such fiscal year as
medical assistance under the State plan (as determined without regard to
this subsection) shall be reduced by the sum of any revenues received by
the State (or by a unit of local government in the State) during the
fiscal year --
(i) from provider-related donations (as defined in paragraph (2)(A)),
other than --
(I) bona fide provider-related donations (as defined in paragraph
(2)(B)), and
(II) donations described in paragraph (2)(C);
(ii) from health care related taxes (as defined in paragraph (3)(A)),
other than broad-based health care related taxes (as defined in
paragraph (3)(B));
(iii) from a broad-based health care related tax, if there is in
effect a hold harmless provision (described in paragraph (4)) with
respect to the tax; or
(iv) only with respect to State fiscal years (or portions thereof)
occurring on or after January 1, 1992, and before October 1, 1995, from
broad-based health care related taxes to the extent the amount of such
taxes collected exceeds the limit established under paragraph (5).
(B) Notwithstanding the previous provisions of this section, for
puroses /8/ of determining the amount to be paid to a State under
subsection (a)(7) of this section for all quarters in a Federal fiscal
year (beginning with fiscal year 1993), the total amount expended during
the fiscal year for administrative expenditures under the State plan (as
determined without regard to this subsection) shall be reduced by the
sum of any revenues received by the State (or by a unit of local
government in the State) during such quarters from donations described
in paragraph (2)(C), to the extent the amount of such donations exceeds
10 percent of the amounts expended under the State plan under this
subchapter during the fiscal year for purposes described in paragraphs
(2), (3), (4), (6), and (7) of subsection (a) of this section.
(C)(i) Except as otherwise provided in clause (ii), subparagraph
(A)(i) shall apply to donations received on or after January 1, 1992.
(ii) Subject to the limits described in clause (iii) and subparagraph
(E), subparagraph (A)(i) shall not apply to donations received before
the effective date specified in subparagraph (F) if such donations are
received under programs in effect or as described in State plan
amendments or related documents submitted to the Secretary by September
30, 1991, and applicable to State fiscal year 1992, as demonstrated by
State plan amendments, written agreements, State budget documentation,
or other documentary evidence in existence on that date.
(iii) In applying clause (ii) in the case of donations received in
State fiscal year 1993, the maximum amount of such donations to which
such clause may be applied may not exceed the total amount of such
donations received in the corresponding period in State fiscal year 1992
(or not later than 5 days after the last day of the corresponding
period).
(D)(i) Except as otherwise provided in clause (ii), subparagraphs
(A)(ii) and (A)(iii) shall apply to taxes received on or after January
1, 1992.
(ii) Subparagraphs (A)(ii) and (A)(iii) shall not apply to
impermissible taxes (as defined in clause (iii)) received before the
effective date specified in subparagraph (F) to the extent the taxes
(including the tax rate or base) were in effect, or the legislation or
regulations imposing such taxes were enacted or adopted, as of November
22, 1991.
(iii) In this subparagraph and subparagraph (E), the term
''impermissible tax'' means a health care related tax for which a
reduction may be made under clause (ii) or (iii) of subparagraph (A).
(E)(i) In no case may the total amount of donations and taxes
permitted under the exception provided in subparagraphs (C)(ii) and
(D)(ii) for the portion of State fiscal year 1992 occurring during
calendar year 1992 exceed the limit under paragraph (5) minus the total
amount of broad-based health care related taxes received in the portion
of that fiscal year.
(ii) In no case may the total amount of donations and taxes permitted
under the exception provided in subparagraphs (C)(ii) and (D)(ii) for
State fiscal year 1993 exceed the limit under paragraph (5) minus the
total amount of broad-based health care related taxes received in that
fiscal year.
(F) In this paragraph in the case of a State --
(i) except as provided in clause (iii), with a State fiscal year
beginning on or before July 1, the effective date is October 1, 1992,
(ii) except as provided in clause (iii), with a State fiscal year
that begins after July 1, the effective date is January 1, 1993, or
(iii) with a State legislature which is not scheduled to have a
regular legislative session in 1992, with a State legislature which is
not scheduled to have a regular legislative session in 1993, or with a
provider-specific tax enacted on November 4, 1991, the effective date is
July 1, 1993.
(2)(A) In this subsection (except as provided in paragraph (6)), the
term ''provider-related donation'' means any donation or other voluntary
payment (whether in cash or in kind) made (directly or indirectly) to a
State or unit of local government by --
(i) a health care provider (as defined in paragraph (7)(B)),
(ii) an entity related to a health care provider (as defined in
paragraph (7)(C)), or
(iii) an entity providing goods or services under the State plan for
which payment is made to the State under paragraph (2), (3), (4), (6),
or (7) of subsection (a) of this section.
(B) For purposes of paragraph (1)(A)(i)(I), the term ''bona fide
provider-related donation'' means a provider-related donation that has
no direct or indirect relationship (as determined by the Secretary) to
payments made under this subchapter to that provider, to providers
furnishing the same class of items and services as that provider, or to
any related entity, as established by the State to the satisfaction of
the Secretary. The Secretary may by regulation specify types of
provider-related donations described in the previous sentence that will
be considered to be bona fide provider-related donations.
(C) For purposes of paragraph (1)(A)(i)(II), donations described in
this subparagraph are funds expended by a hospital, clinic, or similar
entity for the direct cost (including costs of training and of preparing
and distributing outreach materials) of State or local agency personnel
who are stationed at the hospital, clinic, or entity to determine the
eligibility of individuals for medical assistance under this subchapter
and to provide outreach services to eligible or potentially eligible
individuals.
(3)(A) In this subsection (except as provided in paragraph (6)), the
term ''health care related tax'' means a tax (as defined in paragraph
(7)(F)) that --
(i) is related to health care items or services, or to the provision
of, the authority to provide, or payment for, such items or services, or
(ii) is not limited to such items or services but provides for
treatment of individuals or entities that are providing or paying for
such items or services that is different from the treatment provided to
other individuals or entities.
In applying clause (i), a tax is considered to relate to health care
items or services if at least 85 percent of the burden of such tax falls
on health care providers.
(B) In this subsection, the term ''broad-based health care related
tax'' means a health care related tax which is imposed with respect to a
class of health care items or services (as described in paragraph
(7)(A)) or with respect to providers of such items or services and
which, except as provided in subparagraphs (D) and (E) --
(i) is imposed at least with respect to all items or services in the
class furnished by all non-Federal, nonpublic providers in the State
(or, in the case of a tax imposed by a unit of local government, the
area over which the unit has jurisdiction) or is imposed with respect to
all non-Federal, nonpublic providers in the class; and
(ii) is imposed uniformly (in accordance with subparagraph (C)).
(C)(i) Subject to clause (ii), for purposes of subparagraph (B)(ii),
a tax is considered to be imposed uniformly if --
(I) in the case of a tax consisting of a licensing fee or similar tax
on a class of health care items or services (or providers of such items
or services), the amount of the tax imposed is the same for every
provider providing items or services within the class;
(II) in the case of a tax consisting of a licensing fee or similar
tax imposed on a class of health care items or services (or providers of
such services) on the basis of the number of beds (licensed or
otherwise) of the provider, the amount of the tax is the same for each
bed of each provider of such items or services in the class;
(III) in the case of a tax based on revenues or receipts with respect
to a class of items or services (or providers of items or services) the
tax is imposed at a uniform rate for all items and services (or
providers of such items or services) in the class on all the gross
revenues or receipts, or net operating revenues, relating to the
provision of all such items or services (or all such providers) in the
State (or, in the case of a tax imposed by a unit of local government
within the State, in the area over which the unit has jurisdiction); or
(IV) in the case of any other tax, the State establishes to the
satisfaction of the Secretary that the tax is imposed uniformly.
(ii) Subject to subparagraphs (D) and (E), a tax imposed with respect
to a class of health care items and services is not considered to be
imposed uniformly if the tax provides for any credits, exclusions, or
deductions which have as their purpose or effect the return to providers
of all or a portion of the tax paid in a manner that is inconsistent
with subclauses (I) and (II) of subparagraph (E)(ii) or provides for a
hold harmless provision described in paragraph (4).
(D) A tax imposed with respect to a class of health care items and
services is considered to be imposed uniformly --
(i) notwithstanding that the tax is not imposed with respect to items
or services (or the providers thereof) for which payment is made under a
State plan under this subchapter or subchapter XVIII of this chapter, or
(ii) in the case of a tax described in subparagraph (C)(i)(III),
notwithstanding that the tax provides for exclusion (in whole or in
part) of revenues or receipts from a State plan under this subchapter or
subchapter XVIII of this chapter.
(E)(i) A State may submit an application to the Secretary requesting
that the Secretary treat a tax as a broad-based health care related tax,
notwithstanding that the tax does not apply to all health care items or
services in class (or all providers of such items and services),
provides for a credit, deduction, or exclusion, is not applied
uniformly, or otherwise does not meet the requirements of subparagraph
(B) or (C). Permissible waivers may include exemptions for rural or
sole-community providers.
(ii) The Secretary shall approve such an application if the State
establishes to the satisfaction of the Secretary that --
(I) the net impact of the tax and associated expenditures under this
subchapter as proposed by the State is generally redistributive in
nature, and
(II) the amount of the tax is not directly correlated to payments
under this subchapter for items or services with respect to which the
tax is imposed.
The Secretary shall by regulation specify types of credits,
exclusions, and deductions that will be considered to meet the
requirements of this subparagraph.
(4) For purposes of paragraph (1)(A)(iii), there is in effect a hold
harmless provision with respect to a broad-based health care related tax
imposed with respect to a class of items or services if the Secretary
determines that any of the following applies:
(A) The State or other unit of government imposing the tax provides
(directly or indirectly) for a payment (other than under this
subchapter) to taxpayers and the amount of such payment is positively
correlated either to the amount of such tax or to the difference between
the amount of the tax and the amount of payment under the State plan.
(B) All or any portion of the payment made under this subchapter to
the taxpayer varies based only upon the amount of the total tax paid.
(C) The State or other unit of government imposing the tax provides
(directly or indirectly) for any payment, offset, or waiver that
guarantees to hold taxpayers harmless for any portion of the costs of
the tax.
The provisions of this paragraph shall not prevent use of the tax to
reimburse health care providers in a class for expenditures under this
subchapter nor preclude States from relying on such reimbursement to
justify or explain the tax in the legislative process.
(5)(A) For purposes of this subsection, the limit under this
subparagraph with respect to a State is an amount equal to 25 percent
(or, if greater, the State base percentage, as defined in subparagraph
(B)) of the non-Federal share of the total amount expended under the
State plan during a State fiscal year (or portion thereof), as it would
be determined pursuant to paragraph (1)(A) without regard to paragraph
(1)(A)(iv).
(B)(i) In subparagraph (A), the term ''State base percentage'' means,
with respect to a State, an amount (expressed as a percentage) equal to
--
(I) the total of the amount of health care related taxes (whether or
not broad-based) and the amount of provider-related donations (whether
or not bona fide) projected to be collected (in accordance with clause
(ii)) during State fiscal year 1992, divided by
(II) the non-Federal share of the total amount estimated to be
expended under the State plan during such State fiscal year.
(ii) For purposes of clause (i)(I), in the case of a tax that is not
in effect throughout State fiscal year 1992 or the rate (or base) of
which is increased during such fiscal year, the Secretary shall project
the amount to be collected during such fiscal year as if the tax (or
increase) were in effect during the entire State fiscal year.
(C)(i) The total amount of health care related taxes under
subparagraph (B)(i)(I) shall be determined by the Secretary based on
only those taxes (including the tax rate or base) which were in effect,
or for which legislation or regulations imposing such taxes were enacted
or adopted, as of November 22, 1991.
(ii) The amount of provider-related donations under subparagraph
(B)(i)(I) shall be determined by the Secretary based on programs in
effect on September 30, 1991, and applicable to State fiscal year 1992,
as demonstrated by State plan amendments, written agreements, State
budget documentation, or other documentary evidence in existence on that
date.
(iii) The amount of expenditures described in subparagraph (B)(i)(II)
shall be determined by the Secretary based on the best data available as
of December 12, 1991.
(6)(A) Notwithstanding the provisions of this subsection, the
Secretary may not restrict States' use of funds where such funds are
derived from State or local taxes (or funds appropriated to State
university teaching hospitals) transferred from or certified by units of
government within a State as the non-Federal share of expenditures under
this subchapter, regardless of whether the unit of government is also a
health care provider, except as provided in section 1396a(a)(2) of this
title, unless the transferred funds are derived by the unit of
government from donations or taxes that would not otherwise be
recognized as the non-Federal share under this section.
(B) For purposes of this subsection, funds the use of which the
Secretary may not restrict under subparagraph (A) shall not be
considered to be a provider-related donation or a health care related
tax.
(7) For purposes of this subsection:
(A) Each of the following shall be considered a separate class of
health care items and services:
(i) Inpatient hospital services.
(ii) Outpatient hospital services.
(iii) Nursing facility services (other than services of intermediate
care facilities for the mentally retarded).
(iv) Services of intermediate care facilities for the mentally
retarded.
(v) Physicians' services.
(vi) Home health care services.
(vii) Outpatient prescription drugs.
(viii) Services of health maintenance organizations (and other
organizations with contracts under subsection (m) of this section).
(ix) Such other classification of health care items and services
consistent with this subparagraph as the Secretary may establish by
regulation.
(B) The term ''health care provider'' means an individual or person
that receives payments for the provision of health care items or
services.
(C) An entity is considered to be ''related'' to a health care
provider if the entity --
(i) is an organization, association, corporation or partnership
formed by or on behalf of health care providers;
(ii) is a person with an ownership or control interest (as defined in
section 1320a-3(a)(3) of this title) in the provider;
(iii) is the employee, spouse, parent, child, or sibling of the
provider (or of a person described in clause (ii)); or
(iv) has a similar, close relationship (as defined in regulations) to
the provider.
(D) The term ''State'' means only the 50 States and the District of
Columbia but does not include any State whose entire program under this
subchapter is operated under a waiver granted under section 1315 of this
title.
(E) The ''State fiscal year'' means, with respect to a specified
year, a State fiscal year ending in that specified year.
(F) The term ''tax'' includes any licensing fee, assessment, or other
mandatory payment, but does not include payment of a criminal or civil
fine or penalty (other than a fine or penalty imposed in lieu of or
instead of a fee, assessment, or other mandatory payment).
(G) The term ''unit of local government'' means, with respect to a
State, a city, county, special purpose district, or other governmental
unit in the State.
(Aug. 14, 1935, ch. 531, title XIX, 1903, as added July 30, 1965,
Pub. L. 89-97, title I, 121(a), 79 Stat. 349, and amended Jan. 2, 1968,
Pub. L. 90-248, title II, 220(a), 222(c), (d), 225(a), 229(c),
241(f)(5), 81 Stat. 898, 901, 902, 904, 917; June 28, 1968, Pub. L.
90-364, title III, 303(a)(1), 82 Stat. 274; Aug. 9, 1969, Pub. L.
91-56, 2(a), 83 Stat. 99; Oct. 30, 1972, Pub. L. 92-603, title II,
207(a), 221(c)(6), 224(c), 225, 226(e), 229(c), 230, 233(c), 235(a),
237(a)(1), 249B, 278(b)(1), (5), (7), (16), 290, 295, 299E(a), 86 Stat.
1379, 1389, 1395, 1396, 1404, 1410, 1411, 1414, 1415, 1428, 1453, 1454,
1457, 1459, 1462; July 9, 1973, Pub. L. 93-66, title II, 234(a), 87
Stat. 160; Dec. 31, 1973, Pub. L. 93-233, 13(a)(11), (12), 18(r)-(v),
(x)(5), (6), (y)(1), 87 Stat. 963, 971-973; Dec. 31, 1975, Pub. L.
94-182, title I, 110(a), 111(b), 89 Stat. 1054; Oct. 8, 1976, Pub.
L. 94-460, title II, 202(a), 90 Stat. 1957; Oct. 18, 1976, Pub. L.
94-552, 1, 90 Stat. 2540; Aug. 1, 1977, Pub. L. 95-83, title I,
105(a)(1), (2), 91 Stat. 384; Oct. 25, 1977, Pub. L. 95-142,
3(c)(2), 8(c), 10(a), 11(a), 17(a)-(c), 20(a), 91 Stat. 1179, 1195,
1196, 1201, 1205; Nov. 1, 1978, Pub. L. 95-559, 14(c), 92 Stat. 2141;
Nov. 10, 1978, Pub. L. 95-626, title I, 102(b)(3), 92 Stat. 3551; Oct.
4, 1979, Pub. L. 96-79, title I, 128, 93 Stat. 629; Oct. 7, 1980, Pub.
L. 96-398, title IX, 901, 94 Stat. 1609; Dec. 5, 1980, Pub. L. 96-499,
title IX, 905(b), (c), 961(a), 963, 964, 94 Stat. 2618, 2650, 2651;
Aug. 13, 1981, Pub. L. 97-35, title XXI, 2101(a)(2), 2103(b)(1),
2106(b)(3), 2113(n), 2161, 2163, 2164(a), 2174(b), 2178(a), 2183(a), 95
Stat. 786, 788, 792, 795, 803-806, 809, 813, 816; Sept. 3, 1982, Pub.
L. 97-248, title I, 133(a), 137(a)(1), (2), (b)(11)-(16), (27), (g),
146(b), 96 Stat. 373, 376, 378, 379, 381, 394; Jan. 12, 1983, Pub. L.
97-448, title III, 309(b)(16), 96 Stat. 2409; July 18, 1984, Pub. L.
98-369, div. B, title III, 2303(g)(2), 2363(a)(2), (4), (b), 2364,
2373(b)(11)-(14), 98 Stat. 1066, 1106, 1107, 1111, 1112; Nov. 8, 1984,
Pub. L. 98-617, 3(a)(6), 98 Stat. 3295; Apr. 7, 1986, Pub. L. 99-272,
title IX, 9503(b), (f), 9507(a), 9512(a), 9517(a), (c)(1), 9518(a),
100 Stat. 206, 207, 210, 212, 215, 216; Oct. 21, 1986, Pub. L. 99-509,
title IX, 9401(e)(2), 9403(g)(2), 9406(a), 9407(c), 9431(b)(2),
9434(a)(1), (2), (b), 100 Stat. 2052, 2055, 2057, 2060, 2066, 2068,
2069; Oct. 22, 1986, Pub. L. 99-514, title XVIII, 1895(c)(2), 100
Stat. 2935; Nov. 6, 1986, Pub. L. 99-603, title I, 121(b)(2), 100
Stat. 3390; Aug. 18, 1987, Pub. L. 100-93, 8(g), (h)(1), 101 Stat.
694; Dec. 22, 1987, Pub. L. 100-203, title IV, 4112(b), 4113(a)(1),
(b)(3), (d)(1), 4118(d)(1), (e)(11), (h)(1), (p)(5), 4211(d)(1), (g),
(i), 4212(c)(1), (2), (d)(1), (e)(2), 4213(b)(2), 101 Stat. 1330-149,
1330-150, 1330-152, 1330-155, 1330-159, 1330-204, 1330-205, 1330-207,
1330-212, 1330-213, 1330-219, as amended July 1, 1988, Pub. L. 100-360,
title IV, 411(a)(3)(A), (B)(iii), (k)(6)(B)(x), (7)(A), (D), (10)(D),
(G)(ii), 102 Stat. 768, 794, 796; July 1, 1988, Pub. L. 100-360, title
II, 202(h)(2), title III, 301(f), 302(c)(3), (e)(4), title IV,
411(k)(12)(A), (13)(A), 102 Stat. 718, 750, 752, 753, 797, 798; Oct.
13, 1988, Pub. L. 100-485, title VI, 608(d)(26)(K)(ii), (f)(4), 102
Stat. 2422, 2424; Dec. 13, 1989, Pub. L. 101-234, title II, 201(a),
103 Stat. 1981; Dec. 19, 1989, Pub. L. 101-239, title VI, 6401(b),
6411(d)(2), 6901(b)(5)(A), 103 Stat. 2259, 2271, 2299; Nov. 5, 1990,
Pub. L. 101-508, title IV, 4401(a)(1), (b)(1), 4402(b), (d)(3),
4601(a)(3)(A), 4701(b)(2), 4704(b)(1), (2), 4711(c)(2), 4723(a),
4731(a), (b)(2), 4732(a), (b)(2), (c), (d), 4751(b)(1), 4752(a)(2),
(b)(1), (e), 4801(a)(8), (e)(16)(A), 104 Stat. 1388-143, 1388-159,
1388-163, 1388-164, 1388-166, 1388-170, 1388-172, 1388-187, 1388-194 to
1388-196, 1388-205 to 1388-207, 1388-212, 1388-218; Oct. 7, 1991, Pub.
L. 102-119, 26(i)(1), 105 Stat. 607; Dec. 12, 1991, Pub. L. 102-234,
2(a), (b)(2), 3(b)(2)(B), 4(a), 105 Stat. 1793, 1799, 1803, 1804.)
Parts A and B of subchapter XVIII of this chapter, referred to in
subsecs. (b), (i), and (m), are classified to sections 1395c et seq.
and 1395j et seq., respectively, of this title.
The Individuals with Disabilities Education Act, referred to in
subsec. (c), is title VI of Pub. L. 91-230, Apr. 13, 1970, 84 Stat.
175, as amended. Parts B and H of the Act are classified generally to
subchapters II ( 1411 et seq.) and VIII ( 1471 et seq.), respectively,
of chapter 33 of Title 20, Education. For complete classification of
this Act to the Code, see section 1400 of Title 20 and Tables.
Part A of subchapter IV of this chapter, referred to in subsecs. (f)
and (i)(9), is classified to section 601 et seq. of this title.
The Appalachian Regional Development Act of 1965, referred to in
subsec. (m)(2)(B)(ii), (G), is Pub. L. 89-4, Mar. 9, 1965, 79 Stat.
5, as amended, which is set out in the Appendix to Title 40, Public
Buildings, Property, and Works. For complete classification of this Act
to the Code, see Tables.
1991 -- Subsec. (a)(1). Pub. L. 102-234, 3(b)(2)(B), inserted ''and
section 1396r-4(f) of this title'' after ''of this section''.
Subsec. (c). Pub. L. 102-119 substituted ''child with a disability''
for ''handicapped child'', ''Individuals with Disabilities Education
Act'' for ''Education of the Handicapped Act'', and ''an infant or
toddler with a disability'' for ''a handicapped infant or toddler''.
Subsec. (d)(6). Pub. L. 102-234, 4(a), added par. (6).
Subsec. (i)(10). Pub. L. 102-234, 2(b)(2), struck out par. (10)
added by Pub. L. 101-508, 4701(b)(2)(B), which read as follows:
''with respect to any amount expended for medical assistance for care or
services furnished by a hospital, nursing facility, or intermediate care
facility for the mentally retarded to reimburse the hospital or facility
for the costs attributable to taxes imposed by the State soley (sic)
with respect to hospitals or facilities.''
Subsec. (w). Pub. L. 102-234, 2(a), added subsec. (w).
1990 -- Subsec. (a)(1). Pub. L. 101-508, 4402(d)(3), struck out
before semicolon ''(including expenditures for medicare cost-sharing and
including expenditures for premiums under part B of subchapter XVIII of
this chapter, for individuals who are eligible for medical assistance
under the plan and (A) are receiving aid or assistance under any plan of
the State approved under subchapter I, X, XIV, or XVI, or part A of
subchapter IV, or with respect to whom supplemental security income
benefits are being paid under subchapter XVI of this chapter, or (B)
with respect to whom there is being paid a State supplementary payment
and are eligible for medical assistance equal in amount, duration, and
scope to the medical assistance made available to individuals described
in section 1396a(a)(10)(A) of this title, and, except in the case of
individuals sixty-five years of age or older and disabled individuals
entitled to hospital insurance benefits under subchapter XVIII of this
chapter who are not enrolled under part B of subchapter XVIII of this
chapter, other insurance premiums for medical or any other type of
remedial care or the cost thereof)''.
Subsec. (a)(2)(B). Pub. L. 101-508, 4801(a)(8), substituted
''October 1, 1990'' for ''July 1, 1990''.
Subsec. (a)(3)(C), (D). Pub. L. 101-508, 4401(b)(1), substituted
''and'' for ''plus'' at end of subpar. (C) and added subpar. (D).
Subsec. (f)(2). Pub. L. 101-508, 4723(a), inserted ''(A)'' after
''(2)'' and added cl. (B).
Subsec. (f)(4). Pub. L. 101-508, 4601(a)(3)(A), substituted
''1396a(a)(10)(A)(i)(III), 1396a(a)(10) (A)(i)(IV),
1396a(a)(10)(A)(i)(V), 1396a(a)(10) (A)(i)(VI),
1396a(a)(10)(A)(i)(VII)'' for ''1396a(a)(10) (A)(i)(IV),
1396a(a)(10)(A)(i)(VI)''.
Subsec. (i)(8). Pub. L. 101-508, 4711(c)(2), inserted ''(A)'' after
''medical assistance'' and added cl. (B).
Subsec. (i)(10). Pub. L. 101-508, 4701(b)(2), added par. (10)
relating to any amount expended for medical assistance for care or
services.
Pub. L. 101-508, 4401(a)(1), added par. (10) relating to covered
outpatient drugs.
Subsec. (i)(11). Pub. L. 101-508, 4801(e)(16)(A), added par. (11).
Subsec. (i)(12). Pub. L. 101-508, 4752(a)(2), added par. (12).
Subsec. (i)(14). Pub. L. 101-508, 4752(e), added par. (14).
Subsec. (m)(1)(A). Pub. L. 101-508, 4751(b)(1), inserted ''meets the
requirement of section 1396a(w) of this title'' after ''State, which''
and ''meets the requirement of section 1396a(a) of this title and''
after ''or which''.
Subsec. (m)(2)(A)(i). Pub. L. 101-508, 4732(d)(1), struck out ''(or
the State as authorized by paragraph (3))'' after ''the Secretary''.
Subsec. (m)(2)(A)(ix). Pub. L. 101-508, 4704(b)(1), added cl. (ix).
Subsec. (m)(2)(A)(x). Pub. L. 101-508, 4731(a), added cl. (x).
Subsec. (m)(2)(A)(xi). Pub. L. 101-508, 4752(b)(1), added cl. (xi).
Subsec. (m)(2)(B). Pub. L. 101-508, 4704(b)(2), inserted ''except
with respect to clause (ix) of subparagraph (A),'' after ''Subparagraph
(A)''.
Subsec. (m)(2)(D). Pub. L. 101-508, 4732(a), struck out ''(i)
special circumstances warrant such modification or waiver, and (ii)''
after ''the Secretary determines that''.
Subsec. (m)(2)(F)(i). Pub. L. 101-508, 4732(b)(2), substituted
''(G),'' for ''(G) or'' and inserted at end ''or with an eligible
organization with a contract under section 1395mm of this title which
meets the requirement of subparagraph (A)(ii), or''.
Subsec. (m)(2)(H). Pub. L. 101-508, 4732(c), added subpar. (H).
Subsec. (m)(3). Pub. L. 101-508, 4732(d)(2), struck out par. (3)
which read as follows: ''A State may, in the case of an entity which
has submitted an application to the Secretary for determination that it
is a health maintenance organization within the meaning of paragraph (1)
and for which no such determination has been made within 90 days of the
submission of the application, make a provisional determination for the
purposes of this subchapter that such entity is such a health
maintenance organization. Such provisional determination shall remain
in force until such time as the Secretary makes a determination
regarding the entity's qualification under paragraph (1).''
Subsec. (m)(5)(A)(v). Pub. L. 101-508, 4731(b)(2), added cl. (v).
Subsec. (u)(1)(D)(iv). Pub. L. 101-508, 4402(b), which directed
amendment of subpar. (C)(iv) by inserting before period at end ''or
with respect to payments made in violation of section 1396e of this
title'', was executed to subpar. (D)(iv) to reflect the probable intent
of Congress because subpar. (C) does not have a cl. (iv).
1989 -- Subsec. (a)(2)(B). Pub. L. 101-239, 6901(b)(5)(A), inserted
''(including the costs for nurse aides to complete such competency
evaluation programs)'' after ''1396r(e)(1) of this title'' and ''(or,
for calendar quarters beginning on or after July 1, 1988, and before
July 1, 1990, the lesser of 90 percent or the Federal medical assistance
percentage plus 25 percentage points)'' after ''50 percent''.
Subsec. (f)(4). Pub. L. 101-239, 6401(b), inserted
''1396a(a)(10)(A)(i)(VI),'' after ''1396a(a)(10)(A) (i)(IV),''.
Subsec. (i)(2). Pub. L. 101-239, 6411(d)(2), inserted '', not
including items or services furnished in an emergency room of a
hospital'' after ''emergency item or service''.
Subsec. (i)(5). Pub. L. 101-234 repealed Pub. L. 100-360,
202(h)(2), and provided that the provisions of law amended or repealed
by such section are restored or revived as if such section had not been
enacted, see 1988 Amendment note below.
1988 -- Subsec. (a)(1). Pub. L. 100-360, 301(f), amended Pub. L.
99-509, 9403(g)(2), see 1986 Amendment note below.
Subsec. (c). Pub. L. 100-360, 411(k)(13)(A), added subsec. (c).
Subsec. (f)(2). Pub. L. 100-360, 411(k)(10)(G)(ii), amended Pub. L.
100-203, 4118(h)(1), see 1987 Amendment note below.
Subsec. (f)(4). Pub. L. 100-360, 302(e)(4), inserted
''1396a(a)(10)(A)(i)(IV),'' before ''1396a(a)(10)(A)(ii)(IX)'' in
introductory provisions.
Subsec. (i)(2)(A). Pub. L. 100-360, 411(k)(10)(D), as amended by
Pub. L. 100-485, 608(d)(26)(K)(ii), added Pub. L. 100-203,
4118(e)(11)(A), see 1987 Amendment note below.
Subsec. (i)(2)(B). Pub. L. 100-360, 411(k)(10)(D), as amended by
Pub. L. 100-485, 608(d)(26)(K)(ii), added Pub. L. 100-203,
4118(e)(11)(B), see 1987 Amendment note below.
Subsec. (i)(3). Pub. L. 100-360, 411(k)(6)(B)(x), added Pub. L.
100-203, 4112(b), see 1987 Amendment note below.
Subsec. (i)(5). Pub. L. 100-360, 202(h)(2), substituted ''section
1395y(c)(1)'' for ''section 1395y(c)''.
Subsec. (i)(9). Pub. L. 100-360, 302(c)(3), added par. (9).
Subsec. (m)(2)(B)(i)(II). Pub. L. 100-485, 608(f)(4), substituted
''1396a(a)(10)(D) of this title'' for ''1396a(a)(13)(A)(ii) of this
title''.
Subsec. (m)(2)(F). Pub. L. 100-360, 411(k)(7)(D), repealed Pub. L.
100-203, 4113(d)(1), see 1987 Amendment note below.
Pub. L. 100-360, 411(a)(3)(A), (B)(iii), (k)(7)(A), amended Pub. L.
100-203, 4113(a)(1)(B), see 1987 Amendment note below.
Subsec. (m)(5). Pub. L. 100-360, 411(k)(12)(A), amended par. (5)
generally. Prior to amendment, par. (5) read as follows:
''(A) Any entity with a contract under this subsection that fails
substantially to provide medically necessary items and services that are
required (under law or such contract) to be provided to individuals
covered under such contract, if the failure has adversely affected (or
has a substantial likelihood of adversely affecting) these individuals,
is subject to a civil money penalty of not more than $10,000 for each
such failure.
''(B) The provisions of section 1320a-7a of this title (other than
subsection (a)) shall apply to a civil money penalty under subparagraph
(A) in the same manner as they apply to a civil money penalty under that
section.''
1987 -- Subsec. (a)(1). Pub. L. 100-203, 4211(g)(2), substituted
''and (j)'' for '', (h), and (j)''.
Subsec. (a)(2)(A) to (C). Pub. L. 100-203, 4211(d)(1), designated
existing provisions as subpar. (A) and added subpars. (B) and (C).
Subsec. (a)(2)(D). Pub. L. 100-203, 4212(c)(1), added subpar. (D).
Subsec. (a)(3)(C). Pub. L. 100-203, 4113(b)(3), inserted ''or by an
entity which meets the requirements of section 1320c-1 of this title, as
determined by the Secretary,'' after ''organization''.
Subsec. (a)(7). Pub. L. 100-203, 4212(e)(2), inserted ''subject to
section 1396r(g)(3)(B) of this title,'' after ''(7)''.
Subsec. (f)(2). Pub. L. 100-203, 4118(h)(1), as amended by Pub. L.
100-360, 411(k)(10)(G)(ii), substituted ''(whether in the form of
insurance premiums or otherwise and regardless of whether such costs are
reimbursed under another public program of the State or political
subdivision thereof)'' for ''(whether in the form of insurance premiums
or otherwise)''.
Subsec. (f)(4). Pub. L. 100-203, 4118(p)(5), inserted '',
1396a(a)(10)(A)(ii)(X), or 1396d(p)(1)'' after
''1396a(a)(10)(A)(ii)(IX)''.
Subsec. (g)(1). Pub. L. 100-203, 4212(d)(1)(A), substituted ''or
services in an intermediate care facility for the mentally retarded''
for first reference to ''or intermediate care facility services'',
struck out '', skilled nursing facility services for 30 days,'' after
first reference to ''60 days'', substituted ''or services in an
intermediate care facility for the mentally retarded'' for '', skilled
nursing facility services, or intermediate care facility services'', and
substituted ''and intermediate care facilities for the mentally
retarded'' for '', skilled nursing facilities, and intermediate care
facilities''.
Subsec. (g)(4)(B). Pub. L. 100-203, 4212(d)(1)(B), substituted ''and
intermediate care facilities for the mentally retarded'' for '', skilled
nursing facilities, and intermediate care facilities''.
Subsec. (g)(6)(B) to (D). Pub. L. 100-203, 4212(d)(1)(C),
redesignated subpar. (C) as (B) and substituted ''services in an
intermediate care facility for the mentally retarded'' for
''intermediate care facility services'', redesignated subpar. (D) as
(C), and struck out former subpar. (B) which read as follows: ''Such
recertifications in the case of skilled nursing facility services shall
be conducted at least --
''(i) 30 days after the date of the initial certification,
''(ii) 60 days after the date of the initial certification,
''(iii) 90 days after the date of the initial certification, and
''(iv) every 60 days thereafter.''
Subsec. (g)(7). Pub. L. 100-203, 4212(d)(1)(D), struck out par. (7)
which read as follows: ''It is the duty and responsibility of the
Secretary to assure that standards which govern the provision of care in
skilled nursing facilities and intermediate care facilities under plans
approved under this subchapter, and the enforcement of such standards,
are adequate to protect the health and safety of residents and to
promote the effective and efficient use of public moneys.''
Subsec. (h). Pub. L. 100-203, 4211(g)(1), struck out subsec. (h)
which related to reduction by Secretary of amount otherwise considered
as expenditures under State plan where reasonable cost differential
between statewide average cost of skilled nursing facility services and
statewide average cost of intermediate care facility services does not
exist for any calendar quarter beginning after June 30, 1973.
Subsec. (i). Pub. L. 100-203, 4118(d)(1)(B), inserted sentence at
end that nothing in par. (1) be construed as permitting a State to
provide services under its plan under this subchapter that are not
reasonable in amount, duration, and scope to achieve their purpose.
Subsec. (i)(1). Pub. L. 100-203, 4118(d)(1)(A), substituted '';
or'' for period at end.
Subsec. (i)(2). Pub. L. 100-93, 8(g), amended par. (2) generally.
Prior to amendment, par. (2) read as follows: ''with respect to any
amount paid for services furnished under the plan after December 31,
1972, by a provider or other person during any period of time, if
payment may not be made under subchapter XVIII of this chapter with
respect to services furnished by such provider or person during such
period of time solely by reason of a determination by the Secretary
under section 1395y(d)(1) of this title or under clause (D), (E), or (F)
of section 1395cc(b)(2) of this title, or by reason of noncompliance
with a request made by the Secretary under clause (C)(ii) of such
section 1395cc(b)(2) or under section 1396a(a)(38) of this title; or''.
Subsec. (i)(2)(A). Pub. L. 100-203, 4118(e)(11)(A), as added by Pub.
L. 100-360, 411(k)(10)(D), as amended by Pub. L. 100-485,
608(d)(26)(K)(ii), substituted ''under subchapter V, XVIII, or XX of
this chapter or under this subchapter pursuant to section 1320a-7,
1320a-7a, 1320c-5, or 1395u(j)(2) of this title'' for ''in the State
plan under this subchapter pursuant to section 1320a-7 of this title or
section 1320a-7a of this title''.
Subsec. (i)(2)(B). Pub. L. 100-203, 4118(e)(11)(B), as added by Pub.
L. 100-360, 411(k)(10)(D), as amended by Pub. L. 100-485,
608(d)(26)(K)(ii), substituted ''from participation under subchapter V,
XVIII, or XX of this chapter or under this subchapter pursuant to
section 1320a-7, 1320a-7a, 1320c-5, or 1395u(j)(2) of this title'' for
''pursuant to section 1320a-7 of this title or section 1320a-7a of this
title from participation in the program under this subchapter''.
Subsec. (i)(3). Pub. L. 100-203, 4112(b), as added by Pub. L.
100-360, 411(k)(6)(B)(x), inserted ''(other than amounts attributable
to the special situation of a hospital which serves a disproportionate
number of low income patients with special needs)'' before ''to the
extent''.
Subsec. (i)(4). Pub. L. 100-203, 4211(i), struck out ''or skilled
nursing facility'' after ''hospital'' in three places.
Subsec. (i)(8). Pub. L. 100-203, 4213(b)(2), added par. (8).
Subsec. (m)(2)(F). Pub. L. 100-203, 4113(d)(1), which directed the
substitution of ''subparagraphs (E) or (G)'' for ''subparagraph (G)'',
was repealed by Pub. L. 100-360, 411(k)(7)(D).
Pub. L. 100-203, 4113(a)(1)(B), as amended by Pub. L. 100-360,
411(a)(3)(A), (B)(iii), (k)(7)(A), substituted ''(F) In the case of --
'' and cls. (i) and (ii) for ''(F) In the case of a contract with an
entity described in subparagraph (G) or with a qualified health
maintenance organization (as defined in section 300e-9(d) of this title)
which meets the requirement of subparagraph (A)(ii),''.
Subsec. (m)(6). Pub. L. 100-203, 4113(a)(1)(A), added par. (6).
Subsec. (n). Pub. L. 100-93, 8(h)(1), struck out subsec. (n) which
related to State agency action upon disclosure or failure to disclose
required information by institution, organization, etc.
Subsec. (r). Pub. L. 100-203, 4212(c)(2), substituted ''paragraphs
(2)(A)'' for ''paragraphs (2)'' in pars. (1)(A), (C) and (2)(A), (C).
1986 -- Subsec. (a)(1). Pub. L. 99-509, 9403(g)(2), as amended by
Pub. L. 100-360, 301(f), inserted ''including expenditures for
medicare cost-sharing and'' before ''including expenditures''.
Subsec. (a)(3)(C). Pub. L. 99-509, 9431(b)(2), inserted ''or quality
review'' after ''medical and utilization review''.
Subsec. (a)(4). Pub. L. 99-603 added par. (4).
Subsec. (d)(2). Pub. L. 99-272, 9512(a), designated first sentence
as subpar. (A), designated second sentence as subpar. (B), properly
indented and aligned below subpar. (A), and added subpars. (C) and
(D).
Subsec. (f)(4). Pub. L. 99-509, 9401(e)(2), inserted ''for any
individual described in section 1396a(a)(10)(A)(ii)(IX) of this title
or'' after ''as medical assistance''.
Subsec. (i)(1). Pub. L. 99-272, 9507(a), added par. (1).
Subsec. (m)(2)(A). Pub. L. 99-272, 9517(a)(1), substituted
''subparagraphs (B), (C), and (G)'' for ''subparagraphs (B) and (C)'' in
introductory text.
Pub. L. 99-272, 9517(c)(1), inserted ''(including a health insuring
organization)'' after ''any entity'' and ''(directly or through
arrangements with providers of services)'' after ''responsible for the
provision'' in introductory text.
Subsec. (m)(2)(A)(iii). Pub. L. 99-509, 9434(a)(2), inserted before
the semicolon ''and under which the Secretary must provide prior
approval for contracts providing for expenditures in excess of
$100,000''.
Subsec. (m)(2)(A)(viii). Pub. L. 99-509, 9434(a)(1)(A), added cl.
(viii).
Subsec. (m)(2)(F). Pub. L. 99-514, 1895(c)(2), substituted ''In the
case'' for ''in the case''.
Pub. L. 99-272, 9517(a)(2), struck out designation ''(i)'' at
beginning of subpar. (F), substituted ''in the case of a contract with
an entity described in subparagraph (G) or with a qualified health
maintenance organization (as defined in section 300e-9(d) of this title)
which meets the requirement of subparagraph (A)(ii)'' for ''In the case
of a contract with a health maintenance organization described in clause
(ii)'', substituted ''such entity or organization'' for ''such
organization'', and struck out cl. (ii) which defined a health
maintenance organization.
Subsec. (m)(2)(G). Pub. L. 99-272, 9517(a)(3), added subpar. (G).
Subsec. (m)(4). Pub. L. 99-509, 9434(a)(1)(B), added par. (4).
Subsec. (m)(5). Pub. L. 99-509, 9434(b), added par. (5).
Subsec. (r)(1)(B). Pub. L. 99-272, 9518(a), substituted ''September
30, 1985'' for ''the earlier of (i) September 30, 1982, or (ii) the last
day of the sixth month following the date specified for operation of
such systems in the State's most recently approved advance planning
document submitted before October 7, 1980''.
Subsec. (r)(4)(A). Pub. L. 99-272, 9503(b)(2), substituted ''once
every three years'' for ''once each fiscal year'' and inserted at end
''Reviews may, at the Secretary's discretion, constitute reviews of the
entire system or of only those standards, systems requirements, and
other conditions which have demonstrated weakness in previous reviews.''
Subsec. (r)(6)(J). Pub. L. 99-272, 9503(b)(1), amended subpar. (J)
generally. Prior to amendment, subsec. (J) read as follows: ''report
on or before October 1, 1981, to the Congress on the extent to which
States have developed and operated effective mechanized claims
processing and information retrieval systems.''
Subsec. (u)(1)(D)(iv). Pub. L. 99-272, 9503(f), added cl. (iv).
Subsec. (u)(1)(D)(v). Pub. L. 99-509, 9407(c), added cl. (v).
Subsec. (v). Pub. L. 99-509, 9406(a), added subsec. (v).
1984 -- Subsec. (g)(1). Pub. L. 98-369, 2363(a)(2)(A), (B), in
provision preceding subpar. (A), substituted ''inpatient hospital
services or intermediate care facility services for 60 days, skilled
nursing facility services for 30 days, or inpatient mental hospital
services for'' for ''care as an inpatient in a hospital (including an
institution for tuberculosis), skilled nursing facility or intermediate
care facility on 60 days, or in a hospital for mental diseases on'', and
struck out ''which for purposes of this section means the four calendar
quarters ending with June 30,'' before ''the Federal medical assistance
percentage'', and struck out ''in the same fiscal year'' before ''shall
be decreased by a per centum thereof''.
Pub. L. 98-369, 2363(a)(2)(C), substituted '', skilled nursing
facility services, or intermediate care facility services furnished
beyond 60 days (or inpatient mental hospital services furnished beyond
90 days), such State has an effective program of medical review of the
care of patients in mental hospitals, skilled nursing facilities, and
intermediate care facilities pursuant to paragraphs (26) and (31) of
section 1396a(a) of this title whereby the professional management of
each case is reviewed and evaluated at least annually by independent
professional review teams'' for ''(including tuberculosis hospitals),
skilled nursing facility services, or intermediate care facility
services furnished beyond 60 days (or inpatient mental hospital services
furnished beyond 90 days), there is in operation in the State an
effective program of control over utilization of such services; such a
showing must include evidence that -- '' and former subpars. (A)
through (D) requirement for evidence concerning an effective program of
utilization of certain medical services.
Subsec. (g)(4)(B). Pub. L. 98-369, 2373(b)(11), substituted
''paragraphs (26)'' for ''paragraph (26)'' and ''diligence'' for
''deligence''.
Subsec. (g)(6). Pub. L. 98-369, 2363(a)(4), in amending par. (6)
generally, substituted provisions relating to recertifications for
provisions relating to reports to Congress concerning Secretary's
determination and review of showing respecting any decrease of Federal
medical assistance percentage of amounts paid for services.
Subsec. (g)(7). Pub. L. 98-369, 2363(b), as amended by Pub. L.
98-617, 3(a)(6), added par. (7).
Subsec. (i)(7). Pub. L. 98-369, 2303(g)(2), added par. (7).
Subsec. (m)(2)(A)(vi). Pub. L. 98-369, 2364(1), inserted ''except as
provided under subparagraph (F),'' after ''(I)''.
Subsec. (m)(2)(B)(i)(I). Pub. L. 98-369, 2373(b)(12)(A), (C), struck
out ''(II)'' before ''for the period'' and substituted ''period'' for
''peroid''.
Subsec. (m)(2)(B)(i)(II). Pub. L. 98-369, 2373(b)(12)(B),
substituted ''of section 1396d(a) of this title'' for ''of such
section''.
Subsec. (m)(2)(C). Pub. L. 98-369, 2373(b)(13), realigned margin of
subpar. (C).
Subsec. (m)(2)(E), (F). Pub. L. 98-369, 2364(2), added subpars.
(E) and (F).
Subsec. (s)(3)(B). Pub. L. 98-369, 2373(b)(14), substituted
''non-Federal'' for ''nonfederal''.
1983 -- Subsec. (t)(3). Pub. L. 97-448 substituted ''purposes'' for
''purpose'' and ''the lower of the Federal medical assistance percentage
for the State in effect for fiscal year 1981, or the Federal medical
assistance percentage for the State in effect for fiscal year 1982'' for
''the Federal medical assistance percentage for States in effect for
fiscal year 1981, disregarding any change in such percentage after
fiscal year 1981''.
1982 -- Subsec. (a)(3)(C). Pub. L. 97-248, 146(b), substituted
''utilization and quality control peer review organization'' for
''Professional Standards Review Organization''.
Subsec. (f)(3). Pub. L. 97-248, 137(g), struck out ''(without regard
to section 608 of this title)'' after ''consisting of one person if such
plan''.
Subsec. (g)(1). Pub. L. 97-248, 137(b)(11), inserted ''or which is a
qualified health maintenance organization (as defined in section
300e-9(d) of this title)''.
Subsec. (g)(1)(A). Pub. L. 97-248, 137(b)(12), substituted
''provided in an institution for the mentally retarded'' for ''described
in section 1396d(d) of this title''.
Subsec. (k). Pub. L. 97-248, 137(b)(13), substituted ''subsection
(m) of this section'' for ''section 1395mm of this title''.
Subsec. (m)(2)(A). Pub. L. 97-248, 137(b)(14), substituted ''or''
for ''and'' before ''(II)'' in cl. (iv), and substituted ''unforeseen''
for ''unforseen'' in cl. (vii)(II).
Subsec. (s). Pub. L. 97-248, 137(a)(2), amended directory language
of Pub. L. 97-35, 2161(c)(1), to correct an error, and did not involve
any change in text. See 1981 Amendment note below.
Subsec. (s)(1)(A). Pub. L. 97-248, 137(b)(15)(A), (B), in provisions
following cl. (iii), substituted ''fiscal year 1982'' for ''fiscal year
1981'', and ''subsections (a)(6) and (t) of this section, without regard
to payments for claims relating to expenditures made for medical
assistance for services received through a facility of the Indian Health
Service,'' for ''subsection (t) of this section''.
Subsec. (s)(1)(C). Pub. L. 97-248, 137(b)(15)(C), inserted ''a
program in operation under'', before ''a plan approved''.
Subsec. (s)(3)(D). Pub. L. 97-248, 137(b)(15)(D), substituted ''must
determine that'' for ''determines that'', ''most recent year (which
shall consist of a 12-month period determined by the Secretary for this
purpose)'' for ''most recent calendar year'', and ''2- or 3-year
period'' for ''2 or 3 calendar year period'', and struck out
''calendar'' wherever appearing.
Subsec. (s)(4)(B). Pub. L. 97-248, 137(b)(15)(E), inserted ''and
paragraph (3)(D)''.
Subsec. (s)(5)(A)(i). Pub. L. 97-248, 137(b)(15)(F), inserted
''(including amounts saved, to the extent such amounts can be documented
to the satisfaction of the Secretary, by reason of the suspension or
termination of a provider or other person for fraud or abuse, but only
during the period of such suspension or termination or, if shorter, the
1-year period beginning on the date of such termination or suspension)''
after ''recovered or diverted''.
Subsec. (s)(5)(B). Pub. L. 97-248, 137(b)(27), inserted ''or
quarters'' after ''carried forward to the following quarter''.
Subsec. (t). Pub. L. 97-248, 137(a)(1), (2), amended directory
language of Pub. L. 97-35, 2161(b), (c)(2), to correct an error, and
did not involve any change in text. See 1981 Amendment note below.
Subsec. (t)(1)(A). Pub. L. 97-248, 137(b)(16)(A), substituted
''payments under subsection (a)(6) of this section, interest paid under
subsection (d)(5) of this section, and payments for claims relating to
expenditures made for medical assistance for services received through a
facility of the Indian Health Service'' for ''interest paid under
subsection (d)(5) of this section''.
Subsec. (t)(1)(B). Pub. L. 97-248, 137(b)(16)(B), (D), substituted
''Consumer Price Index for all urban consumers (U.S. city average)
published by the Bureau of Labor Statistics'' for ''consumer price index
for all urban consumers (published by the Bureau of Labor Statistics)''
and ''for the 12-month period ending on September 30, 1983'' for
''between September 1982 and September 1983''.
Subsec. (t)(1)(C). Pub. L. 97-248, 137(b)(16)(C), (D), substituted
''Consumer Price Index for all urban consumers (U.S. city average)
published by the Bureau of Labor Statistics'' for ''consumer price index
for all urban consumers (published by the Bureau of Labor Statistics)''
and ''for the 24-month period ending on September 30, 1984'' for
''between September 1982 and September 1984''.
Subsec. (t)(2)(A). Pub. L. 97-248, 137(b)(16)(A), substituted
''payments under subsection (a)(6) of this section, interest paid under
subsection (d)(5) of this section, and payments for claims relating to
expenditures made for medical assistance for services received through a
facility of the Indian Health Service'' for ''interest paid under
subsection (d)(5) of this section''.
Subsec. (t)(3). Pub. L. 97-248, 137(b)(16)(E), substituted ''for
fiscal years 1982, 1983, and 1984'' for ''for fiscal year 1984''
wherever appearing, ''years 1983, 1984, and 1985, respectively'' for
''year 1985'', ''in effect for fiscal year 1981'' for ''in effect for
fiscal year 1983'', and ''after fiscal year 1981'' for ''between fiscal
year 1983 and fiscal year 1984''.
Subsec. (u). Pub. L. 97-248, 133(a), added subsec. (u).
1981 -- Subsec. (a)(3)(B). Pub. L. 97-35, 2113(n), substituted
''and'' for ''plus'' at the end of subpar. (B) and added subpar. (C).
Subsec. (d)(5). Pub. L. 97-35, 2163, substituted ''determination at
a rate'' for ''determination (but not to exceed a period of twelve
months with respect to disallowances made prior to October 1, 1981, or
six months with respect to disallowances made thereafter) at a rate''.
Subsec. (e). Pub. L. 97-35, 2101(a)(2), added subsec. (e).
Subsec. (g)(1)(A). Pub. L. 97-35, 2183(a), inserted ''and the
physician, or a physician assistant or nurse practitioner under the
supervision of a physician'' and ''or, in the case of services that are
intermediate care facility services described in section 1396d(d) of
this title, every year'' in parenthetical text.
Subsec. (i)(1). Pub. L. 97-35, 2174(b), struck out par. (1) which
provided that payments shall not be made with respect to any amount paid
for items or services furnished under the plan after Dec. 31, 1972, to
the extent that such amount exceeds the charge which would be determined
to be reasonable for such items or services under fourth and fifth
sentences of section 1395u(b)(3) of this title.
Subsec. (i)(5). Pub. L. 97-35, 2103(b)(1), added par. (5).
Subsec. (i)(6). Pub. L. 97-35, 2164(a), added par. (6).
Subsec. (m)(1)(A). Pub. L. 97-35, 2178(a)(1), redefined ''Health
Maintenance Organization'' substantially, and substituted reference to
public and private organizations making services to individuals eligible
for benefits under this subchapter and which makes adequate provision
against the risk of insolvency for reference to a legal entity which
provides health services to individuals enrolled in such organization
and providing services and benefits to individuals eligible for benefits
under specified provisions of this subchapter.
Subsec. (m)(2)(A). Pub. L. 97-35, 2178(a)(2), in cl. (ii),
substituted ''75 percent of the membership of the entity which is
enrolled on a prepaid basis'' for ''one-half of the membership of the
entity'', and added cls. (iii) to (vii).
Subsec. (m)(2)(D). Pub. L. 97-35, 2178(a)(3), added subpar. (D).
Subsec. (n). Pub. L. 97-35, 2106(b)(3), struck out ''of this
section'' after ''section 1395cc of this title'' thereby perfecting the
amendment made by Pub. L. 96-499, 905(c)(2).
Subsec. (s). Pub. L. 97-35, 2161(c)(1), as amended by Pub. L.
97-248, 137(a)(2), repealed subsec. (s) which provided for reduction
in medicaid payments to States, limitations on reductions, States
included, and percentage reductions reduced under certain circumstances.
See Effective Date of 1981 Amendment note below.
Pub. L. 97-35, 2161(a), added subsec. (s).
Subsec. (t). Pub. L. 97-35, 2161(c)(2), as amended by Pub. L.
97-248, 137(a)(2), repealed subsec. (t) which provided for offset for
meeting Federal medicaid expenditure targets, and computation for
meeting expenditure targets. See Effective Date of 1981 Amendment note
below.
Pub. L. 97-35, 2161(b), as amended by Pub. L. 97-248, 137(a)(1),
added subsec. (t).
1980 -- Subsec. (a)(1). Pub. L. 96-499, 905(b), inserted reference
to subsection (j) of this section.
Subsec. (a)(6). Pub. L. 96-499, 963, substituted ''such a quarter
within the twelve-quarter period beginning with the first quarter in
which a payment is made to the State pursuant to this paragraph, and (B)
75 per centum of the sums expended during each succeeding calendar
quarter'' for ''each quarter beginning on or after October 1, 1977, and
ending before October 1, 1980''.
Subsec. (d)(5). Pub. L. 96-499, 961(a), added par. (5).
Subsec. (g)(3)(B). Pub. L. 96-499, 964, substituted ''January 1,
1978'' for ''October 1, 1977'' and ''any calendar quarter ending on or
before December 31, 1978'' for ''the calendar quarter ending on December
31, 1977''.
Subsec. (j). Pub. L. 96-499, 905(c)(1), substituted provisions
relating to the adjustment of amounts determined under subsec. (a)(1)
of this section in accordance with section 1396m of this title for
provisions relating to orders for suspension of payment.
Subsec. (n). Pub. L. 96-499, 905(c)(2), struck out ''or is subject
to a suspension of payment order issued under subsection (j)'' after
''section 1395cc of this title''.
Subsec. (r). Pub. L. 96-398 added subsec. (r).
1979 -- Subsec. (m)(2)(C). Pub. L. 96-79 substituted ''the date the
entity qualifies as a health maintenance organization (as determined by
the Secretary)'' for ''the date the entity enters into a contract with
the State under this subchapter for the provision of health services on
a prepaid risk basis''.
1978 -- Subsec. (m)(1)(B). Pub. L. 95-559 struck out ''shall be
administered through the Assistant Secretary for Health and in the
Office of the Assistant Secretary for Health, and the administration of
such duties and functions'' after ''subparagraph (A),''.
Subsec. (m)(2)(B)(i)(I). Pub. L. 95-626 substituted ''section
254b(d)(1)(A)'' for ''section 247d(d)(1)(A)''.
1977 -- Subsec. (a)(3)(B). Pub. L. 95-142, 10(a), inserted
provisions relating to notice to individuals in a sample group and
provisions exempting notice respecting confidential services from notice
requirements.
Subsec. (a)(6), (7). Pub. L. 95-142, 17(a), added par. (6) and
redesignated former par. (6) as (7).
Subsec. (b)(3). Pub. L. 95-142, 17(b), added par. (3).
Subsec. (g). Pub. L. 95-142, 20(a), in par. (1) substituted
''Subject to paragraph (3), with respect to'' for ''With respect to''
and ''by a per centum thereof (determined under paragraph (5))'' for
''by 33 1/3 per centum thereof'', in par. (2) inserted ''timely''
before ''sample onsite surveys'', and added pars. (3) to (6).
Subsec. (i)(2). Pub. L. 95-142, 3(c)(2), inserted provisions
relating to noncompliance under sections 1395cc(b)(2) and 1396a(a)(38)
of this title.
Subsec. (m)(2)(A). Pub. L. 95-83, 105(a)(1), in revising text,
incorporated former cl. (i) (I) and (II) provisions in introductory
text relating to responsibility for providing inpatient hospital
services and other described services, substituting ''capitation basis''
for ''capitation risk basis'' and inserting ''unless''; redesignated as
cl. (i) former cl. (ii), substituting ''has determined that the entity
is a health maintenance organization'' for ''has not determined to be a
health maintenance organization''; and redesignated as cl. (ii) former
cl. (iii), substituting ''less than one-half of the membership of the
entity consists of individuals who (I) are insured for benefits under
part B of subchapter XVIII of this chapter or for benefits under both
parts A and B of such subchapter, or (II) are eligible to receive
benefits under this subchapter'' for ''more than one-half of the
membership of which consists of individuals who are insured under parts
A and B of subchapter XVIII of this chapter or recipients of benefits
under this subchapter.''
Subsec. (m)(2)(C). Pub. L. 95-83, 105(a)(2), substituted reference
to subpar. ''(A)(ii)'' for ''(A)(iii)'' wherever appearing.
Subsec. (n). Pub. L. 95-142, 8(c), added subsec. (n).
Subsecs. (o), (p). Pub. L. 95-142, 11(a), added subsecs. (o) and
(p).
Subsec. (q). Pub. L. 95-142, 17(c), added subsec. (q).
1976 -- Subsec. (l). Pub. L. 94-552 repealed subsec. (l) which
provided for reduction of amount of payments to States found not to be
in compliance with section 1396a(g) of this title.
Subsec. (m). Pub. L. 94-460 added subsec. (m).
1975 -- Subsec. (g)(1)(C). Pub. L. 94-182, 110(a), inserted
provisions specifying the method by which the size and composition of
the sample of admissions subject to review is to be established.
Subsec. (l). Pub. L. 94-182, 111(b), added subsec. (l).
1973 -- Subsec. (a). Pub. L. 93-233, 18(x)(5), struck out reference
to section 1317 of this title in introductory parenthetical phrase.
Subsec. (a)(1). Pub. L. 93-233, 13(a)(11), 18(r)(1), substituted
''individuals who are eligible for medical assistance under the plan and
(A) are receiving aid or assistance under any plan of the State approved
under subchapter I, X, XIV, or part A of subchapter IV of this chapter,
or with respect to whom supplemental security income benefits are being
paid under subchapter XVI of this chapter, or (B) with respect to whom
there is being paid a State supplementary payment and are eligible for
medical assistance equal in amount, duration, and scope to the medical
assistance made available to individuals described in section
1396a(a)(10)(A) of this title'' for ''individuals who are recipients of
money payments under a State plan approved under subchapter I, X, XIV,
or XVI, or part A of subchapter IV of this chapter'' and inserted ''and
disabled individuals entitled to hospital insurance benefits under
subchapter XVIII of this chapter,'' after ''individuals sixty-five years
of age or older''.
Subsec. (a)(4). Pub. L. 93-233, 18(s), substituted ''sums expended
with respect to costs incurred'' for ''sums expended''.
Subsec. (a)(5). Pub. L. 93-233, 18(t), struck out ''(as found
necessary by the Secretary for the proper and efficient administration
of the plan)'' after ''such quarter''.
Subsec. (b). Pub. L. 93-233, 18(r)(2), (u), (x)(6), inserted in
par. (2) after ''individuals sixty-five years of age or older'' text
reading ''and disabled individuals entitled to hospital insurance
benefits under subchapter XVIII of this chapter'' and end text reading
'', other than amounts expended under provisions of the plan of such
State required by section 1396a(a)(34) of this title,'' and redesignated
pars. (2) and (3) as (1) and (2), respectively.
Subsec. (c). Pub. L. 93-233, 18(y)(1)(A), struck out subsec. (c)
which provided for Federal medical assistance percentage and Federal
share of State medical expenses during fiscal year ending June 30, 1965.
Subsec. (d)(1). Pub. L. 93-233, 18(y)(1)(B), struck out reference to
subsec. (c) of this section.
Subsec. (f)(4). Pub. L. 93-233, 13(a)(12), in subpar. (A), made
payment limitations inapplicable to individual with respect to whom
supplemental security income benefits are being paid under subchapter
XVI of this chapter; in subpar. (B), made payment limitations
inapplicable to individual with respect to whom such benefits are not
being paid, and in cls. (i) and (ii) inserted ''to have such benefits
paid with respect to him'', and added subpar. (C).
Subsec. (g)(1)(C). Pub. L. 93-233, 18(v), substituted ''directly
responsible for the care of the patient or financially interested in any
such institution or, except in the case of hospitals, employed by the
institution'' for ''directly responsible for the care of the patient and
who are not employed by or financially interested in any such
institution''.
Subsec. (j). Pub. L. 93-66 struck out provisions respecting skilled
nursing facility services and intermediate care facility services.
1972 -- Subsec. (a)(1). Pub. L. 92-603, 207(a)(2), inserted
reference to subsecs. (g) and (h) and of this section.
Subsec. (a)(3). Pub. L. 92-603, 235(a), added par. (3). Former par.
(3) redesignated (4).
Subsec. (a)(4). Pub. L. 92-603, 249B, temporarily added par. (4)
which provided for payments to States of 100 per centum of sums expended
for costs incurred during a quarter attributable to compensation or
training of personnel responsible for inspecting public or private
institutions providing long-term care to recipients of medical
assistance to determine compliance with health or safety standards.
Former par. 4 redesignated (5). See Effective Date of 1972 Amendment
note below.
Pub. L. 92-603, 235(a), redesignated former par. (3) as (4).
Subsec. (a)(5). Pub. L. 92-603, 299E(a), added par. (5). Former
par. (5) redesignated (6).
Pub. L. 92-603, 249B, redesignated former par. (4) as (5).
Subsec. (a)(6). Pub. L. 92-603, 299E, redesignated former par. (5)
as (6).
Subsec. (b)(1). Pub. L. 92-603, 295, struck out par. (1) which
related to amount of quarterly expenditures exceeding average of total
expenditures for each quarter of fiscal year ending June 30, 1965.
Subsec. (b)(3). Pub. L. 92-603, 221(c)(6), added par. (3).
Subsec. (e). Pub. L. 92-603, 230, repealed subsec. (e) which
related to furnishing for comprehensive care and services by July 1,
1977.
Subsec. (g). Pub. L. 92-603, 207(a)(1), 278(b)(1), added subsec.
(g) and substituted ''skilled nursing facility'' for ''skilled nursing
home'' and ''skilled nursing facilities'' for ''skilled nursing homes''
wherever appearing.
Subsec. (h). Pub. L. 92-603, 207(a)(1), 278(b)(1)(5), added subsec.
(h) and substituted ''skilled nursing facility'' for ''skilled nursing
home'' wherever appearing.
Subsec. (i). Pub. L. 92-603, 224(c), 229(c), 233(c), 237(a)(1),
278(b)(7), added subsec. (i) and substituted ''skilled nursing
facility'' for ''skilled nursing home'' wherever appearing.
Subsec. (j). Pub. L. 92-603, 290, added subsec. (j) relating to
orders for suspension of payment.
Pub. L. 92-603, 225, 278(b)(16), added subsec. (j) relating to
skilled nursing facilities services, and substituted ''skilled nursing
facility for ''skilled nursing home'' wherever appearing.
Subsec. (k). Pub. L. 92-603, 226(e), added subsec. (k).
1969 -- Subsec. (e). Pub. L. 91-56 extended from July 1, 1975, to
July 1, 1977, the date by which comprehensive care and services for
eligible individuals must be made available for a State to be eligible
for payments.
1968 -- Subsec. (a)(1). Pub. L. 90-248, 222(d), substituted ''and,
except in the case of individuals sixty-five years of age or older who
are not enrolled under part B of subchapter XVIII of this chapter, other
insurance premiums'' for ''and other insurance premiums''.
Pub. L. 90-248, 241(f)(5), struck out ''IV,'' after ''I,'' and
inserted ''or part A of subchapter IV of this chapter,'' after ''XVI of
this chapter,''.
Subsec. (a)(2). Pub. L. 90-248, 225(a), substituted ''of the State
agency or any other public agency'' for ''of the State agency (or of the
local agency administering the State plan in the political
subdivision)''.
Subsec. (b). Pub. L. 90-248, 222(c), designated existing provisions
as par. (1) and added par. (2).
Subsec. (b)(2). Pub. L. 90-364 substituted ''1969'' for ''1967''.
Subsec. (d)(2). Pub. L. 90-248, 229(c), provided for treatment of
expenditures for which payments were made to the State under subsec.
(a) as an overpayment to the extent that the State or local agency
administering the plan has been reimbursed for such expenditures by a
third party pursuant to the provisions of its plan in compliance with
section 1396a(a)(25) of this title.
Subsec. (f). Pub. L. 90-248, 220(a), added subsec. (f).
Amendments by section 2(a), (b)(2) of Pub. L. 102-234 effective Jan.
1, 1992, without regard to whether or not regulations have been
promulgated to carry out such amendments by such date, see section
2(c)(1) of Pub. L. 102-234, set out as a note under section 1396a of
this title.
Amendment by section 3(b)(2)(B) of Pub. L. 102-234 effective Jan.
1, 1992, see section 3(e)(1) of Pub. L. 102-234, set out as a note
under section 1396a of this title.
Section 4(b) of Pub. L. 102-234 provided that: ''The amendment made
by subsection (a) (amending this section) shall apply to fiscal years
ending after the date of the enactment of this Act (Dec. 12, 1991).''
Amendment by section 4402(b), (d)(3) of Pub. L. 101-508 applicable,
except as otherwise provided, to payments under this subchapter for
calendar quarters beginning on or after Jan. 1, 1991, without regard to
whether or not final regulations to carry out the amendments by section
4402 of Pub. L. 101-508 have been promulgated by such date, see section
4402(e) of Pub. L. 101-508, set out as a note under section 1396a of
this title.
Amendment by section 4601(a)(3)(A) of Pub. L. 101-508 applicable,
except as otherwise provided, to payments under this subchapter for
calendar quarters beginning on or after July 1, 1991, without regard to
whether or not final regulations to carry out the amendments by section
4601 of Pub. L. 101-508 have been promulgated by such date, see section
4601(b) of Pub. L. 101-508, set out as a note under section 1396a of
this title.
Section 4701(c) of Pub. L. 101-508 provided that: ''The amendment
made by subsection (b) (amending this section and section 1396a of this
title) shall take effect on January 1, 1991.''
Amendment by section 4704(b)(1), (2) of Pub. L. 101-508 effective as
if included in the enactment of the Omnibus Budget Reconciliation Act of
1989, Pub. L. 101-239, see section 4704(f) of Pub. L. 101-508, set
out as a note under section 1396a of this title.
Amendment by section 4711(c)(2) of Pub. L. 101-508 applicable to
civil money penalties imposed after Nov. 5, 1990, see section
4711(e)(2)(B) of Pub. L. 101-508, set out as a note under section 1396a
of this title.
Section 4731(c) of Pub. L. 101-508 provided that: ''The amendments
made by subsections (a) and (b)(2) (amending this section) shall apply
with respect to contract years beginning on or after January 1, 1992,
and the amendments made by subsection (b)(1) (amending section 1320a-7a
of this title) shall take effect on the date of the enactment of this
Act (Nov. 5, 1990).''
Amendment by section 4751(b)(1) of Pub. L. 101-508 applicable with
respect to services furnished on or after first day of first month
beginning more than 1 year after Nov. 5, 1990, see section 4751(c) of
Pub. L. 101-508, set out as a note under section 1396a of this title.
Section 4752(b)(2) of Pub. L. 101-508 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
contract years beginning after the date of the establishment of the
system described in section 1902(x) of the Social Security Act (section
1396a(x) of this title).''
Section 4801(a)(9) of Pub. L. 101-508 provided that: ''Except as
provided in paragraph (6), the amendments made by this subsection
(amending this section and section 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).''
Section 4801(e)(16)(B) of Pub. L. 101-508 provided that: ''The
amendments made by subparagraph (A) (amending this section) shall apply
with respect to actions initiated on or after the date of the enactment
of this Act (Nov. 5, 1990).''
Amendment by section 6401(b) of Pub. L. 101-239 applicable, except
as otherwise provided, to payments under this subchapter for calendar
quarters beginning on or after Apr. 1, 1990, with respect to
eligibility for medical assistance on or after such date, without regard
to whether or not final regulations to carry out the amendments by
section 6401 of Pub. L. 101-239 have been promulgated by such date, see
section 6401(c) of Pub. L. 101-239, set out as a note under section
1396a of this title.
Amendment by section 6901(b)(5)(A) of Pub. L. 101-239 effective as
if included in the enactment of the Omnibus Budget Reconciliation Act of
1987, Pub. L. 100-203, see section 6901(b)(6) of Pub. L. 101-239, set
out as a note under section 1395i-3 of this title.
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.
Amendment by section 608(d)(26)(K)(ii) of Pub. L. 100-485 effective
as if included in the enactment of the Medicare Catastrophic Coverage
Act of 1988, Pub. L. 100-360, see section 608(g)(1) of Pub. L.
100-485, set out as a note under section 704 of this title.
Amendment by section 608(f)(4) of Pub. L. 100-485 effective Oct.
13, 1988, see section 608(g)(2) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 202(h)(2) of Pub. L. 100-360 applicable to
items dispensed on or after Jan. 1, 1990, see section 202(m)(1) of Pub.
L. 100-360, set out as a note under section 1395u of this title.
Section 301(f) of Pub. L. 100-360 provided that the amendment made
by that section is effective as though included in the enactment of the
Omnibus Budget Reconciliation Act of 1986, Pub. L. 99-509.
Amendment by section 302(c)(3) of Pub. L. 100-360 applicable, except
as otherwise provided, to payments under this subchapter for calendar
quarters beginning on or after July 1, 1989, with respect to eligibility
for medical assistance on or after that date, without regard to whether
or not final regulations to carry out such amendment have been
promulgated by such date, see section 302(f) of Pub. L. 100-360, set
out as a note under section 1396a of this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(a)(3)(A), (B)(iii), (k)(6)(B)(x), (7)(A), (D),
(10)(D), (G)(ii) 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.
Section 411(k)(12)(B) of Pub. L. 100-360 provided that: ''The
amendment made by subparagraph (A) (amending this section) shall apply
to actions occurring on or after the date of the enactment of this Act
(July 1, 1988).''
Section 411(k)(13)(B) of Pub. L. 100-360 provided that: ''The
amendment made by subparagraph (A) (amending this section) shall take
effect on the date of the enactment of this Act (July 1, 1988).''
Section 4118(d)(2) of Pub. L. 100-203 provided that: ''The
amendments made by paragraph (1) (amending this section) shall be
effective as if included in the enactment of section 9507 of the
Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub. L.
99-272).''
Amendment by section 4118(h)(1) of Pub. L. 100-203 applicable to
costs incurred after Dec. 22, 1987, see section 4118(h)(3) of Pub. L.
100-203, as amended, set out as a note under section 1396a of this
title.
Amendments by sections 4211(d)(1), (g), (i), 4212(c)(1), (2), (d)(1),
(e)(2) of Pub. L. 100-203 applicable to nursing facility services
furnished on or after Oct. 1, 1990, without regard to whether
regulations implementing such amendments are promulgated by such date,
except as otherwise specifically provided in section 1396r of this
title, with transitional rule, see section 4214(a), (b)(2) of Pub. L.
100-203, as amended, set out as an Effective Date note under section
1396r of this title.
Amendment by section 4212(d)(1) of Pub. L. 100-203 not applicable
until such date as of which the State has specified the resident
assessment instrument under section 1396r(e)(5) of this title, and the
State has begun conducting surveys under section 1396r(g)(2) of this
title, see section 4212(d)(4) of Pub. L. 100-203, set out as a note
under section 1396a of this title.
Amendment by section 4213(b)(2) of Pub. L. 100-203 applicable to
payments under this subchapter for calendar quarters beginning on or
after Dec. 22, 1987, without regard to whether regulations implementing
such amendment are promulgated by such date, except as otherwise
specifically provided in section 1396r of this title, see section
4214(b)(1) of Pub. L. 100-203, as amended, set out as an Effective Date
note under section 1396r of this title.
Amendment by Pub. L. 100-93 effective at end of fourteen-day period
beginning Aug. 18, 1987, and inapplicable to administrative proceedings
commenced before end of such period, see section 15(a) of Pub. L.
100-93, set out as a note under section 1320a-7 of this title.
Amendment by Pub. L. 99-603 effective Oct. 1, 1987, see section
121(c)(2) of Pub. L. 99-603, set out as a note under section 502 of
this title.
Amendment by Pub. L. 99-514 effective, except as otherwise provided,
as if included in enactment of the Consolidated Omnibus Budget
Reconciliation Act of 1985, Pub. L. 99-272, see section 1895(e) of Pub.
L. 99-514, set out as a note under section 162 of Title 26, Internal
Revenue Code.
Amendment by section 9401(e)(2) of Pub. L. 99-509 applicable to
medical assistance furnished in calendar quarters beginning on or after
Apr. 1, 1987, without regard to whether of not final regulations to
carry out such amendment have been promulgated by such date, see section
9401(f) of Pub. L. 99-509, set out as a note under section 1396a of
this title.
Amendment by section 9403(g)(2) of Pub. l. 99-509 applicable to
payments under this subchapter for calendar quarters beginning on or
after July 1, 1987, without regard to whether or not final regulations
to carry out such amendments have been promulgated by such date, see
section 9403(h) of Pub. L. 99-509, set out as a note under section
1396a of this title.
Amendment by section 9406(a) of Pub. L. 99-509 applicable, except as
otherwise provided, to medical assistance furnished to aliens on or
after Jan. 1, 1987, without regard to whether or not final regulations
to carry out such amendments have been promulgated by such date, see
section 9406(c) of Pub. L. 99-509, set out as a note under section
1396a of this title.
Amendment by section 9407(c) of Pub. L. 99-509 applicable to
ambulatory prenatal care furnished in calendar quarters beginning on or
after Apr. 1, 1987, without regard to whether or not final regulations
to carry out such amendments have been promulgated by such date, see
section 9407(d) of Pub. L. 99-509, set out as a note under section
1396a of this title.
Amendment by section 9431(b)(2) of Pub. L. 99-509 applicable to
payments under this subchapter for calendar quarters beginning on or
after July 1, 1987, without regard to whether or not final regulations
to carry out such amendments have been promulgated by such date, see
section 9431(c) of Pub. L. 99-509, set out as a note under section
1396a of this title.
Section 9434(a)(3) of Pub. L. 99-509 provided that:
''(A) The amendments made by paragraph (1) (amending this section)
shall take effect 6 months after the date of the enactment of this Act
(Oct. 21, 1986).
''(B) The amendment made by paragraph (2) (amending this section)
shall take effect on the date of the enactment of this Act and shall
apply to contracts entered into, renewed, or extended after the end of
the 30-day period beginning on the date of the enactment of this Act.''
Amendment by section 9503(b), (f) of Pub. L. 99-272 applicable to
calendar quarters beginning on or after Apr. 7, 1986, except as
otherwise provided, see section 9503(g)(1), (2) of Pub. L. 99-272, set
out as a note under section 1396a of this title.
Section 9507(b) of Pub. L. 99-272 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply to medical
assistance furnished on or after January 1, 1987.''
Section 9512(b) of Pub. L. 99-272 provided that: ''The amendments
made by this section (amending this section) shall apply to overpayments
identified for quarters beginning on or after October 1, 1985.''
Section 9517(c)(2), (3) of Pub. L. 99-272, as amended by Pub. L.
99-509, title IX, 9435(e), Oct. 21, 1986, 100 Stat. 2070; Pub. L.
99-514, title XVIII, 1895(c)(4), Oct. 22, 1986, 100 Stat. 2935; Pub.
L. 101-508, title IV, 4734, Nov. 5, 1990, 104 Stat. 1388-196,
provided that:
''(2)(A) Except as provided in subparagraph (B) and in paragraph (3),
the amendments made by paragraph (1) (amending this section) shall apply
to expenditures incurred for health insuring organizations which first
become operational on or after January 1, 1986. For purposes of this
paragraph, a health insuring organization is not considered to be
operational until the date on which it first enrolls patients.
''(B) In the case of a health insuring organization --
''(i) which first becomes operational on or after January 1, 1986,
but
''(ii) for which the Secretary of Health and Human Services has
waived, under section 1915(b) of the Social Security Act (section
1396n(b) of this title) and before such date, certain requirements of
section 1902 of such Act (section 1396a of this title),
clauses (ii) and (vi) of section 1903(m)(2)(A) of such Act (subsec.
(m)(2)(A)(ii) and (vi) of this section) shall not apply during the
period for which such waiver is effective.
''(C) In the case of the Hartford Health Network, Inc., clauses (ii)
and (vi) of section 1903(m)(2)(A) of the Social Security Act shall not
apply during the period for which a waiver by the Secretary of Health
and Human Services, under section 1915(b) of such Act, of certain
requirements of section 1902 of such Act is in effect (pursuant to a
request for a waiver under section 1915(b) of such Act submitted before
January 1, 1986).
''(D) Nothing in section 1903(m)(1)(A) of the Social Security Act
shall be construed as requiring a health-insuring organization to be
organized under the health maintenance organization laws of a State.
''(3)(A) Subject to subparagraph (C), in the case of up to 3 health
insuring organizations which are described in subparagraph (B), which
first become operational on or after January 1, 1986, and which are
designated by the Governor, and approved by the Legislature, of
California, the amendments made by paragraph (1) shall not apply.
''(B) A health insuring organization described in this subparagraph
is one that --
''(i) is operated directly by a public entity established by a county
government in the State of California under a State enabling statute;
''(ii) enrolls all medicaid beneficiaries residing in the county in
which it operates;
''(iii) meets the requirements for health maintenance organizations
under the Knox-Keene Act (Cal. Health and Safety Code, section 1340 et
seq.) and the Waxman-Duffy Act (Cal. Welfare and Institutions Code,
section 14450 et seq.);
''(iv) assures a reasonable choice of providers, which includes
providers that have historically served medicaid beneficiaries and which
does not impose any restriction which substantially impairs access to
covered services of adequate quality where medically necessary;
''(v) provides for a payment adjustment for a disproportionate share
hospital (as defined under State law consistent with section 1923 of the
Social Security Act (section 1396r-4 of this title)) in a manner
consistent with the requirements of such section; and
''(vi) provides for payment, in the case of childrens' hospital
services provided to medicaid beneficiaries who are under 21 years of
age, who are children with special health care needs under title V of
the Social Security Act (subchapter V of this chapter), and who are
receiving care coordination services under such title, at rates
determined by the California Medical Assistance Commission.
''(C) Subparagraph (A) shall not apply with respect to any period for
which the Secretary of Health and Human Services determines that the
number of medicaid beneficiaries enrolled with health insuring
organizations described in subparagraph (B) exceeds 10 percent of the
number of such beneficiaries in the State of California.
''(D) In this paragraph, the term 'medicaid beneficiary' means an
individual who is entitled to medical assistance under the State plan
under title XIX of the Social Security Act (this subchapter), other than
a qualified medicare beneficiary who is only entitled to such assistance
because of section 1902(a)(10)(E) of such title (section 1396a(a)(10)(E)
of this title).''
Section 9518(b) of Pub. L. 99-272 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply to payment
under section 1903(a) of the Social Security Act (subsec. (a) of this
section) for calendar quarters beginning on or after October 1, 1982.''
Amendment by Pub. L. 98-617 effective as if originally included in
the Deficit Reduction Act of 1984, Pub. L. 98-369, see section 3(c) of
Pub. L. 98-617, set out as a note under section 1395f of this title.
Amendment by section 2303(g)(2) of Pub. L. 98-369 applicable to
payments for calendar quarters beginning on or after Oct. 1, 1984, but
not applicable to clinical diagnostic laboratory tests furnished to
inpatients of a provider operating under a waiver granted pursuant to
section 602(k) of Pub. L. 98-21, set out as a note under section 1395y
of this title, see section 2303(j)(2) and (3) of Pub. L. 98-369, set
out as a note under section 1395l of this title.
Section 2363(c) of Pub. L. 98-369 provided that: ''The amendments
made by subsection (a) (amending this section and section 1396a of this
title) apply to calendar quarters beginning on or after the date of the
enactment of this Act (July 18, 1984), except that, in the case of
individuals admitted to skilled nursing facilities before such date, the
amendments made by such subsection shall not require recertifications
sooner or more frequently than were required under the law in effect
before such date.''
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.
Section 133(b) of Pub. L. 97-248 provided that: ''The amendment
made by subsection (a) (amending this section) shall become effective on
the date of the enactment of this Act (Sept. 3, 1982).''
Amendment by section 137(a)(1), (2) of Pub. L. 97-248 effective as
if originally included in the provision of the Omnibus Budget
Reconciliation Act of 1981, Pub. L. 97-35, to which such amendment
relates, see section 137(d)(1) of Pub. L. 97-248, set out as a note
under section 1396a of this title.
Amendment by section 137(b)(11)-(16), (27) of Pub. L. 97-248
effective as if originally included as part of this section as this
section was amended by the Omnibus Budget Reconciliation Act of 1981,
Pub. L. 97-35, see section 137(d)(2) of Pub. L. 97-248, set out as a
note under section 1396a of this title.
Section 137(g) of Pub. L. 97-248 provided that the amendment made by
that section is effective Oct. 1, 1982.
Amendment by section 146(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.
Amendment by section 2101(a)(2) of Pub. L. 97-35 applicable only to
services furnished by a hospital during any accounting year beginning on
or after Oct. 1, 1981, see section 2101(c) of Pub. L. 97-35, set out
as an Effective Date note under section 1395uu of this title.
Section 2103(b)(2) of Pub. L. 97-35 provided that: ''The amendment
made by paragraph (1) (amending this section) shall apply to amounts
expended on or after October 1, 1981.''
Amendment by section 2113(n) of Pub. L. 97-35 applicable to
agreements with Professional Standards Review Organizations entered into
on or after Oct. 1, 1981, see section 2113(o) of Pub. L. 97-35, set
out as a note under section 1396a of this title.
Section 2161(c)(1) of Pub. L. 97-35, as amended by Pub. L. 97-248,
title I, 137(a)(2), Sept. 3, 1982, 96 Stat. 376, provided that the
amendment made by such section 2161(c)(1) is effective for calendar
quarters beginning on or after Oct. 1, 1984.
Section 2161(c)(2) of Pub. L. 97-35, as amended by Pub. L. 97-248,
title I, 137(a)(2), Sept. 3, 1982, 96 Stat. 376, provided that the
amendment made by such section 2161(c)(2) is effective after payments
for the first quarter of fiscal year 1985.
Section 2164(b) of Pub. L. 97-35 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply to tests
occurring on or after October 1, 1981.''
Amendment by section 2174(b) of Pub. L. 97-35 applicable to services
furnished on or after Oct. 1, 1981, see section 2174(c) of Pub. L.
97-35, set out as a note under section 1396a of this title.
Amendment by section 2178(a) of Pub. L. 97-35 applicable with
respect to services furnished, under a State plan approved under this
subchapter, on or before Oct. 1, 1981, except that such amendments not
applicable with respect to services furnished by a health maintenance
organization under a contract with a State entered into under this
subchapter before Oct. 1, 1981, unless the organization requests that
such amendments apply and the Secretary and the State agency agree to
such request, see section 2178(c) of Pub. L. 97-35, set out as a note
under section 1396a of this title.
Section 2183(b) of Pub. L. 97-35 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply to payments
made to States for calendar quarters beginning on or after October 1,
1981.''
Section 961(b) of Pub. L. 96-499 provided that: ''The amendment
made by subsection (a) (amending this section) shall be effective with
respect to expenditures for services furnished on or after October 1,
1980.''
Amendment by section 3(c)(2) of Pub. L. 95-142 effective Jan. 1,
1978, see section 3(e) of Pub. L. 95-142, set out as an Effective Date
note under section 1320a-3 of this title.
Amendment by section 8(c) of Pub. L. 95-142 effective with respect
to contracts, agreements, etc., made on and after the first day of the
fourth month beginning after Oct. 25, 1977, see section 8(e) of Pub.
L. 95-142, set out as an Effective Date note under section 1320a-5 of
this title.
Section 10(b) of Pub. L. 95-142 provided that: ''The amendment made
by subsection (a) (amending this section) shall apply with respect to
calendar quarters beginning after the date of the enactment of this Act
(Oct. 25, 1977).''
Section 11(c) of Pub. L. 95-142 provided that: ''The amendment made
by subsection (a) (amending this section) shall apply with respect to
medical assistance provided, under a State plan approved under title XIX
of the Social Security Act (this subchapter), on and after January 1,
1978.''
Section 17(e)(1) of Pub. L. 95-142 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply with respect
to calendar quarters beginning after September 30, 1977.''
Section 20(c) of Pub. L. 95-142, as amended by Pub. L. 95-292,
8(e), June 13, 1978, 92 Stat. 316, provided that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (amending this section and section 1396a of this title)
shall be effective on October 1, 1977, and the Secretary of Health,
Education, and Welfare shall promptly adjust payments made to States
under section 1903 of the Social Security Act (this section) to reflect
the changes made by such amendments.
''(2) The amount of any reduction in the Federal medical assistance
percentage of a State, otherwise required to be imposed under section
1903(g)(1) of the Social Security Act (subsec. (g)(1) of this section)
because of an unsatisfactory or invalid showing made by the State with
respect to a calendar quarter beginning on or after January 1, 1977,
shall be determined under such section as amended by this section.
Subparagraph (B) of paragraph (4) of section 1903(g) of such Act
(subsec. (g)(4)(B) of this section), as added by this section, shall
apply to any showing made by a State under such section with respect to
a calendar quarter beginning on or after January 1, 1977.''
Section 105(a)(3) of Pub. L. 95-83 provided that: ''The amendments
made by paragraphs (1) and (2) (amending this section) shall apply with
respect to payments under title XIX of the Social Security Act (this
subchapter) to States for services provided --
''(A) after October 8, 1976, under contracts under such title (this
subchapter) entered into or renegotiated after such date, or
''(B) after the expiration of the one-year period beginning on such
date,
whichever occurs first.''
Amendment by Pub. L. 94-552 effective Jan. 1, 1976, see section 2
of Pub. L. 94-552, set out as a note under section 1396a of this title.
Section 202(b) of Pub. L. 94-460 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply with respect
to payments under title XIX of the Social Security Act (this subchapter)
to States for services provided --
''(1) after the date of enactment of subsection (a) (Oct. 8, 1976)
under contracts under such title entered into or renegotiated after such
date, or
''(2) after the expiration of the 1-year period beginning on such
date of enactment,
whichever occurs first.''
Section 110(b) of Pub. L. 94-182 provided that: ''The amendment
made by subsection (a) (amending this section) shall take effect on the
first day of the first calendar month which begins not less than 90 days
after the date of enactment of this Act (Dec. 31, 1975).''
Amendment by section 111(b) of Pub. L. 94-182 effective January 1,
1976, except as otherwise provided therein, see section 111(c) of Pub.
L. 94-182, set out as a note under section 1396a of this title.
Amendment by section 13(a)(11), (12) of Pub. L. 93-233 effective
with respect to payments under this section for calendar quarters
commencing after Dec. 31, 1973, see section 13(d) of Pub. L. 93-233,
set out as a note under section 1396a of this title.
Amendment by section 18(u) of Pub. L. 93-233 effective July 1, 1973,
see section 18(z-3)(4) of Pub. L. 93-233, set out as a note under
section 1396a of this title.
Section 234(b) of Pub. L. 93-66 provided that: ''The amendment made
by subsection (a) (amending this section) shall be applicable in the
case of expenditures for skilled nursing services and for intermediate
care facility services furnished in calendar quarters which begin after
December 31, 1972.''
Section 207(b) of Pub. L. 92-603 provided that: ''The amendments
made by subsection (a) (amending this section) shall, except as
otherwise provided therein, be effective July 1, 1973.''
Amendment by section 226(e) of Pub. L. 92-603 effective with respect
to services provided on or after July 1, 1973, see section 226(f) of
Pub. L. 92-603, set out as an Effective Date note under section 1395mm
of this title.
Amendment by section 233(c) of Pub. L. 92-603 applicable with
respect to services furnished by hospitals in accounting periods
beginning after Dec. 31, 1972, see section 233(f) of Pub. L. 92-603,
set out as a note under section 1395f of this title. See, also, section
16 of Pub. L. 93-233, set out as an Effective Date note under section
1395f of this title.
Section 235(b) of Pub. L. 92-603 provided that: ''The amendments
made by subsection (a) (amending this section) shall apply with respect
to expenditures under State plans approved under title XIX of the Social
Security Act (this subchapter), made after June 30, 1971.''
Section 237(d)(1) of Pub. L. 92-603 provided that: ''The amendments
made by subsections (a)(1) and (b) (amending this section and section
706 of this title) shall apply with respect to services furnished in
calendar quarters beginning after June 30, 1973.''
Section 249B of Pub. L. 92-603, as amended by Pub. L. 93-368, 8,
Aug. 7, 1974, 88 Stat. 422; Pub. L. 95-83, title III, 309(b), Aug.
1, 1977, 91 Stat. 396, provided that the amendment made by that section
is effective for period beginning Oct. 1, 1972, and ending Sept. 30,
1980.
Section 220(b) of Pub. L. 90-248 provided that:
''(b)(1) In the case of any State whose plan under title XIX of the
Social Security Act (this subchapter) is approved by the Secretary of
Health, Education, and Welfare under section 1902 (section 1396a of this
title) after July 25, 1967, the amendment made by subsection (a)
(amending this section) shall apply with respect to calendar quarters
beginning after the date of enactment of this Act (Jan. 2, 1968).
''(2) In the case of any State whose plan under title XIX of the
Social Security Act (this subchapter) was approved by the Secretary of
Health, Education, and Welfare under section 1902 of the Social Security
Act (section 1396a of this title) prior to July 26, 1967, amendments
made by subsection (a) (amending this section) shall apply with respect
to calendar quarters beginning after June 30, 1968, except that --
''(A) with respect to the third and fourth calendar quarters of 1968,
such subsection shall be applied by substituting in subsection (f) of
section 1903 of the Social Security Act (subsec. (f) of this section)
150 percent for 133 1/2 percent each time such latter figure appears in
such subsection (f), and
''(B) with respect to all calendar quarters during 1969, such
subsection shall be applied by substituting in subsection (f) of section
1903 of such Act (subsec. (f) of this section) 140 percent for 133 1/2
percent each time such latter figure appears in such subsection (f).''
Section 222(d) of Pub. L. 90-248, as amended by section 303(a)(2) of
Pub. L. 90-364, provided that the amendment made by such section 222(d)
is effective with respect to calendar quarters beginning after December
31, 1969.
Section 225(b) of Pub. L. 90-248 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply with respect
to expenditures made after December 31, 1967.''
Section 303(b) of Pub. L. 90-364 provided that: ''The amendments
made by subsection (a) (amending this section) shall be effective with
respect to calendar quarters beginning after December 31, 1967.''
Section 5 of Pub. L. 102-234 provided that:
''(a) In General. -- Subject to subsection (b), the Secretary of
Health and Human Services shall issue such regulations (on an interim
final or other basis) as may be necessary to implement this Act (see
Short Title of 1991 Amendment note set out under section 1305 of this
title) and the amendments made by this Act.
''(b) Regulations Changing Treatment of Intergovernmental Transfers.
-- The Secretary may not issue any interim final regulation that changes
the treatment (specified in section 433.45(a) of title 42, Code of
Federal Regulations) of public funds as a source of State share of
financial participation under title XIX of the Social Security Act (this
subchapter), except as may be necessary to permit the Secretary to deny
Federal financial participation for public funds described in section
1903(w)(6)(A) of such Act (subsection (w)(6)(A) of this section) (as
added by section 2(a) of this Act) that are derived from donations or
taxes that would not otherwise be recognized as the non-Federal share
under section 1903(w) of such Act.
''(c) Consultation With States. -- The Secretary shall consult with
the States before issuing any regulations under this Act.''
Section 2(c)(2) of Pub. L. 102-234 provided that: ''Except as
specifically provided in section 1903(w) of the Social Security Act
(subsec. (w) of this section) and notwithstanding any other provision of
such Act (this chapter), the Secretary of Health and Human Services
shall not, with respect to expenditures prior to the effective date
specified in section 1903(w)(1)(F) of such Act, disallow any claim
submitted by a State for, or otherwise withhold Federal financial
participation with respect to, amounts expended for medical assistance
under title XIX of the Social Security Act (this subchapter) by reason
of the fact that the source of the funds used to constitute the
non-Federal share of such expenditures is a tax imposed on, or a
donation received from, a health care provider, or on the ground that
the amount of any donation or tax proceeds must be credited against the
amount of the expenditure.''
Section 4401(b)(2) of Pub. L. 101-508 provided that: ''The per
centum to be applied under section 1903(a)(7) of the Social Security Act
(subsec. (a)(7) of this section) for amounts expended during calendar
quarters in fiscal year 1991 which are attributable to administrative
activities necessary to carry out section 1927 (other than subsection
(g)) of such Act (section 1396r-8 of this title) shall be 75 percent,
rather than 50 percent; after fiscal year 1991, the match shall revert
back to 50 percent.''
Rate Transition Rules
Section 4607 of Pub. L. 101-508 provided that:
''(a) Report. -- The Secretary of Health and Human Services shall
report to Congress, by not later than July 1, 1991, on error rates by
States in determining eligibility of individuals described in
subparagraph (A) or (B) of section 1902(l)(1) of the Social Security Act
(section 1396a(l)(1) of this title) for medical assistance under plans
approved under title XIX of such Act (this subchapter). Such report may
include data for medical assistance provided before July 1, 1989.
''(b) Error Rate Transition. -- There shall not be taken into
account, for purposes of section 1903(u) of the Social Security Act
(subsec. (u) of this section), payments and expenditures for medical
assistance which --
''(1) are attributable to medical assistance for individuals
described in subparagraph (A) or (B) of section 1902(l)(1) of such Act,
and
''(2) are made on or after July 1, 1989, and before the first
calendar quarter that begins more than 12 months after the date of
submission of the report under subsection (a).''
Medically Needy Income Levels for Certain
1-Member Families
Section 4718 of Pub. L. 101-508 provided that:
''(a) In General. -- For purposes of section 1903(f)(1)(B) (probably
means subsec. (f)(1)(B) of this section), for payments made before, on,
or after the date of the enactment of this Act (Nov. 5, 1990), a State
described in subparagraph (B) may use, in determining the 'highest
amount which would ordinarily be paid to a family of the same size'
(under the State's plan approved under part A of title IV of such Act
(probably means part A of subchapter IV of this chapter)) in the case of
a family consisting only of one individual and without regard to whether
or not such plan provides for aid to families consisting only of one
individual, an amount reasonably related to the highest money payment
which would ordinarily be made under such a plan to a family of two
without income or resources.
''(b) States Covered. -- Subsection (a) shall only apply to a State
the State plan of which (under title XIX of the Social Security Act
(this subchapter)) as of June 1, 1989, provided for the policy described
in such paragraph. For purposes of the previous sentence, a State plan
includes all the matter included in a State plan under section
2373(c)(5) of the Deficit Reduction Act of 1984 (Pub. L. 98-369, set
out as a note under section 1396a of this title) (as amended by section
9 of the Medicare and Medicaid Patient and Program Protection Act of
1987 (Pub. L. 100-93)).''
Section 6411(g) of Pub. L. 101-239 provided that:
''(1) Prohibition of disallowance pending issuance of regulations.
-- Except as specifically permitted under paragraph (3), the Secretary
of Health and Human Services may not --
''(A) withhold, suspend, disallow, or deny Federal financial
participation under section 1903(a) of the Social Security Act (subsec.
(a) of this section) for day habilitation and related services under
paragraph (9) or (13) of section 1905(a) of such Act (section
1396d(a)(9), (13) of this title) on behalf of persons with mental
retardation or with related conditions pursuant to a provision of its
State plan as approved on or before June 30, 1989, or
''(B) withdraw Federal approval of any such State plan provision.
''(2) Requirements for regulation. -- A final regulation described in
this paragraph is a regulation, promulgated after a notice of proposed
rule-making and a period of at least 60 days for public comment, that --
''(A) specifies the types of day habilitation and related services
that a State may cover under paragraph (9) or (13) of section 1905(a) of
the Social Security Act on behalf of persons with mental retardation or
with related conditions, and
''(B) any requirements respecting such coverage.
''(3) Prospective application of regulation. -- If the Secretary
promulgates a final regulation described in paragraph (2) and the
Secretary determines that a State plan under title XIX of the Social
Security Act (this subchapter) does not comply with such regulation, the
Secretary shall notify the State of the determination and its basis, and
such determination shall not apply to day habilitation and related
services furnished before the first day of the first calendar quarter
beginning after the date of the notice to the State.''
of Costs Before October 1, 1990
Section 6901(b)(5)(B) of Pub. L. 101-239 provided that: ''In making
payments under section 1903(a)(2)(B) of the Social Security Act (subsec.
(a)(2)(B) of this section) for amounts expended for nurse aide training
and competency evaluation programs, and competency evaluation programs,
described in section 1919(e)(1) of such Act (section 1396r(e)(1) of this
title), in the case of activities conducted before October 1, 1990, the
Secretary of Health and Human Services shall not take into account, or
allocate amounts on the basis of, the proportion of residents of nursing
facilities that is entitled to benefits under title XVIII or XIX of such
Act (this subchapter and subchapter XVIII of this chapter).''
Section 6901(d)(2) of Pub. L. 101-239 provided that: ''During the
period before October 1, 1990, the Federal percentage matching payment
rate under section 1903(a) of the Social Security Act (subsec. (a) of
this section) for so much of the sums expended under a State plan under
title XIX of such Act (this subchapter) as are attributable to
compensation or training of personnel responsible for inspecting public
or private skilled nursing or intermediate care facilities to
individuals receiving medical assistance to determine compliance with
health or safety standards shall be 75 percent.''
Section 608(h) of Pub. L. 100-485 provided that: ''There shall not
be taken into account, for purposes of section 1903(u) of the Social
Security Act (subsec. (u) of this section), payments and expenditures
for medical assistance which are made on or after January 1, 1989, and
before July 1, 1989, and which are attributable to medicare-cost (sic)
sharing for qualified medicare beneficiaries (as defined in section
1905(p) of such Act (section 1396d(p) of this title)).''
Section 4117 of Pub. L. 100-203 provided that: ''The Secretary of
Health and Human Services shall not, prior to July 1, 1988, implement
any reductions in payments to States pursuant to section 1903(u) of the
Social Security Act (subsec. (u) of this section) (or any provision of
law described in subsection (c) of section 133 of the Tax Equity and
Fiscal Responsibility Act of 1982 (section 133(c) of Pub. L. 97-248, set
out below)).''
Section 4118(n) of Pub. L. 100-203 provided that: ''For purposes of
section 1903(u)(1)(E)(ii) of the Social Security Act (subsec.
(u)(1)(E)(ii) of this section), effective for the period beginning on
the date of enactment of this Act (Dec. 22, 1987) and ending December
31, 1988, a 'technical error' is an error in eligibility condition (such
as assignment of social security numbers and assignment of rights to
third-party benefits as a condition of eligibility) that, if corrected,
would not result in a difference in the amount of medical assistance
paid.''
Section 4211(d)(2) of Pub. L. 100-203, as amended by Pub. L.
100-360, title IV, 411(l)(3)(F), July 1, 1988, 102 Stat. 803, provided
that: ''For the 8 calendar quarters (beginning with the calendar
quarter that begins on July 1, 1988), with respect to payment under
section 1903(a)(2)(B) of the Social Security Act (subsec. (a)(2)(B) of
this section) to a State for additional amounts expended by the State
under its plan approved under title XIX of such Act (this subchapter)
for nursing aide training and competency evaluation programs, and
competency evaluation programs, described in section 1919(e)(1) of such
title (section 1396r(e)(1) of this title), any reference to '50 percent'
is deemed a reference to the sum of the Federal medical assistance
percentage (determined under section 1905(b) of such Act (section
1396d(b) of this title)) plus 25 percentage points, but not to exceed 90
percent.''
Section 4212(c)(3) of Pub. L. 100-203 provided that: ''For purposes
of section 1903(a) of the Social Security Act (subsec. (a) of this
section), proper expenses incurred by a State for medical review by
independent professionals of the care provided to residents of nursing
facilities who are entitled to medical assistance under title XIX of
such Act (this subchapter) shall be reimbursable as expenses necessary
for the proper and efficient administration of the State plan under that
title.''
Secretary of Health and Human Services to promulgate final
regulations necessary to carry out subsec. (r)(6)(j) of this section
within 6 months after Apr. 7, 1986, see section 9503(c) of Pub. L.
99-272, set out as a note under section 1396a of this title.
Section 133(c) of Pub. L. 97-248 provided that: ''No provision of
law limiting Federal financial participation with respect to erroneous
payments made by States under a State plan approved under title XIX of
the Social Security Act (this subchapter) (including any provision
contained in, or incorporated by reference into, any appropriation Act
or resolution making continuing appropriations), other than the
limitations contained in section 1903 of such Act (this section), shall
be effective with respect to payments to States under such section 1903
for quarters beginning on or after October 1, 1982, unless such
provision of law is enacted after the date of the date of the enactment
of this Act (Sept. 3, 1982) and expressly provides that such limitation
is in addition to or in lieu of the limitations contained in section
1903 of the Social Security Act.''
Payments to States in Computation of Target Amount of
Federal Medicaid Expenditures
Pub. L. 97-92, 102, 118, Dec. 15, 1981, 95 Stat. 1193, 1197, as
amended by Pub. L. 97-161, Mar. 31, 1982, 96 Stat. 22, provided, for
the period Dec. 15, 1981, to not later than Sept. 30, 1982, that:
''Notwithstanding section 1903(s) of the Social Security Act (subsec.
(s) of this section), all medicaid payments to the States for Indian
health service facilities as defined by section 1911 of the Social
Security Act (section 1396j of this title) shall be paid entirely by
Federal funds, and notwithstanding section 1903(t) of the Social
Security Act (subsec. (t) of this section), all medicaid payments to the
States for Indian health service facilities shall not be included in the
computation of the target amount of Federal medicaid expenditures.''
Section 17(e)(2) of Pub. L. 95-142 required Secretary of Health,
Education, and Welfare to establish regulations, not later than 90 days
after Oct. 25, 1977, to carry out amendments made by section 17
(amending sections 1395b-1 and 1396b of this title). See section 1302
of this title.
Section 6 of Pub. L. 95-59, June 30, 1977, 91 Stat. 255, provided
that: ''Notwithstanding the provisions of subsection (g) of section
1903 of the Social Security Act (subsec. (g) of this section), the
amount payable to any State for the calendar quarters during the period
commencing April 1, 1977, and ending September 30, 1977, on account of
expenditures made under a State plan approved under title XIX of such
Act (this subchapter), shall not be decreased by reason of the
application of the provisions of such subsection with respect to any
period for which such State plan was in operation prior to April 1,
1977.''
Period Prior to July 1, 1971; Regulations; Advice to
States
Section 2(b) of Pub. L. 91-56, which provided that subsection (e) of
this section was inapplicable to the period prior to July 1, 1971, and
which authorized the Secretary to issue regulations, was repealed by
Pub. L. 92-603, title II, 230, Oct. 30, 1972, 86 Stat. 1410.
Section 248(d) of Pub. L. 90-248 provided that: ''The amendment
made by section 220(a) of this Act (amending this section) shall not
apply in the case of Puerto Rico, the Virgin Islands, or Guam.''
Institutional Care
Section 121(b) of Pub. L. 89-97, as amended by section 249D of Pub.
L. 92-603, provided that: ''No payment may be made to any State under
title I, IV, X, XIV, or XVI of the Social Security Act (subchapter I,
IV, X, XIV, or XVI of this chapter) with respect to aid or assistance in
the form of medical or any other type of remedial care for any period
for which such State receives payments under title XIX of such Act (this
subchapter), or for any period after December 31, 1969. After the date
of enactment of the Social Security Amendments of 1972 (Oct. 30, 1972),
Federal matching shall not be available for any portion of any payment
by any State under title I, X, XIV, or XVI, or part A of title IV, of
the Social Security Act (subchapter I, X, XIV, or XVI, or part A of
subchapter IV of this chapter) for or on account of any medical or any
other type of remedial care provided by an institution to any individual
as an inpatient thereof, in the case of any State which has a plan
approved under title XIX of such Act (this subchapter), if such care is
(or could be) provided under a State plan approved under title XIX of
such Act (this subchapter) by an institution certified under such title
XIX (this subchapter).''
/1/ So in original.
/2/ So in original. Probably should end with ''; or''.
/3/ So in original. There is no par. (13).
/4/ So in original. The comma probably should be a semicolon.
/5/ So in original. Probably should be followed by a comma.
/6/ So in original.
/7/ So in original. The comma probably should be a semicolon.
/8/ So in original. Probably should be ''purposes''.
42 USC 1396c. Operation of State plans
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
If the Secretary, 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 1396a of this title; or
(2) that in the administration of the plan there is a failure to
comply substantially with any such provision;
the Secretary shall notify such State agency that further payments
will not be made to the State (or, in his discretion, that payments will
be limited to categories under or parts of the State plan not affected
by such failure), until the Secretary is satisfied that there will no
longer be any such failure to comply. Until he is so satisfied he 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 XIX, 1904, as added July 30, 1965,
Pub. L. 89-97, title I, 121(a), 79 Stat. 351.)
42 USC 1396d. Definitions
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
For purposes of this subchapter --
(a) Medical assistance
The term ''medical assistance'' means payment of part or all of the
cost of the following care and services (if provided in or after the
third month before the month in which the recipient makes application
for assistance or, in the case of medicare cost-sharing with respect to
a qualified medicare beneficiary described in subsection (p)(1) of this
section, if provided after the month in which the individual becomes
such a beneficiary) for individuals, and, with respect to physicians' or
dentists' services, at the option of the State, to individuals (other
than individuals with respect to whom there is being paid, or who are
eligible, or would be eligible if they were not in a medical
institution, to have paid with respect to them a State supplementary
payment and are eligible for medical assistance equal in amount,
duration, and scope to the medical assistance made available to
individuals described in section 1396a(a)(10)(A) of this title) not
receiving aid or assistance under any plan of the State approved under
subchapter I, X, XIV, or XVI of this chapter, or part A of subchapter IV
of this chapter, and with respect to whom supplemental security income
benefits are not being paid under subchapter XVI of this chapter, who
are --
(i) under the age of 21, or, at the option of the State, under the
age of 20, 19, or 18 as the State may choose,
(ii) relatives specified in section 606(b)(1) of this title with whom
a child is living if such child is (or would, if needy, be) a dependent
child under part A of subchapter IV of this chapter,
(iii) 65 years of age or older,
(iv) blind, with respect to States eligible to participate in the
State plan program established under subchapter XVI of this chapter,
(v) 18 years of age or older and permanently and totally disabled,
with respect to States eligible to participate in the State plan program
established under subchapter XVI of this chapter,
(vi) persons essential (as described in the second sentence of this
subsection) to individuals receiving aid or assistance under State plans
approved under subchapter I, X, XIV, or XVI of this chapter,
(vii) blind or disabled as defined in section 1382c of this title,
with respect to States not eligible to participate in the State plan
program established under subchapter XVI of this chapter,
(viii) pregnant women,
(ix) individuals provided extended benefits under section 1396r-6 of
this title, or
(x) individuals described in section 1396a(u)(1) of this title,
but whose income and resources are insufficient to meet all of such
cost --
(1) inpatient hospital services (other than services in an
institution for mental diseases);
(2)(A) outpatient hospital services, (B) consistent with State law
permitting such services, rural health clinic services (as defined in
subsection (l)(1) of this section) and any other ambulatory services
which are offered by a rural health clinic (as defined in subsection
(l)(1) of this section) and which are otherwise included in the plan,
and (C) Federally-qualified health center services (as defined in
subsection (l)(2) of this section) and any other ambulatory services
offered by a Federally-qualified health center and which are otherwise
included in the plan;
(3) other laboratory and X-ray services;
(4)(A) nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or
older; (B) early and periodic screening, diagnostic, and treatment
services (as defined in subsection (r) of this section) for individuals
who are eligible under the plan and are under the age of 21; and (C)
family planning services and supplies furnished (directly or under
arrangements with others) to individuals of child-bearing age (including
minors who can be considered to be sexually active) who are eligible
under the State plan and who desire such services and supplies;
(5)(A) physicians' services furnished by a physician (as defined in
section 1395x(r)(1) of this title), whether furnished in the office, the
patient's home, a hospital, or a nursing facility, or elsewhere, and (B)
medical and surgical services furnished by a dentist (described in
section 1395x(r)(2) of this title) to the extent such services may be
performed under State law either by a doctor of medicine or by a doctor
of dental surgery or dental medicine and would be described in clause
(A) if furnished by a physician (as defined in section 1395x(r)(1) of
this title);
(6) medical care, or any other type of remedial care recognized under
State law, furnished by licensed practitioners within the scope of their
practice as defined by State law;
(7) home health care services;
(8) private duty nursing services;
(9) clinic services furnished by or under the direction of a
physician, without regard to whether the clinic itself is administered
by a physician, including such services furnished outside the clinic by
clinic personnel to an eligible individual who does not reside in a
permanent dwelling or does not have a fixed home or mailing address;
(10) dental services;
(11) physical therapy and related services;
(12) prescribed drugs, dentures, and prosthetic devices; and
eyeglasses prescribed by a physician skilled in diseases of the eye or
by an optometrist, whichever the individual may select;
(13) other diagnostic, screening, preventive, and rehabilitative
services, including any medical or remedial services (provided in a
facility, a home, or other setting) recommended by a physician or other
licensed practitioner of the healing arts within the scope of their
practice under State law, for the maximum reduction of physical or
mental disability and restoration of an individual to the best possible
functional level;
(14) inpatient hospital services and nursing facility services for
individuals 65 years of age or over in an institution for mental
diseases;
(15) services in an intermediate care facility for the mentally
retarded (other than in an institution for mental diseases) for
individuals who are determined, in accordance with section
1396a(a)(31)(A) of this title, to be in need of such care;
(16) effective January 1, 1973, inpatient psychiatric hospital
services for individuals under age 21, as defined in subsection (h) of
this section;
(17) services furnished by a nurse-midwife (as defined in section
1395x(gg) of this title) which the nurse-midwife is legally authorized
to perform under State law (or the State regulatory mechanism provided
by State law), whether or not the nurse-midwife is under the supervision
of, or associated with, a physician or other health care provider;
(18) hospice care (as defined in subsection (o) of this section);
(19) case-management services (as defined in section 1396n(g)(2) of
this title);
(20) respiratory care services (as defined in section 1396a(e)(9)(C)
of this title);
(21) services furnished by a certified pediatric nurse practitioner
or certified family nurse practitioner (as defined by the Secretary)
which the certified pediatric nurse practitioner or certified family
nurse practitioner is legally authorized to perform under State law (or
the State regulatory mechanism provided by State law), whether or not
the certified pediatric nurse practitioner or certified family nurse
practitioner is under the supervision of, or associated with, a
physician or other health care provider; and /1/
(22) any other medical care, and any other type of remedial care
recognized under State law, specified by the Secretary;
(23) home and community care (to the extent allowed and as defined in
section 1396t of this title) for functionally disabled elderly
individuals; /1/
(24) community supported living arrangements services (to the extent
allowed and as defined in section 1396u of this title). /2/
except as otherwise provided in paragraph (16), such term does not
include --
(A) any such payments with respect to care or services for any
individual who is an inmate of a public institution (except as a patient
in a medical institution); or
(B) any such payments with respect to care or services for any
individual who has not attained 65 years of age and who is a patient in
an institution for mental diseases.
For purposes of clause (vi) of the preceding sentence, a person shall
be considered essential to another individual if such person is the
spouse of and is living with such individual, the needs of such person
are taken into account in determining the amount of aid or assistance
furnished to such individual (under a State plan approved under
subchapter I, X, XIV, or XVI of this chapter), and such person is
determined, under such a State plan, to be essential to the well-being
of such individual. The payment described in the first sentence may
include expenditures for medicare cost-sharing and for premiums under
part B of subchapter XVIII of this chapter for individuals who are
eligible for medical assistance under the plan and (A) are receiving aid
or assistance under any plan of the State approved under subchapter I,
X, XIV, or XVI of this chapter, or part A of subchapter IV of this
chapter, or with respect to whom supplemental security income benefits
are being paid under subchapter XVI of this chapter, or (B) with respect
to whom there is being paid a State supplementary payment and are
eligible for medical assistance equal in amount, duration, and scope to
the medical assistance made available to individuals described in
section 1396a(a)(10)(A) of this title, and, except in the case of
individuals 65 years of age or older and disabled individuals entitled
to health insurance benefits under subchapter XVIII of this chapter who
are not enrolled under part B of subchapter XVIII of this chapter, other
insurance premiums for medical or any other type of remedial care or the
cost thereof. No service (including counseling) shall be excluded from
the definition of ''medical assistance'' solely because it is provided
as a treatment service for alcoholism or drug dependency.
(b) Federal medical assistance percentage; State percentage; Indian
health care percentage
The term ''Federal medical assistance percentage'' for any State
shall be 100 per centum less the State percentage; and the State
percentage shall be that percentage which bears the same ratio to 45 per
centum as the square of the per capita income of such State bears to the
square of the per capita income of the continental United States
(including Alaska) and Hawaii; except that (1) the Federal medical
assistance percentage shall in no case be less than 50 per centum or
more than 83 per centum, and (2) the Federal medical assistance
percentage for Puerto Rico, the Virgin Islands, Guam, the Northern
Mariana Islands, and American Samoa shall be 50 per centum. The Federal
medical assistance percentage for any State shall be determined and
promulgated in accordance with the provisions of section 1301(a)(8)(B)
of this title. Notwithstanding the first sentence of this section, the
Federal medical assistance percentage shall be 100 per centum with
respect to amounts expended as medical assistance for services which are
received through an Indian Health Service facility whether operated by
the Indian Health Service or by an Indian tribe or tribal organization
(as defined in section 1603 of title 25).
(c) Nursing facility
For definition of the term ''nursing facility'', see section 1396r(a)
of this title.
(d) Intermediate care facility for mentally retarded
The term ''intermediate care facility for the mentally retarded''
means an institution (or distinct part thereof) for the mentally
retarded or persons with related conditions if --
(1) the primary purpose of such institution (or distinct part
thereof) is to provide health or rehabilitative services for mentally
retarded individuals and the institution meets such standards as may be
prescribed by the Secretary;
(2) the mentally retarded individual with respect to whom a request
for payment is made under a plan approved under this subchapter is
receiving active treatment under such a program; and
(3) in the case of a public institution, the State or political
subdivision responsible for the operation of such institution has agreed
that the non-Federal expenditures in any calendar quarter prior to
January 1, 1975, with respect to services furnished to patients in such
institution (or distinct part thereof) in the State will not, because of
payments made under this subchapter, be reduced below the average amount
expended for such services in such institution in the four quarters
immediately preceding the quarter in which the State in which such
institution is located elected to make such services available under its
plan approved under this subchapter.
(e) Physicians' services
In the case of any State the State plan of which (as approved under
this subchapter) --
(1) does not provide for the payment of services (other than services
covered under section 1396a(a)(12) of this title) provided by an
optometrist; but
(2) at a prior period did provide for the payment of services
referred to in paragraph (1);
the term ''physicians' services'' (as used in subsection (a)(5) of
this section) shall include services of the type which an optometrist is
legally authorized to perform where the State plan specifically provides
that the term ''physicians' services'', as employed in such plan,
includes services of the type which an optometrist is legally authorized
to perform, and shall be reimbursed whether furnished by a physician or
an optometrist.
(f) Nursing facility services
For purposes of this subchapter, the term ''nursing facility
services'' means services which are or were required to be given an
individual who needs or needed on a daily basis nursing care (provided
directly by or requiring the supervision of nursing personnel) or other
rehabilitation services which as a practical matter can only be provided
in a nursing facility on an inpatient basis.
(g) Chiropractors' services
If the State plan includes provision of chiropractors' services, such
services include only --
(1) services provided by a chiropractor (A) who is licensed as such
by the State and (B) who meets uniform minimum standards promulgated by
the Secretary under section 1395x(r)(5) of this title; and
(2) services which consist of treatment by means of manual
manipulation of the spine which the chiropractor is legally authorized
to perform by the State.
(h) Inpatient psychiatric hospital services for individuals under age
21
(1) For purposes of paragraph (16) of subsection (a) of this section,
the term ''inpatient psychiatric hospital services for individuals under
age 21'' includes only --
(A) inpatient services which are provided in an institution (or
distinct part thereof) which is a psychiatric hospital as defined in
section 1395x(f) of this title or in another inpatient setting that the
Secretary has specified in regulations;
(B) inpatient services which, in the case of any individual (i)
involve active treatment which meets such standards as may be prescribed
in regulations by the Secretary, and (ii) a team, consisting of
physicians and other personnel qualified to make determinations with
respect to mental health conditions and the treatment thereof, has
determined are necessary on an inpatient basis and can reasonably be
expected to improve the condition, by reason of which such services are
necessary, to the extent that eventually such services will no longer be
necessary; and
(C) inpatient services which, in the case of any individual, are
provided prior to (i) the date such individual attains age 21, or (ii)
in the case of an individual who was receiving such services in the
period immediately preceding the date on which he attained age 21, (I)
the date such individual no longer requires such services, or (II) if
earlier, the date such individual attains age 22;
(2) Such term does not include services provided during any calendar
quarter under the State plan of any State if the total amount of the
funds expended, during such quarter, by the State (and the political
subdivisions thereof) from non-Federal funds for inpatient services
included under paragraph (1), and for active psychiatric care and
treatment provided on an outpatient basis for eligible mentally ill
children, is less than the average quarterly amount of the funds
expended, during the 4-quarter period ending December 31, 1971, by the
State (and the political subdivisions thereof) from non-Federal funds
for such services.
(i) Institution for mental diseases
The term ''institution for mental diseases'' means a hospital,
nursing facility, or other institution of more than 16 beds, that is
primarily engaged in providing diagnosis, treatment, or care of persons
with mental diseases, including medical attention, nursing care, and
related services.
(j) State supplementary payment
The term ''State supplementary payment'' means any cash payment made
by a State on a regular basis to an individual who is receiving
supplemental security income benefits under subchapter XVI of this
chapter or who would but for his income be eligible to receive such
benefits, as assistance based on need in supplementation of such
benefits (as determined by the Secretary), but only to the extent that
such payments are made with respect to an individual with respect to
whom supplemental security income benefits are payable under subchapter
XVI of this chapter, or would but for his income be payable under that
subchapter.
(k) Supplemental security income benefits
Increased supplemental security income benefits payable pursuant to
section 211 of Public Law 93-66 shall not be considered supplemental
security income benefits payable under subchapter XVI of this chapter.
(l) Rural health clinics
(1) The terms ''rural health clinic services'' and ''rural health
clinic'' have the meanings given such terms in section 1395x(aa) of this
title, except that (A) clause (ii) of section 1395x(aa)(2) of this title
shall not apply to such terms, and (B) the physician arrangement
required under section 1395x(aa)(2)(B) of this title shall only apply
with respect to rural health clinic services and, with respect to other
ambulatory care services, the physician arrangement required shall be
only such as may be required under the State plan for those services.
(2)(A) The term ''Federally-qualified health center services'' means
services of the type described in subparagraphs (A) through (C) of
section 1395x(aa)(1) of this title when furnished to an individual as an
/3/ patient of a Federally-qualified health center and, for this
purpose, any reference to a rural health clinic or a physician described
in section 1395x(aa)(2)(B) of this title is deemed a reference to a
Federally-qualified health center or a physician at the center,
respectively.
(B) The term ''Federally-qualified health center'' means a /4/ entity
which --
(i) is receiving a grant under section 254b, 254c, or 256 of this
title, or /5/
(ii)(I) is receiving funding from such a grant under a contract with
the recipient of such a grant, and
(II) meets the requirements to receive a grant under section 254b,
254c, or 256 of this title; /6/
(iii) based on the recommendation of the Health Resources and
Services Administration within the Public Health Service, is determined
by the Secretary to meet the requirements for receiving such a grant,
and includes an outpatient health program or facility operated by a
tribe or tribal organization under the Indian Self-Determination Act
(Public Law 93-638) (25 U.S.C. 450f et seq.). In applying clause (ii),
/7/ the Secretary may waive any requirement referred to in such clause
for up to 2 years for good cause shown.
(m) Qualified family member
(1) Subject to paragraph (2), the term ''qualified family member''
means an individual (other than a qualified pregnant woman or child, as
defined in subsection (n) of this section) who is a member of a family
that would be receiving aid under the State plan under part A of
subchapter IV of this chapter pursuant to section 607 of this title if
the State had not exercised the option under section 607(b)(2)(B)(i) of
this title.
(2) No individual shall be a qualified family member for any period
after September 30, 1998.
(n) ''Qualified pregnant woman or child'' defined
The term ''qualified pregnant woman or child'' means --
(1) a pregnant woman who --
(A) would be eligible for aid to families with dependent children
under part A of subchapter IV of this chapter (or would be eligible for
such aid if coverage under the State plan under part A of subchapter IV
of this chapter included aid to families with dependent children of
unemployed parents pursuant to section 607 of this title) if her child
had been born and was living with her in the month such aid would be
paid, and such pregnancy has been medically verified;
(B) is a member of a family which would be eligible for aid under the
State plan under part A of subchapter IV of this chapter pursuant to
section 607 of this title if the plan required the payment of aid
pursuant to such section; or
(C) otherwise meets the income and resources requirements of a State
plan under part A of subchapter IV of this chapter; and
(2) a child who has not attained the age of 19, who was born after
September 30, 1983 (or such earlier date as the State may designate),
and who meets the income and resources requirements of the State plan
under part A of subchapter IV of this chapter.
(o) Optional hospice benefits
(1)(A) Subject to subparagraph (B), the term ''hospice care'' means
the care described in section 1395x(dd)(1) of this title furnished by a
hospice program (as defined in section 1395x(dd)(2) of this title) to a
terminally ill individual who has voluntarily elected (in accordance
with paragraph (2)) to have payment made for hospice care instead of
having payment made for certain benefits described in section
1395d(d)(2)(A) of this title and for which payment may otherwise be made
under subchapter XVIII of this chapter and intermediate care facility
services under the plan. For purposes of such election, hospice care
may be provided to an individual while such individual is a resident of
a skilled nursing facility or intermediate care facility, but the only
payment made under the State plan shall be for the hospice care.
(B) For purposes of this subchapter, with respect to the definition
of hospice program under section 1395x(dd)(2) of this title, the
Secretary may allow an agency or organization to make the assurance
under subparagraph (A)(iii) of such section without taking into account
any individual who is afflicted with acquired immune deficiency syndrome
(AIDS).
(2) An individual's voluntary election under this subsection --
(A) shall be made in accordance with procedures that are established
by the State and that are consistent with the procedures established
under section 1395d(d)(2) of this title;
(B) shall be for such a period or periods (which need not be the same
periods described in section 1395d(d)(1) of this title) as the State may
establish; and
(C) may be revoked at any time without a showing of cause and may be
modified so as to change the hospice program with respect to which a
previous election was made.
(3) In the case of an individual --
(A) who is residing in a nursing facility or intermediate care
facility for the mentally retarded and is receiving medical assistance
for services in such facility under the plan,
(B) who is entitled to benefits under part A of subchapter XVIII of
this chapter and has elected, under section 1395d(d) of this title, to
receive hospice care under such part, and
(C) with respect to whom the hospice program under such subchapter
and the nursing facility or intermediate care facility for the mentally
retarded have entered into a written agreement under which the program
takes full responsibility for the professional management of the
individual's hospice care and the facility agrees to provide room and
board to the individual,
instead of any payment otherwise made under the plan with respect to
the facility's services, the State shall provide for payment to the
hospice program of an amount equal to the additional amount described in
section 1396a(a)(13)(D) of this title and, if the individual is an
individual described in section 1396a(a)(10)(A) of this title, shall
provide for payment of any coinsurance amounts imposed under section
1395e(a)(4) of this title.
(p) Qualified medicare beneficiary; medicare cost-sharing
(1) The term ''qualified medicare beneficiary'' means an individual
--
(A) who is entitled to hospital insurance benefits under part A of
subchapter XVIII of this chapter (including an individual entitled to
such benefits pursuant to an enrollment under section 1395i-2 of this
title, but not including an individual entitled to such benefits only
pursuant to an enrollment under section 1395i-2a of this title),
(B) whose income (as determined under section 1382a of this title for
purposes of the supplemental security income program, except as provided
in paragraph (2)(D)) does not exceed an income level established by the
State consistent with paragraph (2), and
(C) whose resources (as determined under section 1382b of this title
for purposes of the supplemental security income program) do not exceed
twice the maximum amount of resources that an individual may have and
obtain benefits under that program.
(2)(A) The income level established under paragraph (1)(B) shall be
at least the percent provided under subparagraph (B) (but not more than
100 percent) of the official poverty line (as defined by the Office of
Management and Budget, and revised annually in accordance with section
9902(2) of this title) applicable to a family of the size involved.
(B) Except as provided in subparagraph (C), the percent provided
under this clause, with respect to eligibility for medical assistance on
or after --
(i) January 1, 1989, is 85 percent,
(ii) January 1, 1990, is 90 percent, and
(iii) January 1, 1991, is 100 percent.
(C) In the case of a State which has elected treatment under section
1396a(f) of this title and which, as of January 1, 1987, used an income
standard for individuals age 65 or older which was more restrictive than
the income standard established under the supplemental security income
program under subchapter XVI of this chapter, the percent provided under
subparagraph (B), with respect to eligibility for medical assistance on
or after --
(i) January 1, 1989, is 80 percent,
(ii) January 1, 1990, is 85 percent,
(iii) January 1, 1991, is 95 percent, and
(iv) January 1, 1992, is 100 percent.
(D)(i) In determining under this subsection the income of an
individual who is entitled to monthly insurance benefits under
subchapter II of this chapter for a transition month (as defined in
clause (ii)) in a year, such income shall not include any amounts
attributable to an increase in the level of monthly insurance benefits
payable under such subchapter which have occurred pursuant to section
415(i) of this title for benefits payable for months beginning with
December of the previous year.
(ii) For purposes of clause (i), the term ''transition month'' means
each month in a year through the month following the month in which the
annual revision of the official poverty line, referred to in
subparagraph (A), is published.
(3) The term ''medicare cost-sharing'' means the following costs
incurred with respect to a qualified medicare beneficiary, without
regard to whether the costs incurred were for items and services for
which medical assistance is otherwise available under the plan:
(A)(i) premiums under section 1395i-2 or 1395i-2a of this title, and
(ii) premiums under section 1395r of this title, /8/
(B) Coinsurance under subchapter XVIII of this chapter (including
coinsurance described in section 1395e of this title).
(C) Deductibles established under subchapter XVIII of this chapter
(including those described in section 1395e of this title and section
1395l(b) of this title).
(D) The difference between the amount that is paid under section
1395l(a) of this title and the amount that would be paid under such
section if any reference to ''80 percent'' therein were deemed a
reference to ''100 percent''.
Such term also may include, at the option of a State, premiums for
enrollment of a qualified medicare beneficiary with an eligible
organization under section 1395mm of this title.
(4) Notwithstanding any other provision of this subchapter, in the
case of a State (other than the 50 States and the District of Columbia)
--
(A) the requirement stated in section 1396a(a)(10)(E) of this title
shall be optional, and
(B) for purposes of paragraph (2), the State may substitute for the
percent provided under subparagraph (B) /9/ or /10/ 1396a(a)(10)(E)(iii)
of this title of such paragraph /9/ any percent.
In the case of any State which is providing medical assistance to its
residents under a waiver granted under section 1315 of this title, the
Secretary shall require the State to meet the requirement of section
1396a(a)(10)(E) of this title in the same manner as the State would be
required to meet such requirement if the State had in effect a plan
approved under this subchapter.
(q) Qualified severely impaired individual
The term ''qualified severely impaired individual'' means an
individual under age 65 --
(1) who for the month preceding the first month to which this
subsection applies to such individual --
(A) received (i) a payment of supplemental security income benefits
under section 1382(b) of this title on the basis of blindness or
disability, (ii) a supplementary payment under section 1382e of this
title or under section 212 of Public Law 93-66 on such basis, (iii) a
payment of monthly benefits under section 1382h(a) of this title, or
(iv) a supplementary payment under section 1382e(c)(3), and
(B) was eligible for medical assistance under the State plan approved
under this subchapter; and
(2) with respect to whom the Secretary determines that --
(A) the individual continues to be blind or continues to have the
disabling physical or mental impairment on the basis of which he was
found to be under a disability and, except for his earnings, continues
to meet all non-disability-related requirements for eligibility for
benefits under subchapter XVI of this chapter,
(B) the income of such individual would not, except for his earnings,
be equal to or in excess of the amount which would cause him to be
ineligible for payments under section 1382(b) of this title (if he were
otherwise eligible for such payments),
(C) the lack of eligibility for benefits under this subchapter would
seriously inhibit his ability to continue or obtain employment, and
(D) the individual's earnings are not sufficient to allow him to
provide for himself a reasonable equivalent of the benefits under
subchapter XVI of this chapter (including any federally administered
State supplementary payments), this subchapter, and publicly funded
attendant care services (including personal care assistance) that would
be available to him in the absence of such earnings.
In the case of an individual who is eligible for medical assistance
pursuant to section 1382h(b) of this title in June, 1987, the individual
shall be a qualified severely impaired individual for so long as such
individual meets the requirements of paragraph (2).
(r) Early and periodic screening, diagnostic, and treatment services
The term ''early and periodic screening, diagnostic, and treatment
services'' means the following items and services:
(1) Screening services --
(A) which are provided --
(i) at intervals which meet reasonable standards of medical and
dental practice, as determined by the State after consultation with
recognized medical and dental organizations involved in child health
care, and
(ii) at such other intervals, indicated as medically necessary, to
determine the existence of certain physical or mental illnesses or
conditions; and
(B) which shall at a minimum include --
(i) a comprehensive health and developmental history (including
assessment of both physical and mental health development),
(ii) a comprehensive unclothed physical exam,
(iii) appropriate immunizations according to age and health history,
(iv) laboratory tests (including lead blood level assessment
appropriate for age and risk factors), and
(v) health education (including anticipatory guidance).
(2) Vision services --
(A) which are provided --
(i) at intervals which meet reasonable standards of medical practice,
as determined by the State after consultation with recognized medical
organizations involved in child health care, and
(ii) at such other intervals, indicated as medically necessary, to
determine the existence of a suspected illness or condition; and
(B) which shall at a minimum include diagnosis and treatment for
defects in vision, including eyeglasses.
(3) Dental services --
(A) which are provided --
(i) at intervals which meet reasonable standards of dental practice,
as determined by the State after consultation with recognized dental
organizations involved in child health care, and
(ii) at such other intervals, indicated as medically necessary, to
determine the existence of a suspected illness or condition; and
(B) which shall at a minimum include relief of pain and infections,
restoration of teeth, and maintenance of dental health.
(4) Hearing services --
(A) which are provided --
(i) at intervals which meet reasonable standards of medical practice,
as determined by the State after consultation with recognized medical
organizations involved in child health care, and
(ii) at such other intervals, indicated as medically necessary, to
determine the existence of a suspected illness or condition; and
(B) which shall at a minimum include diagnosis and treatment for
defects in hearing, including hearing aids.
(5) Such other necessary health care, diagnostic services, treatment,
and other measures described in subsection (a) of this section to
correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services, whether or not such
services are covered under the State plan.
Nothing in this subchapter shall be construed as limiting providers
of early and periodic screening, diagnostic, and treatment services to
providers who are qualified to provide all of the items and services
described in the previous sentence or as preventing a provider that is
qualified under the plan to furnish one or more (but not all) of such
items or services from being qualified to provide such items and
services as part of early and periodic screening, diagnostic, and
treatment services. The Secretary shall, not later than July 1, 1990,
and every 12 months thereafter, develop and set annual participation
goals for each State for participation of individuals who are covered
under the State plan under this subchapter in early and periodic
screening, diagnostic, and treatment services.
(s) Qualified disabled and working individual
The term ''qualified disabled and working individual'' means an
individual --
(1) who is entitled to enroll for hospital insurance benefits under
part A of subchapter XVIII of this chapter under section 1395i-2a of
this title;
(2) whose income (as determined under section 1382a of this title for
purposes of the supplemental security income program) does not exceed
200 percent of the official poverty line (as defined by the Office of
Management and Budget and revised annually in accordance with section
9902(2) of this title) applicable to a family of the size involved;
(3) whose resources (as determined under section 1382b of this title
for purposes of the supplemental security income program) do not exceed
twice the maximum amount of resources that an individual or a couple (in
the case of an individual with a spouse) may have and obtain benefits
for supplemental security income benefits under subchapter XVI of this
chapter; and
(4) who is not otherwise eligible for medical assistance under this
subchapter.
(Aug. 14, 1935, ch. 531, title XIX, 1905, as added July 30, 1965,
Pub. L. 89-97, title I, 121(a), 79 Stat. 351, and amended Jan. 2, 1968,
Pub. L. 90-248, title II, 230, 233, 241(f)(6), 248(e), title III,
302(a), 81 Stat. 905, 917, 919, 929; Dec. 28, 1971, Pub. L. 92-223,
4(a), 85 Stat. 809; Oct. 30, 1972, Pub. L. 92-603, title II, 212(a),
247(b), 275(a), 278(a)(21)-(23), 280, 297(a), 299, 299B, 299E(b), 299L,
86 Stat. 1384, 1425, 1452-1454, 1459-1462, 1464; Dec. 31, 1973, Pub.
L. 93-233, 13(a)(13)-(88), 18(w), (x)(7)-(10), (y)(2), 87 Stat. 963,
964, 972, 973; Sept. 30, 1976, Pub. L. 94-437, title IV, 402(e), 90
Stat. 1410; Dec. 13, 1977, Pub. L. 95-210, 2(a), (b), 91 Stat. 1488;
June 13, 1978, Pub. L. 95-292, 8(a), (b), 92 Stat. 316; Oct. 19, 1980,
Pub. L. 96-473, 6(k), 94 Stat. 2266; Dec. 5, 1980, Pub. L. 96-499,
title IX, 965(a), 94 Stat. 2651; Aug. 13, 1981, Pub. L. 97-35, title
XXI, 2162(a)(2), 2172(b), 95 Stat. 806, 808; Sept. 3, 1982, Pub. L.
97-248, title I, 136(c), 137(b)(17), (18), (f), 96 Stat. 376, 379,
381; July 18, 1984, Pub. L. 98-369, div. B, title III, 2335(f),
2340(b), 2361(b), 2371(a), 2373(b)(15)-(20), 98 Stat. 1091, 1093, 1104,
1110, 1112; Apr. 7, 1986, Pub. L. 99-272, title IX, 9501(a), 9505(a),
9511(a), 100 Stat. 201, 208, 212; Oct. 21, 1986, Pub. L. 99-509, title
IX, 9403(b), (d), (g)(3), 9404(b), 9408(c)(1), 9435(b)(2), 100 Stat.
2053, 2054, 2056, 2061, 2070; Oct. 22, 1986, Pub. L. 99-514, title
XVIII, 1895(c)(3)(A), 100 Stat. 2935; Dec. 22, 1987, Pub. L. 100-203,
title IV, 4073(d), 4101(c)(1), 4103(a), 4105(a), 4114, 4118(p)(8),
4211(e), (f), (h)(6), 101 Stat. 1330-119, 1330-141, 1330-146, 1330-147,
1330-152, 1330-159, 1330-204 to 1330-206; July 1, 1988, Pub. L.
100-360, title III, 301(a)(2)-(d), (g)(2), title IV, 411(h)(4)(E),
(k)(4), (8), (14)(A), 102 Stat. 748-750, 787, 791, 794, 798; Oct. 13,
1988, Pub. L. 100-485, title III, 303(b)(2), title IV, 401(d)(2),
title VI, 608(d)(14)(A)-(G), (J), (f)(3), 102 Stat. 2392, 2396, 2415,
2416, 2424; Nov. 10, 1988, Pub. L. 100-647, title VIII, 8434(a),
(b)(3), (4), 102 Stat. 3805; Dec. 13, 1989, Pub. L. 101-234, title II,
201(b), 103 Stat. 1981; Dec. 19, 1989, Pub. L. 101-239, title VI,
6402(c)(1), 6403(a), (c), (d)(2), 6404(a), (b), 6405(a), 6408(d)(2),
(4)(A), (B), 103 Stat. 2261-2265, 2268, 2269; Nov. 5, 1990, Pub. L.
101-508, title IV, 4402(d)(2), 4501(a), (c), (e)(1), 4601(a)(2),
4704(c), (d), (e)(1), 4705(a), 4711(a), 4712(a), 4713(b), 4717, 4719(a),
4721(a), 4722, 4755(a)(1)(A), 104 Stat. 1388-163 to 1388-166, 1388-172,
1388-174, 1388-187, 1388-191, 1388-193, 1388-194, 1388-209.)
Pub. L. 101-508, title IV, 4721, Nov. 5, 1990, 104 Stat. 1388-194,
provided that, effective with respect to personal care services provided
on or after Oct. 1, 1994, subsection (a)(7) of this section is amended
by striking ''services'' and inserting ''services including personal
care services (A) prescribed by a physician for an individual in
accordance with a plan of treatment, (B) provided by an individual who
is qualified to provide such services and who is not a member of the
individual's family, (C) supervised by a registered nurse, and (D)
furnished in a home or other location; but not including such services
furnished to an inpatient or resident of a nursing facility''.
Part A of subchapter IV of this chapter, referred to in subsecs.
(a), (m)(1), and (n), is classified to section 601 et seq. of this
title.
Parts A and B of subchapter XVIII of this chapter, referred to in
subsecs. (a), (o)(3)(B), (p)(1)(A), and (s)(1), are classified to
sections 1395c et seq. and 1395j et seq., respectively, of this title.
Section 211 of Pub. L. 93-66, referred to in subsec. (k), is
section 211 of Pub. L. 93-66, July 9, 1973, 87 Stat. 152, as amended,
which is set out as a note under section 1382 of this title.
The Indian Self-Determination Act, referred to in subsec. (l)(2)(B),
is title I of Pub. L. 93-638, Jan. 4, 1975, 88 Stat. 2206, as
amended, which is classified principally to subchapter II ( 450f et
seq.) of chapter 14 of Title 25, Indians. For complete classification
of this Act to the Code, see Short Title note set out under section 450
of Title 25 and Tables.
Clause (ii), referred to in subsec. (l)(2)(B), was redesignated as
cl. (iii) by Pub. L. 101-508, title IV, 4704(c)(3), Nov. 5, 1990,
104 Stat. 1388-172.
Section 212 of Public Law 93-66, referred to in subsec. (q)(1)(A),
is section 212 of Pub. L. 93-66, title II, July 9, 1973, 87 Stat. 155,
as amended, which is set out as a note under section 1382 of this title.
1990 -- Subsec. (a). Pub. L. 101-508, 4722, inserted at end ''No
service (including counseling) shall be excluded from the definition of
'medical assistance' solely because it is provided as a treatment
service for alcoholism or drug dependency.''
Pub. L. 101-508, 4402(d)(2), inserted at end ''The payment described
in the first sentence may include expenditures for medicare cost-sharing
and for premiums under part B of subchapter XVIII of this chapter for
individuals who are eligible for medical assistance under the plan and
(A) are receiving aid or assistance under any plan of the State approved
under subchapter I, X, XIV, or XVI of this chapter, or part A of
subchapter IV of this chapter, or with respect to whom supplemental
security income benefits are being paid under subchapter XVI of this
chapter, or (B) with respect to whom there is being paid a State
supplementary payment and are eligible for medical assistance equal in
amount, duration, and scope to the medical assistance made available to
individuals described in section 1396a(a)(10)(A) of this title, and,
except in the case of individuals 65 years of age or older and disabled
individuals entitled to health insurance benefits under subchapter XVIII
of this chapter who are not enrolled under part B of subchapter XVIII of
this chapter, other insurance premiums for medical or any other type of
remedial care or the cost thereof.''
Subsec. (a)(x). Pub. L. 101-508, 4713(b), added cl. (x).
Subsec. (a)(2)(C). Pub. L. 101-508, 4704(e)(1), repealed Pub. L.
101-239, 6402(c)(1). See 1989 Amendment note below.
Subsec. (a)(13). Pub. L. 101-508, 4719(a), inserted before semicolon
at end '', including any medical or remedial services (provided in a
facility, a home, or other setting) recommended by a physician or other
licensed practitioner of the healing arts within the scope of their
practice under State law, for the maximum reduction of physical or
mental disability and restoration of an individual to the best possible
functional level''.
Subsec. (a)(22). Pub. L. 101-508, 4711(a)(1), which directed
amendment of par. (22) by striking ''and'' at end, could not be
executed because the word did not appear.
Subsec. (a)(23). Pub. L. 101-508, 4712(a)(1), inserted ''and'' after
semicolon at end.
Pub. L. 101-508, 4711(a)(2), (3), which directed amendment of
subsec. (a) by redesignating par. (23) as (24) and adding a new par.
(23), was executed by adding the new par. (23), there being no former
par. (23).
Subsec. (a)(24). Pub. L. 101-508, 4712(a)(2), (3), which directed
amendment of subsec. (a) by redesignating par. (24) as (25) and adding
a new par. (24), was executed by adding the new par. (24), there being
no former par. (24).
Subsec. (h)(1)(A). Pub. L. 101-508, 4755(a)(1)(A), inserted ''or in
another inpatient setting that the Secretary has specified in
regulations'' after ''section 1395x(f) of this title''.
Subsec. (l)(2)(A). Pub. L. 101-508, 4704(c)(1), substituted
''patient'' for ''outpatient''.
Subsec. (l)(2)(B). Pub. L. 101-508, 4704(d)(2), which directed
amendment of subpar. (B) by inserting ''and includes an outpatient
health program or facility operated by a tribe or tribal organization
under the Indian Self-Determination Act (Public Law 93-638).'' after and
below cl. (ii), was executed by inserting the new language after cl.
(iii) to reflect the probable intent of Congress and the intervening
redesignation of former cl. (ii) as (iii) by Pub. L. 101-508,
4704(c)(3). See below.
Pub. L. 101-508, 4704(c)(2), substituted ''entity'' for ''facility''
in introductory provisions.
Subsec. (l)(2)(B)(ii), (iii). Pub. L. 101-508, 4704(c)(3), (d)(1),
added cl. (ii), redesignated former cl. (ii) as (iii), and substituted
comma for period at end of cl. (iii).
Subsec. (n)(2). Pub. L. 101-508, 4601(a)(2), substituted ''age of
19'' for ''age of 7 (or any age designated by the State that exceeds 7
but does not exceed 8)''.
Subsec. (o)(1)(A). Pub. L. 101-508, 4717, inserted ''and for which
payment may otherwise be made under subchapter XVIII of this chapter''
after ''section 1395d(d)(2)(A) of this title''.
Subsec. (o)(3). Pub. L. 101-508, 4705(a)(1), struck out ''a State
which elects not to provide medical assistance for hospice care, but
provides medical assistance for skilled nursing or intermediate care
facility services with respect to'' after ''In the case of'' in
introductory provisions.
Pub. L. 101-508, 4705(a)(3), (4), in concluding provisions,
substituted ''the additional amount described in section 1396a(a)(13)(D)
of this title'' for ''the amounts allocated under the plan for room and
board in the facility, in accordance with the rates established under
section 1396a(a)(13) of this title,'' and struck out at end ''For
purposes of this paragraph and section 1396a(a)(13)(D) of this title,
the term 'room and board' includes performance of personal care
services, including assistance in activities of daily living, in
socializing activities, administration of medication, maintaining the
cleanliness of a resident's room, and supervising and assisting in the
use of durable medical equipment and prescribed therapies.''
Subsec. (o)(3)(A), (C). Pub. L. 101-508, 4705(a)(2), substituted
''nursing facility or intermediate care facility for the mentally
retarded'' for ''skilled nursing or intermediate care facility''.
Subsec. (p)(1)(B). Pub. L. 101-508, 4501(e)(1)(A), which directed
amendment of subpar. (B) by inserting '', except as provided in
paragraph (2)(D)'' after ''supplementary social security income
program'', was executed by inserting the new language after
''supplemental security income program'' to reflect the probable intent
of Congress.
Subsec. (p)(2)(B). Pub. L. 101-508, 4501(a)(1), inserted ''and'' at
end of cl. (ii), substituted ''100 percent.'' for ''95 percent, and''
in cl. (iii), and struck out cl. (iv) which read as follows:
''January 1, 1992, is 100 percent.''
Subsec. (p)(2)(C). Pub. L. 101-508, 4501(a)(2), substituted ''95
percent, and'' for ''90 percent,'' in cl. (iii) and ''100 percent.''
for ''95 percent, and'' in cl. (iv) and struck out cl. (v) which read
as follows: ''January 1, 1993, is 100 percent.''
Subsec. (p)(2)(D). Pub. L. 101-508, 4501(e)(1)(B), added subpar.
(D).
Subsec. (p)(4). Pub. L. 101-508, 4501(c)(2), inserted at end ''In
the case of any State which is providing medical assistance to its
residents under a waiver granted under section 1315 of this title, the
Secretary shall require the State to meet the requirement of section
1396a(a)(10)(E) of this title in the same manner as the State would be
required to meet such requirement if the State had in effect a plan
approved under this subchapter.''
Subsec. (p)(4)(B). Pub. L. 101-508, 4501(c)(1), inserted ''or
1396a(a)(10)(E)(iii) of this title'' after ''subparagraph (B)''.
1989 -- Subsec. (a)(2)(B). Pub. L. 101-239, 6404(a)(2), substituted
''subsection (l)(1)'' for ''subsection (l)'' in two places.
Subsec. (a)(2)(C). Pub. L. 101-239, 6404(a)(3), added cl. (C)
relating to Federally-qualified health center services.
Pub. L. 101-239, 6402(c)(1), which directed addition of cl. (C)
relating to ambulatory services, was repealed by Pub. L. 101-508,
4704(e)(1).
Subsec. (a)(4)(B). Pub. L. 101-239, 6403(d)(2), amended cl. (B)
generally. Prior to amendment, cl. (B) read as follows: ''effective
July 1, 1969, such early and periodic screening and diagnosis of
individuals who are eligible under the plan and are under the age of 21
to ascertain their physical or mental defects, and such health care,
treatment, and other measures to correct or ameliorate defects and
chronic conditions discovered thereby, as may be provided in regulations
of the Secretary; and''.
Subsec. (a)(21), (22). Pub. L. 101-239, 6405(a), added par. (21)
and redesignated former par. (21) as (22).
Subsec. (l). Pub. L. 101-239, 6404(b), designated existing
provisions as par. (1), redesignated former cls. (1) and (2) as (A)
and (B), respectively, and added par. (2).
Subsec. (p)(1)(A). Pub. L. 101-239, 6408(d)(4)(B), inserted '', but
not including an individual entitled to such benefits only pursuant to
an enrollment under section 1395i-2a of this title'' after ''section
1395i-2 of this title''.
Subsec. (p)(3)(A). Pub. L. 101-239, 6408(d)(4)(A)(i), amended
subpar. (A) generally. Prior to amendment, subpar. (A) read as
follows: ''Premiums under subchapter XVIII of this chapter (including
under part B and, if applicable, under section 1395i-2 of this title).''
Subsec. (p)(3)(A)(i). Pub. L. 101-239, 6408(d)(4)(A)(ii),
substituted ''section 1395i-2 or 1395i-2a'' for ''section 1395i-2''.
Subsec. (p)(3)(C). Pub. L. 101-234, 201(b)(1), substituted
''Deductibles'' for ''Subject to paragraph (4), deductibles'' and
''section 1395e of this title and section 1395l(b) of this title)'' for
''section 1395e of this title, section 1395l(b) of this title, and
section 1395m(c)(1) of this title''.
Subsec. (p)(4), (5). Pub. L. 101-234, 201(b)(2), redesignated par.
(5) as (4) and struck out former par. (4) which read as follows: ''In
a State which provides medical assistance for prescribed drugs under
subsection (a)(12) of this section, instead of providing to qualified
medicare beneficiaries, under paragraph (3)(C), medicare cost-sharing
with respect to the annual deductible for covered outpatient drugs under
section 1395m(c)(1) of this title, the State may provide to such
beneficiaries, before charges for covered outpatient drugs for a year
reach such deductible amount, benefits for prescribed drugs in the same
amount, duration, and scope as the benefits made available under the
State plan for individuals described in section 1396a(a)(10)(A)(i) of
this title.''
Subsec. (r). Pub. L. 101-239, 6403(c), inserted at end ''The
Secretary shall, not later than July 1, 1990, and every 12 months
thereafter, develop and set annual participation goals for each State
for participation of individuals who are covered under the State plan
under this subchapter in early and periodic screening, diagnostic, and
treatment services.''
Pub. L. 101-239, 6403(a), added subsec. (r).
Subsec. (s). Pub. L. 101-239, 6408(d)(2), added subsec. (s).
1988 -- Subsec. (a). Pub. L. 100-647, 8434(b)(3), substituted ''in
the case of medicare cost-sharing with respect to a qualified medicare
beneficiary'' for ''in the case of a qualified medicare beneficiary'' in
introductory provisions.
Subsec. (a)(ix). Pub. L. 100-485, 303(b)(2), added cl. (ix).
Subsec. (a)(5)(B). Pub. L. 100-360, 411(k)(4), substituted
''described in clause (A) if'' for ''described in subparagraph (A) if''.
Subsec. (a)(17). Pub. L. 100-360, 411(h)(4)(E), amended Pub. L.
100-203, 4073(d)(1), see 1987 Amendment note below.
Subsec. (i). Pub. L. 100-360, 411(k)(14)(A), added subsec. (i).
Subsec. (m). Pub. L. 100-485, 401(d)(2), added subsec. (m).
Subsec. (o)(1). Pub. L. 100-360, 411(k)(8)(A), made clarifying
amendment to directory language of Pub. L. 100-203, 4114, see 1987
Amendment note below.
Subsec. (o)(1)(B). Pub. L. 100-360, 411(k)(8)(B), struck out
''only'' after ''For purposes of this subchapter'' and substituted
''immune deficiency syndrome (AIDS)'' for ''immunodeficiency syndrome''.
Subsec. (o)(3). Pub. L. 100-485, 608(f)(3), realigned the margin of
par. (3).
Subsec. (p)(1). Pub. L. 100-647, 8434(a), redesignated subpars. (C)
and (D) as (B) and (C), respectively, and struck out former subpar. (B)
which read: ''who, but for section 1396a(a)(10)(E) of this title, is
not eligible for medical assistance under the plan,''.
Subsec. (p)(1)(B). Pub. L. 100-360, 301(a)(2), struck out ''and the
election of the State'' after ''1396a(a)(10)(E) of this title''.
Subsec. (p)(1)(C). Pub. L. 100-360, 301(c)(1), as amended by Pub.
L. 100-485, 608(d)(14)(E)(i), substituted ''paragraph (2)'' for
''paragraph (2)(A)''.
Subsec. (p)(1)(D). Pub. L. 100-360, 301(c)(2), as amended by Pub.
L. 100-485, 608(d)(14)(E)(ii), substituted ''twice'' for ''(except as
provided in paragraph (2)(B))''.
Subsec. (p)(2)(A). Pub. L. 100-647, 8434(b)(4), substituted
''paragraph (1)(B)'' for ''paragraph (1)(C)''.
Pub. L. 100-360, 301(b)(1), as amended by Pub. L. 100-485,
608(d)(14)(A), substituted ''shall be at least the percent provided
under subparagraph (B) (but not more than 100 percent)'' for ''may not
exceed a percentage (not more than 100 percent)''.
Pub. L. 100-360, 301(c)(3)(A), which directed amendment of subpar.
(A) by striking ''(2)(A)'' and inserting ''(2)'', was repealed by Pub.
L. 100-485, 608(d)(14)(E)(iii).
Pub. L. 100-360, 301(b)(2), which directed amendment of subpar. (A)
by inserting ''(i)'' after ''(2)(A)'', was repealed by Pub. L.
100-485, 608(d)(14)(B).
Subsec. (p)(2)(B). Pub. L. 100-360, 301(b)(2), formerly 301(b)(3),
as renumbered and amended by Pub. L. 100-485, 608(d)(14)(B)-(D)(ii),
added subpar. (B) and struck out former subpar. (B) which read as
follows: ''In the case of a State that provides medical assistance to
individuals not described in section 1396a(a)(10)(A) of this title and
at the State's option, the State may use under paragraph (1)(D) such
resource level (which is higher than the level described in that
paragraph) as may be applicable with respect to individuals described in
paragraph (1)(A) who are not described in section 1396a(a)(10)(A) of
this title.''
Pub. L. 100-360, 301(c)(3)(B), which directed amendment of par. (2)
by striking subpar. (B), was repealed by Pub. L. 100-485,
608(d)(14)(E)(iii).
Subsec. (p)(2)(C). Pub. L. 100-360, 301(b)(2), formerly 301(b)(3),
as renumbered and amended by Pub. L. 100-485, 608(d)(14)(B), (C),
(D)(i), (iii), added subpar. (C).
Subsec. (p)(3). Pub. L. 100-360, 301(d)(1), as added by Pub. L.
100-485, 608(d)(14)(G)(ii), inserted ''without regard to whether the
costs incurred were for items and services for which medical assistance
is otherwise available under the plan'' after ''qualified medicare
beneficiary'' in introductory provisions.
Subsec. (p)(3)(A). Pub. L. 100-360, 301(d)(2), formerly 301(d)(1),
as renumbered by Pub. L. 100-485, 608(d)(14)(G)(i), substituted
''under subchapter XVIII of this chapter (including under part B and, if
applicable, under section 1395i-2 of this title)'' for ''under part B
and (if applicable) under section 1395i-2 of this title''.
Subsec. (p)(3)(B). Pub. L. 100-360, 301(d)(3), formerly 301(d)(2),
as renumbered by Pub. L. 100-485, 608(d)(14)(G)(i), amended subpar.
(B) generally. Prior to amendment, subpar. (B) read as follows:
''Deductibles and coinsurance described in section 1395e of this
title.''
Subsec. (p)(3)(C). Pub. L. 100-360, 301(d)(3), formerly 301(d)(2),
as renumbered and amended by Pub. L. 100-485, 608(d)(14)(F), (G)(i),
amended subpar. (C) generally. Prior to amendment, subpar. (C) read
as follows: ''The annual deductible described in section 1395l(b) of
this title.''
Subsec. (p)(4). Pub. L. 100-360, 301(d)(4), formerly 301(d)(3), as
renumbered by Pub. L. 100-485, 618(d)(14)(G)(i), added par. (4).
Subsec. (p)(5). Pub. L. 100-360, 301(g)(2), as amended by Pub. L.
100-485, 608(d)(14)(J), added par. (5).
1987 -- Subsec. (a)(4)(A). Pub. L. 100-203, 4211(f), struck out
''skilled'' before ''nursing''.
Subsec. (a)(5). Pub. L. 100-203, 4211(h)(6)(A), struck out
''skilled'' before ''nursing'' in cl. (A).
Pub. L. 100-203, 4103(a), designated existing provisions as cl. (A)
and added cl. (B).
Subsec. (a)(9). Pub. L. 100-203, 4105(a), inserted provision
including services furnished to an eligible individual who does not
reside in a permanent dwelling or have a fixed home or mailing address.
Subsec. (a)(14). Pub. L. 100-203, 4211(h)(6)(B), substituted ''and
nursing facility services'' for '', skilled nursing facility services,
and intermediate care facility services''.
Subsec. (a)(15). Pub. L. 100-203, 4211(h)(6)(C), substituted
''services in an intermediate care facility for the mentally retarded
(other than'' for ''intermediate care facility services (other than such
services''.
Subsec. (a)(17). Pub. L. 100-203, 4073(d)(1), as amended by Pub. L.
100-360, 411(h)(4)(E), substituted ''(as defined in section 1395x(gg)
of this title)'' for ''(as defined in subsection (m) of this section)''.
Subsec. (c). Pub. L. 100-203, 4211(e)(1), amended subsec. (c)
generally. Prior to amendment, subsec. (c) defined ''intermediate care
facility''.
Subsec. (d). Pub. L. 100-203, 4211(e)(2), substituted ''intermediate
care facility for the mentally retarded'' for ''intermediate care
facility'' and ''means an'' for ''may include services in a public'',
and in par. (3) inserted ''in the case of a public institution'' after
''(3)''.
Subsec. (f). Pub. L. 100-203, 4211(e)(3), struck out ''skilled''
before ''nursing'' in four places and before ''rehabilitation''.
Subsec. (i). Pub. L. 100-203, 4211(e)(4), struck out subsec. (i)
which provided that for purposes of this subchapter ''skilled nursing
facility'' also includes any institution which is located in a State on
an Indian reservation and is certified by the Secretary as being a
qualified skilled nursing facility by meeting the requirements of
section 1395x(j) of this title.
Subsec. (m). Pub. L. 100-203, 4073(d)(2), struck out subsec. (m)
which defined ''nurse-midwife''. See section 1395x(gg) of this title.
Subsec. (n)(2). Pub. L. 100-203, 4101(c)(1), substituted ''has not
attained the age of 7 (or any age designated by the State that exceeds 7
but does not exceed 8)'' for ''is under 5 years of age''.
Subsec. (o)(1). Pub. L. 100-203, 4114, as amended by Pub. L.
100-360, 411(k)(8)(A), designated existing provisions as subpar. (A),
substituted ''Subject to subparagraph (B), the'' for ''The'', and added
subpar. (B).
Subsec. (p)(2)(A). Pub. L. 100-203, 4118(p)(8), struck out
''nonfarm'' before ''official''.
1986 -- Subsec. (a). Pub. L. 99-509, 9403(g)(3), inserted ''or, in
the case of a qualified medicare beneficiary described in subsection
(p)(1) of this section, if provided after the month in which the
individual becomes such a beneficiary'' after ''makes application for
assistance''.
Subsec. (a)(18). Pub. L. 99-272, 9505(a)(1), added par. (18).
Former par. (18) redesignated (19).
Subsec. (a)(19). Pub. L. 99-514, 1895(c)(3)(A), added par. (19).
Former par. (19) redesignated (20).
Pub. L. 99-272, 9505(a)(1)(B), redesignated former par. (18) as
(19).
Subsec. (a)(20). Pub. L. 99-509, 9408(c)(1), added par. (20).
Former par. (20) redesignated (21).
Pub. L. 99-514, 1895(c)(3)(A)(ii), redesignated former par. (19) as
(20).
Subsec. (a)(21). Pub. L. 99-509, 9408(c)(1)(B), redesignated former
par. (20) as (21).
Subsec. (n)(1)(C). Pub. L. 99-272, 9501(a), added subpar. (C).
Subsec. (n)(2). Pub. L. 99-272, 9511(a), inserted ''(or such earlier
date as the State may designate)'' after ''September 30, 1983''.
Subsec. (o). Pub. L. 99-272, 9505(a)(2), added subsec. (o).
Subsec. (o)(3). Pub. L. 99-509, 9435(b)(2), added par. (3).
Subsec. (p). Pub. L. 99-509, 9403(b), (d), added subsec. (p).
Subsec. (q). Pub. L. 99-509, 9404(b), added subsec. (q).
1984 -- Subsec. (a). Pub. L. 98-369, 2335(f), substituted ''mental
diseases'' for ''tuberculosis or mental diseases'' in subd. (B)
following par. (18).
Pub. L. 98-369, 2373(b)(17), substituted ''clause (vi)'' for
''clauses (vi)'' and ''well-being'' for ''well being'' in last sentence.
Subsec. (a)(1). Pub. L. 98-369, 2335(f), substituted ''mental
diseases'' for ''tuberculosis or mental diseases''.
Subsec. (a)(4). Pub. L. 98-369, 2335(f), substituted ''mental
diseases'' for ''tuberculosis or mental diseases''.
Pub. L. 98-369, 2373(b)(15), inserted a semicolon before ''(B)''.
Subsec. (a)(9). Pub. L. 98-369, 2371(a), amended par. (9)
generally, inserting ''furnished by or under the direction of a
physician, without regard to whether the clinic itself is administered
by a physician''.
Subsec. (a)(14), (15). Pub. L. 98-369, 2335(f), substituted
''mental diseases'' for ''tuberculosis or mental diseases''.
Subsec. (a)(17). Pub. L. 98-369, 2373(b)(16), substituted ''the
nurse-midwife'' for ''he'' in two places.
Subsec. (b). Pub. L. 98-369, 2373(b)(18), substituted ''section
1301(a)(8)(B) of this title'' for ''subparagraph (B) of section
1301(a)(8) of this title''.
Subsec. (d)(1). Pub. L. 98-369, 2373(b)(19), substituted ''the
institution meets'' for ''which meet''.
Subsec. (h)(1)(A). Pub. L. 98-369, 2340(b), amended subpar. (A)
generally. Prior to amendment, subpar. (A) read as follows:
''inpatient services which are provided in an institution which is
accredited as a psychiatric hospital by the Joint Commission on
Accreditation of Hospitals;''.
Subsec. (m). Pub. L. 98-369, 2373(b)(20), substituted ''the nurse''
for ''he'' in two places.
Subsec. (n). Pub. L. 98-369, 2361(b), added subsec. (n).
1982 -- Subsec. (a)(i). Pub. L. 97-248, 137(b)(17), struck out ''or
any reasonable category of such individuals,'' after ''as the State may
choose,''.
Subsec. (a)(viii). Pub. L. 97-248, 137(b)(18), added cl. (viii).
Subsec. (b)(2). Pub. L. 97-248, 136(c), substituted ''the Northern
Mariana Islands, and American Samoa'' for ''and the Northern Mariana
Islands''.
Subsec. (h)(1)(C). Pub. L. 97-248, 137(f), redesignated cls. (i)
and (ii) as subcls. (I) and (II), respectively, and redesignated cls.
(A) and (B) as cls. (i) and (ii), respectively.
1981 -- Subsec. (a). Pub. L. 97-35, 2172(b), in cl. (i), inserted
''or, at the option of the State, under the age of 20, 19, or 18 as the
State may choose, or any reasonable category of such individuals,'' and
in cl. (ii), struck out reference to section 606(a)(2) of this title.
Subsec. (b). Pub. L. 97-35, 2162(a)(2), inserted reference to
Northern Mariana Islands.
1980 -- Subsec. (a)(17), (18). Pub. L. 96-499, 965(a)(1)(B), (C),
added par. (17) and redesignated former par. (17) as (18).
Subsec. (c). Pub. L. 96-473 substituted ''clause (1)'' for ''clauses
(1)''.
Subsec. (m). Pub. L. 96-499, 965(a)(2), added subsec. (m).
1978 -- Subsec. (c). Pub. L. 95-292 added cl. (4) to first sentence
relating to a requirement that intermediate care facilities meet section
1395x(j)(14) of this title with respect to protection of patients'
personal funds, and inserted reference to that cl. (4) in provisions
covering intermediate care facilities on Indian reservations.
1977 -- Subsec. (a)(2). Pub. L. 95-210, 2(a), designated existing
provisions as cl. (A) and added cl. (B).
Subsec. (l). Pub. L. 95-210, 2(b), added subsec. (l).
1976 -- Subsec. (b). Pub. L. 94-437 inserted provision requiring
that the Federal medical assistance percentage be 100 per centum for
services received through an Indian Health Service facility.
1973 -- Subsec. (a). Pub. L. 93-233, 13(a)(13), substituted in
introductory text ''individuals (other than individuals with respect to
whom there is being paid, or who are eligible or would be eligible if
they were not in a medical institution, to have paid with respect to
them a State supplementary payment and are eligible for medical
assistance equal in amount, duration, and scope to the medical
assistance made available to individuals described in section
1396a(a)(10)(A) of this title) not receiving aid or assistance under any
plan of the State approved under subchapter I, X, XIV, or XVI, or part A
of subchapter IV of this chapter, and with respect to whom supplemental
security income benefits are not being paid under subchapter XVI of this
chapter'' for ''individuals not receiving aid or assistance under the
State's plan approved under subchapter I, X, XIV, or XVI, or part A of
subchapter IV of this chapter''.
Subsec. (a)(iv). Pub. L. 93-233, 13(a)(14), inserted ''with respect
to States eligible to participate in the State plan program established
under subchapter XVI of this chapter,'' after ''blind,''.
Subsec. (a)(v). Pub. L. 93-233, 13(a)(15), substituted ''with
respect to States eligible to participate in the State plan program
established under subchapter XVI of this chapter,'' for ''or''.
Subsec. (a)(vi). Pub. L. 93-233, 13(a)(16), inserted ''or'' at end
of text.
Subsec. (a)(vii). Pub. L. 93-233, 13(a)(17), added cl. (vii).
Subsec. (a)(16). Pub. L. 93-233, 18(x)(7), substituted ''under age
21, as defined in subsection (h) of this section; and'' for ''under 21,
as defined in subsection (e) of this section;''.
Subsec. (b). Pub. L. 93-233, 18(y)(2), struck out ''; except that
the Secretary shall promulgate such percentage as soon as possible after
July 30, 1965, which promulgation shall be conclusive for each of the
six quarters in the period beginning January 1, 1966, and ending with
the close of June 30, 1966'' after ''section 1301(a)(8) of this title''.
Subsec. (c). Pub. L. 93-233, 18(x)(8), substituted ''skilled nursing
facility'' for ''skilled nursing home'' wherever appearing.
Subsec. (h)(1)(B). Pub. L. 93-233, 18(w), substituted ''(i) involve
active treatment'' for '', involves active treatment (i)''; struck out
''pursuant to subchapter XVIII of this chapter'' after ''may be
prescribed''; and substituted ''(ii)'' for ''(ii) which'',
respectively.
Subsec. (h)(2). Pub. L. 93-233, 18(x)(10), substituted ''paragraph
(1)'' for ''paragraph (e)(1)''.
Subsec. (i). Pub. L. 93-233, 18(x)(9), redesignated subsec. (h) as
added by Pub. L. 92-603, 299L(b), as subsec. (i).
Subsecs. (j), (k). Pub. L. 93-233, 13(a)(18), added subsecs. (j)
and (k).
1972 -- Subsec. (a). Pub. L. 92-603, 299B(c), in text following
redesignated subsec. (a)(17) substituted ''as otherwise provided in
paragraph (16),'' for ''that''.
Subsec. (a)(4). Pub. L. 92-603, 278(a)(21), 299E(b), substituted
''skilled nursing facility'' for ''skilled nursing home'' and added cl.
(C).
Subsec. (a)(5). Pub. L. 92-603, 278(a)(22), 280, substituted
''skilled nursing facility'' for ''skilled nursing home'' and inserted
''furnished by a physician (as defined in section 1395x(r)(1) of this
title) after ''physicians' services''.
Subsec. (a)(14). Pub. L. 92-603, 278(a)(23), 297(a), substituted
''skilled nursing facility'' for ''skilled nursing home'' and inserted
reference to intermediate care facility services.
Subsec. (a)(15) to (17). Pub. L. 92-603, 299B(a), added par. (16)
and redesignated existing pars. (15) and (16) as (17) and (15),
respectively.
Subsec. (c). Pub. L. 92-603, 299L(a), inserted provision defining
''intermediate care facility'' with respect to any institution located
in a State on an Indian reservation.
Subsec. (d)(3). Pub. L. 92-603, 299, inserted provisions relating to
reduction of non-Federal expenditures in any calendar quarter prior to
January 1, 1975.
Subsec. (e). Pub. L. 92-603, 212(a), added subsec. (e).
Subsec. (f). Pub. L. 92-603, 247(b), added subsec. (f).
Subsec. (g). Pub. L. 92-603, 275(a), added subsec. (g).
Subsec. (h). Pub. L. 92-603, 299B(b), added subsec. (h).
Subsec. (i). Pub. L. 92-603, 299L(b), added subsec. (i),
1971 -- Subsec. (a)(16). Pub. L. 92-223, 4(a)(1)(C), added cl.
(16).
Subsecs. (c), (d). Pub. L. 92-223, 4(a)(2), added subsecs. (c) and
(d).
1968 -- Subsec. (a). Pub. L. 90-248, 230, inserted '', and with
respect to physicians' or dentists' services, at the option of the
State, to individuals not receiving aid or assistance under the State's
plan approved under subchapter I, X, XIV, XVI of this chapter, or part A
of subchapter IV of this chapter'' after ''for individuals'' in text
preceding cl. (i).
Pub. L. 90-248, 233(b), inserted provision deeming, for purposes of
cl. (vi) of the preceding sentence, a person as essential to another
individual if such person is the spouse of and is living with such
individual, the needs of such person are taken into account in
determining the amount of aid or assistance furnished to such individual
(under a State plan approved under subchapter I, X, XIV, or XV of this
chapter, and such person is determined, under such a State plan, to be
essential to the well being of such individual.
Subsec. (a)(ii). Pub. L. 90-248, 241(f)(6), inserted ''part A of''
before ''subchapter IV''.
Subsec. (a)(vi). Pub. L. 90-248, 233(a), added cl. (vi).
Subsec. (a)(4). Pub. L. 90-248, 302(a), designated existing
provisions as cl. (A) and added cl. (B).
Subsec. (b). Pub. L. 90-248, 248(e), substituted in cl. (2) of
first sentence ''50'' for ''55''.
Amendment by section 4402(d)(2) of Pub. L. 101-508 applicable,
except as otherwise provided, to payments under this subchapter for
calendar quarters beginning on or after Jan. 1, 1991, without regard to
whether or not final regulations to carry out the amendments by section
4402 of Pub. L. 101-508 have been promulgated by such date, see section
4402(e) of Pub. L. 101-508, set out as a note under section 1396a of
this title.
Amendment by section 4501(a), (c), (e)(1) of Pub. L. 101-508
applicable to calendar quarters beginning on or after Jan. 1, 1991,
without regard to whether or not regulations to implement the amendments
by section 4501 of Pub. L. 101-508 are promulgated by such date, except
that amendment by section 4501(e)(1) of Pub. L. 101-508 is applicable
to determinations of income for months beginning with January 1991, see
section 4501(f) of Pub. L. 101-508, set out as a note under section
1396a of this title.
Amendment by section 4601(a)(2) of Pub. L. 101-508 applicable,
except as otherwise provided, to payments under this subchapter for
calendar quarters beginning on or after July 1, 1991, without regard to
whether or not final regulations to carry out the amendments by section
4601 of Pub. L. 101-508 have been promulgated by such date, see section
4601(b) of Pub. L. 101-508, set out as a note under section 1396a of
this title.
Amendment by section 4704(c), (d), (e)(1) of Pub. L. 101-508
effective as if included in the enactment of the Omnibus Budget
Reconciliation Act of 1989, Pub. L. 101-239, see section 4704(f) of
Pub. L. 101-508, set out as a note under section 1396a of this title.
Section 4705(b) of Pub. L. 101-508 provided that: ''The amendments
made by subsection (a) (amending this section) shall be effective as if
included in the amendments made by section 6408(c)(1) of the Omnibus
Budget Reconciliation Act of 1989 (Pub. L. 101-239, amending section
1396a of this title).''
Amendment by section 4711(a) of Pub. L. 101-508 applicable to home
and community care furnished on or after July 1, 1991, without regard to
whether or not final regulations to carry out the amendments by section
4711 of Pub. L. 101-508 have been promulgated by such date, see section
4711(e) of Pub. L. 101-508, set out as a note under section 1396a of
this title.
Amendment by section 4712(a) of Pub. L. 101-508 applicable to
community supported living arrangements services furnished on or after
the later of July 1, 1991, or 30 days after the publication of
regulations setting forth interim requirements under section 1396u(h) of
this title without regard to whether or not final regulations to carry
out the amendments by section 4712 of Pub. L. 101-508 have been
promulgated by such date, see section 4712(c) of Pub. L. 101-508, set
out as an Effective Date note under section 1396u of this title.
Amendment by section 4713(b) of Pub. L. 101-508 applicable to
medical assistance furnished on or after Jan. 1, 1991, see section
4713(c) of Pub. L. 101-508, set out as a note under section 1396a of
this title.
Section 4719(b) of Pub. L. 101-508 provided that: ''The amendment
made by subsection (a) (amending this section) shall take effect on the
date of the enactment of this Act (Nov. 5, 1990).''
Section 4721(b) of Pub. L. 101-508 provided that: ''The amendment
made by this section (amending this section) shall become effective with
respect to personal care services provided on or after October 1,
1994.''
Section 4755(a)(1)(B) of Pub. L. 101-508 provided that: ''The
amendment made by subparagraph (A) (amending this section) shall be
effective as if included in the enactment of the Deficit Reduction Act
of 1984 (Pub. L. 98-369).''
Amendment by section 6403(a), (c), (d)(2) of Pub. L. 101-239
effective Apr. 1, 1990, without regard to whether or not final
regulations to carry out the amendments by section 6403 of Pub. L.
101-239 have been promulgated by such date, see section 6403(e) of Pub.
L. 101-239, set out as a note under section 1396a of this title.
Amendment by section 6404(a), (b) of Pub. L. 101-239 applicable,
except as otherwise provided, to payments under this subchapter for
calendar quarters beginning on or after Apr. 1, 1990, without regard to
whether or not final regulations to carry out the amendments by section
6404 of Pub. L. 101-239 have been promulgated by such date, see section
6404(d) of Pub. L. 101-239, set out as a note under section 1396a of
this title.
Amendment by section 6405(a) of Pub. L. 101-239 effective with
respect to services furnished by a certified pediatric nurse
practitioner or certified family nurse practitioner on or after July 1,
1990, see section 6405(c) of Pub. L. 101-239, set out as a note under
section 1396a of this title.
Amendment by section 6408(d)(2), (4)(A), (B) of Pub. L. 101-239
applicable, except as otherwise provided, to payments under this
subchapter for calendar quarters beginning on or after July 1, 1990,
without regard to whether or not final regulations to carry out the
amendments by section 6408(d) of Pub. L. 101-239 have been promulgated
by such date, see section 6408(d)(5) of Pub. L. 101-239, set out as a
note under section 1396a of this title.
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.
Amendment by Pub. L. 100-647 effective as if included in the
enactment of section 301 of the Medicare Catastrophic Coverage Act of
1988, Pub. L. 100-360, see section 8434(c) of Pub. L. 100-647, set out
as a note under section 1396a of this title.
Amendment by section 303(b)(2) of Pub. L. 100-485 applicable to
payments under this subchapter for calendar quarters beginning on or
after Apr. 1, 1990 (or, in the case of the Commonwealth of Kentucky,
Oct. 1, 1990) (without regard to whether regulations to implement such
amendment are promulgated by such date), with respect to families that
cease to be eligible for aid under part A of subchapter IV of this
chapter on or after that date, see section 303(f)(1) of Pub. L.
100-485, set out as an Effective and Termination Dates of 1988 Amendment
note under section 602 of this title.
Amendment by section 401(d)(2) of Pub. L. 100-485 effective Oct. 1,
1990, except as provided in subsec. (m)(2) of this section and not
effective for Puerto Rico, Guam, American Samoa, and the Virgin Islands,
until Oct. 1, 1992, see section 401(g) of Pub. L. 100-485, set out as
an Effective and Termination Dates of 1988 Amendment note under section
602 of this title.
Amendment by section 608(d)(14)(A)-(G), (J) of Pub. L. 100-485
effective as if included in the enactment of the Medicare Catastrophic
Coverage Act of 1988, Pub. L. 100-360, see section 608(g)(1) of Pub.
L. 100-485, set out as a note under section 704 of this title.
Amendment by section 608(f)(3) of Pub. L. 100-485 effective Oct.
13, 1988, see section 608(g)(2) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 301(a)(2)-(d) of Pub. L. 100-360 applicable,
except as otherwise provided, to payments under this subchapter for
calendar quarters beginning on or after Jan. 1, 1989, without regard to
whether or not final regulations to carry out such amendment have been
promulgated by that date, with respect to medical assistance for monthly
premiums under subchapter XVIII of this chapter for months beginning
with January 1989, and items and services furnished on and after Jan.
1, 1989, see section 301(h) of Pub. L. 100-360, set out as a note under
section 1396a of this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(h)(4)(E), (k)(4), (8) 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.
Section 411(k)(14)(B) of Pub. L. 100-360 provided that: ''The
amendment made by subparagraph (A) (amending this section) shall take
effect on the date of the enactment of this Act (July 1, 1988).''
Amendment by section 4073(d) of Pub. L. 100-203 effective with
respect to services performed on or after July 1, 1988, see section
4073(e) of Pub. L. 100-203, set out as a note under section 1395k of
this title.
Section 4101(c)(3) of Pub. L. 100-203 provided that:
''(A) The amendments made by this subsection (amending this section
and section 1396a of this title) shall apply to medical assistance
furnished on or after October 1, 1988.
''(B) For purposes of section 1905(n)(2) of the Social Security Act
(section 1396d(n)(2) of this title) (as amended by subsection (a)
(probably means ''subsection (c)'')) for medical assistance furnished
during fiscal year 1989, any reference to 'age of 7' is deemed to be a
reference to 'age of 6'.''
Section 4103(b) of Pub. L. 100-203 provided that:
''(1) The amendment made by subsection (a) (amending this section)
applies (except as provided under paragraph (2)) to payments under title
XIX of the Social Security Act (42 U.S.C. 1396 et seq.) for calendar
quarters beginning on or after January 1, 1988, without regard to
whether or not final regulations to carry out such amendment have been
promulgated by such date.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than legislation
appropriating funds) in order for the plan to meet the additional
requirement imposed by the amendment made by subsection (a), the State
plan shall not be regarded as failing to comply with the requirements of
such title solely on the basis of its failure to meet this additional
requirement before the first day of the first calendar quarter beginning
after the close of the first regular session of the State legislature
that begins after the date of enactment of this Act (Dec. 22, 1987).''
Section 4105(b) of Pub. L. 100-203 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply to services
furnished on or after January 1, 1988, without regard to whether
regulations to implement such amendment are promulgated by such date.''
Amendments by section 4211(e), (f), (h)(6) of Pub. L. 100-203
applicable to nursing facility services furnished on or after Oct. 1,
1990, without regard to whether regulations implementing such amendments
are promulgated by such date, except as otherwise specifically provided
in section 1396r of this title, with transitional rule, see section
4214(a), (b)(2) of Pub. L. 100-203, as amended, set out as an Effective
Date note under section 1396r of this title.
Amendment by Pub. L. 99-514 effective, except as otherwise provided,
as if included in enactment of the Consolidated Omnibus Budget
Reconciliation Act of 1985, Pub. L. 99-272, see section 1895(e) of Pub.
L. 99-514, set out as a note under section 162 of Title 26, Internal
Revenue Code.
Amendment by section 9403(b), (d), (g)(3) of Pub. L. 99-509
applicable to payments under this subchapter for calendar quarters
beginning on or after July 1, 1987, without regard to whether or not
final regulations to carry out such amendments have been promulgated by
such date, see section 9403(h) of Pub. L. 99-509, set out as a note
under section 1396a of this title.
Amendment by section 9404(b) of Pub. L. 99-509 applicable, except as
otherwise provided, to payments under this subchapter for calendar
quarters beginning on or after July 1, 1987, without regard to whether
regulations to implement such amendments are promulgated by such date,
see section 9404(c) of Pub. L. 99-509, set out as a note under section
1396a of this title.
Amendment by section 9408(c)(1) of Pub. L. 99-509 applicable to
services furnished on or after Oct. 21, 1986, see section 9408(d) of
Pub. L. 99-509, set out as a note under section 1396a of this title.
Section 9501(d)(1) of Pub. L. 99-272 provided that:
''(A) The amendments made by subsection (a) (amending this section)
apply (except as provided under subparagraph (B)) to payments under
title XIX of the Social Security Act (this subchapter) for calendar
quarters beginning on or after the (sic) July 1, 1986, without regard to
whether or not final regulations to carry out the amendments have been
promulgated by that date.
''(B) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than legislation
appropriating funds) in order for the plan to meet the additional
requirement imposed by the amendments made by subsection (a), the State
plan shall not be regarded as failing to comply with the requirements of
such title solely on the basis of its failure to meet this additional
requirement before the first day of the first calendar quarter beginning
after the close of the first regular session of the State legislature
that begins after the date of the enactment of this Act (Apr. 7,
1986).''
Amendment by section 9505(a) of Pub. L. 99-272 applicable to medical
assistance provided for hospice care furnished on or after Apr. 7,
1986, see section 9505(e) of Pub. L. 99-272, set out as a note under
section 1396a of this title.
Section 9511(b) of Pub. L. 99-272, as amended by Pub. L. 99-509,
title IX, 9435(d)(2), Oct. 21, 1986, 100 Stat. 2070, provided that:
''The amendment made by this section (amending this section) shall apply
to services furnished on or after April 1, 1986, without regard to
whether or not regulations to carry out the amendment have been
promulgated by that date.''
Amendment by section 2335(f) of Pub. L. 98-369 effective July 18,
1984, see section 2335(g) of Pub. L. 98-369, set out as a note under
section 1395f of this title.
Amendment by section 2340(b) of Pub. L. 98-369 effective July 18,
1984, see section 2340(c) of Pub. L. 98-369, set out as a note under
section 1395x of this title.
Amendment by section 2361(b) of Pub. L. 98-369 applicable to
calendar quarters beginning on or after Oct. 1, 1984, without regard to
whether or not final regulations to carry out the amendment have been
promulgated by such date, except as otherwise provided, see section
2361(d) of Pub. L. 98-369, set out as a note under section 1396a of
this title.
Section 2371(b) of Pub. L. 98-369 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply to services
furnished on or after the date of the enactment of this Act (July 18,
1984).''
Amendment by section 136(c) of Pub. L. 97-248 effective Oct. 1,
1982, see section 136(e) of Pub. L. 97-248, set out as a note under
section 1301 of this title.
Amendment by section 137(b)(17), (18) of Pub. L. 97-248 effective as
if originally included as part of this section as this section was
amended by the Omnibus Budget Reconciliation Act of 1981, Pub. L.
97-35, see section 137(d)(2) of Pub. L. 97-248, set out as a note under
section 1396a of this title.
Amendment by section 2172(b) of Pub. L. 97-35 effective Aug. 13,
1981, see section 2172(c) of Pub. L. 97-35, set out as a note under
section 1396a of this title.
For effective date of amendment by Pub. L. 96-499, see section
965(c) of Pub. L. 96-499, set out as a note under section 1396a of this
title.
Section 8(d)(1) of Pub. L. 95-292 provided that: ''The amendments
made by subsections (a) and (b) (amending this section) shall become
effective on July 1, 1978.''
Amendment by Pub. L. 95-210 applicable to medical assistance
provided, under a State plan approved under subchapter XIX of this
chapter, on and after the first day of the first calender quarter that
begins more than six months after Dec. 13, 1977, with exception for
plans requiring State legislation, see section 2(f) of Pub. L. 95-210,
set out as a note under section 1395cc of this title.
Amendment by section 13(a)(13)-(18) of Pub. L. 93-233 effective with
respect to payments under section 1396b of this title for calendar
quarters commencing after Dec. 31, 1973, see section 13(d) of Pub. L.
93-233, set out as a note under section 1396a of this title.
Section 212(b) of Pub. L. 92-603 provided that: ''The provisions of
subsection (e) of section 1905 of the Social Security Act (subsec. (e)
of this section) (as added by subsection (a) of this section) shall be
applicable in the case of services performed on or after the date of
enactment of this Act (Oct. 30, 1972).''
Amendment by section 247(b) of Pub. L. 92-603 effective with respect
to services furnished after Dec. 31, 1972, see section 247(c) of Pub.
L. 92-603, set out as a note under section 1395f of this title.
Section 275(b) of Pub. L. 92-603 provided that: ''The amendment
made by this section (amending this section) shall be effective with
respect to services furnished after June 30, 1973.''
Section 297(b) of Pub. L. 92-603 provided that: ''The amendment
made by this section (amending this section) shall apply with respect to
services furnished after December 31, 1972.''
Amendment by Pub. L. 92-223 effective Jan. 1, 1972, see section
4(d) of Pub. L. 92-223, set out as a note under section 1396a of this
title.
Section 248(e) of Pub. L. 90-248 provided that the amendment made by
that section is effective with respect to quarters after 1967.
Section 4706 of Pub. L. 101-508 provided that:
''(a) In General. -- (1) If the Secretary of Health and Human
Services makes a determination that a psychiatric facility has failed to
comply with certification of need requirements for inpatient psychiatric
hospital services for individuals under age 21 pursuant to section
1905(h) of the Social Security Act (subsec. (h) of this section), and
such determination has not been subject to a final judicial decision,
any disallowance or deferral of Federal financial participation under
such Act (this chapter) based on such determination shall only apply to
the period of time beginning with the first day of noncompliance and
ending with the date by which the psychiatric facility develops
documentation (using plan of care or utilization review procedures) of
the need for inpatient care with respect to such individuals.
''(2) Any disallowance of Federal financial participation under title
XIX of the Social Security Act (this subchapter) relating to the failure
of a psychiatric facility to comply with certification of need
requirements --
''(A) shall not exceed 25 percent of the amount of Federal financial
participation for the period described in paragraph (1); and
''(B) shall not apply to any fiscal year before the fiscal year that
is 3 years before the fiscal year in which the determination of
noncompliance described in paragraph (1) is made.
''(b) Effective Date. -- Subsection (a) shall apply to disallowance
actions and deferrals of Federal financial participation with respect to
services provided before the date of enactment of this Act (Nov. 5,
1990).''
Section 411(l)(3)(C)(i), formerly 411(l)(3)(C), of Pub. L.
100-360, as redesignated by Pub. L. 100-485, title VI, 608(d)(27)(E),
Oct. 13, 1988, 102 Stat. 2423, provided that: ''Effective as of the
date of the enactment of this Act (July 1, 1988) and until the effective
date of section 1919(c) of such Act (section 1396r(c) of this title, see
Effective Date note set out under section 1396r of this title), section
1905(c) of the Social Security Act (subsec. (c) of this section) is
deemed to include the requirement described in section 1919(c)(3)(A) of
such Act (as inserted by section 4211(a)(3) of OBRA).''
Section 9514 of Pub. L. 99-272 provided that: ''The Secretary of
Health and Human Services shall promulgate proposed regulations revising
standards for intermediate care facilities for the mentally retarded
under title XIX of the Social Security Act (this subchapter) within 60
days after the date of the enactment of this Act (Apr. 7, 1986).''
Section 9515 of Pub. L. 99-272 provided that: ''For purposes of
section 1905(c) of the Social Security Act (subsec. (c) of this
section), an intermediate care facility for the mentally retarded (as
defined in section 1905(d) of such Act) which meets the requirements of
the relevant sections of the 1985 edition of the Life Safety Code of the
National Fire Protection Association shall be deemed to meet the fire
safety requirements for intermediate care facilities for the mentally
retarded until such time as the Secretary specifies a later edition of
the Life Safety Code for purposes of such section, or the Secretary
determines that more stringent standards are necessary to protect the
safety of residents of such facilities.''
Section 2165 of Pub. L. 97-35 directed the Comptroller General, in
consultation with the Advisory Committee for Intergovernmental
Relations, to study the Federal medical assistance percentage formula as
applicable to distribution of Federal funds to States, with a view to
revising the medicaid matching formula so as to take into account
factors which might result in a more equitable distribution of Federal
funds to States under this chapter, and to report to Congress on such
study not later than Oct. 1, 1982.
Charges for Services; Regulations
Section 8(c), (d)(2) of Pub. L. 95-292 required the Secretary of
Health, Education, and Welfare to issue regulations, within 90 days
after enactment of Pub. L. 95-292 but not later than July 1, 1978,
defining those costs that may be charged to the personal funds of
patients in intermediate care facilities who are individuals receiving
medical assistance under a State plan approved under title XIX of the
Social Security Act, and those costs that are to be included in the
reasonable cost or reasonable charge for intermediate care facility
services. See section 1302 of this title.
/1/ So in original. The word ''and'' appearing at end of par. (21)
probably should appear at end of par. (23).
/2/ So in original. The period probably should be a semicolon.
/3/ So in original. Probably should be ''a''.
/4/ So in original. Probably should be ''an''.
/5/ So in original. The word ''or'' probably should not appear.
/6/ So in original. The semicolon probably should be '', or''.
/7/ So in original. Probably should be clause ''(iii),''. See
References in Text note below.
/8/ So in original. The comma probably should be a period.
/9/ So in original. The words ''of such paragraph'' probably should
follow ''subparagraph (B)''.
/10/ So in original. Probably should be ''or section''.
42 USC 1396e. Enrollment of individuals under group health plans
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Requirements of each State plan; guidelines
For purposes of section 1396a(a)(25)(G) of this title and subject to
subsection (d) of this section, each State plan --
(1) shall implement guidelines established by the Secretary,
consistent with subsection (b) of this section, to identify those cases
in which enrollment of an individual otherwise entitled to medical
assistance under this subchapter in a group health plan (in which the
individual is otherwise eligible to be enrolled) is cost-effective (as
defined in subsection (e)(2) of this section);
(2) shall require, in case of an individual so identified and as a
condition of the individual being or remaining eligible for medical
assistance under this subchapter and subject to subsection (b)(2) of
this section, notwithstanding any other provision of this subchapter,
that the individual (or in the case of a child, the child's parent)
apply for enrollment in the group health plan; and
(3) in the case of such enrollment (except as provided in subsection
(c)(1)(B) of this section), shall provide for payment of all enrollee
premiums for such enrollment and all deductibles, coinsurance, and other
cost-sharing obligations for items and services otherwise covered under
the State plan under this subchapter (exceeding the amount otherwise
permitted under section 1396o of this title), and shall treat coverage
under the group health plan as a third party liability (under section
1396a(a)(25) of this title).
(b) Timing of enrollment; failure to enroll
(1) In establishing guidelines under subsection (a)(1) of this
section, the Secretary shall take into account that an individual may
only be eligible to enroll in group health plans at limited times and
only if other individuals (not entitled to medical assistance under the
plan) are also enrolled in the plan simultaneously.
(2) If a parent of a child fails to enroll the child in a group
health plan in accordance with subsection (a)(2) of this section, such
failure shall not affect the child's eligibility for benefits under this
subchapter.
(c) Premiums considered payments for medical assistance; eligibility
(1)(A) In the case of payments of premiums, deductibles, coinsurance,
and other cost-sharing obligations under this section shall be
considered, for purposes of section 1396b(a) of this title, to be
payments for medical assistance.
(B) If all members of a family are not eligible for medical
assistance under this subchapter and enrollment of the members so
eligible in a group health plan is not possible without also enrolling
members not so eligible --
(i) payment of premiums for enrollment of such other members shall be
treated as payments for medical assistance for eligible individuals, if
it would be cost-effective (taking into account payment of all such
premiums), but
(ii) payment of deductibles, coinsurance, and other cost-sharing
obligations for such other members shall not be treated as payments for
medical assistance for eligible individuals.
(2) The fact that an individual is enrolled in a group health plan
under this section shall not change the individual's eligibility for
benefits under the State plan, except insofar as section 1396a(a)(25) of
this title provides that payment for such benefits shall first be made
by such plan.
(d) Applicability of section to medical assistance granted under
waiver of State plan
(1) In the case of any State which is providing medical assistance to
its residents under a waiver granted under section 1315 of this title,
the Secretary shall require the State to meet the requirements of this
section in the same manner as the State would be required to meet such
requirement if the State had in effect a plan approved under this
subchapter.
(2) This section, and section 1396a(a)(25)(G) of this title, shall
only apply to a State that is one of the 50 States or the District of
Columbia.
(e) Definitions
In this section:
(1) The term ''group health plan'' has the meaning given such term in
section 5000(b)(1) of the Internal Revenue Code of 1986, and includes
the provision of continuation coverage by such a plan pursuant to title
XXII of the Public Health Service Act (42 U.S.C. 300bb-1 et seq.),
section 4980B of the Internal Revenue Code of 1986, or title VI /1/ of
the Employee Retirement Income Security Act of 1974.
(2) The term ''cost-effective'' means, as established by the
Secretary, that the reduction in expenditures under this subchapter with
respect to an individual who is enrolled in a group health plan is
likely to be greater than the additional expenditures for premiums and
cost-sharing required under this section with respect to such
enrollment.
(Aug. 14, 1935, ch. 531, title XIX, 1906, as added Nov. 5, 1990,
Pub. L. 101-508, title IV, 4402(a)(2), 104 Stat. 1388-161.)
The Internal Revenue Code of 1986, referred to in subsec. (e)(1), is
classified generally to Title 26, Internal Revenue Code.
The Public Health Service Act, referred to in subsec. (e)(1), is act
July 1, 1944, ch. 373, 58 Stat. 682, as amended. Title XXII of the
Act is classified generally to subchapter XX ( 300bb-1 et seq.) of
chapter 6A of this title. For complete classification of this Act to
the Code, see Short Title note set out under section 201 of this title
and Tables.
The Employee Retirement Income Security Act of 1974, referred to in
subsec. (e)(1), is Pub. L. 93-406, Sept. 2, 1974, 88 Stat. 829, as
amended. Title VI of the Act probably means part 6 of subtitle B of
title I of the Act which is classified generally to part 6 ( 1161 et
seq.) of subtitle B of subchapter I of chapter 18 of Title 29, Labor,
because the Act has no title VI. For complete classification of this
Act to the Code, see Short Title note set out under section 1001 of
Title 29 and Tables.
A prior section 1396e, act Aug. 14, 1935, ch. 531, title XIX,
1906, as added Jan. 2, 1968, Pub. L. 90-248, title II, 226, 81 Stat.
903, which created the Advisory Council on Medical Assistance, set forth
the composition of the Council, term of membership of the members, and
the purposes of the Council, and provided for the compensation of the
members, was repealed by Pub. L. 92-603, title II, 287, Oct. 30,
1972, 86 Stat. 1457, effective on the first day of the third calendar
month following Oct. 30, 1972.
Section applicable, except as otherwise provided, to payments under
this subchapter for calendar quarters beginning on or after Jan. 1,
1991, without regard to whether or not final regulations to carry out
the amendments by section 4402 of Pub. L. 101-508 have been promulgated
by such date, see section 4402(e) of Pub. L. 101-508, set out as an
Effective Date of 1990 Amendment note under section 1396a of this title.
/1/ See References in Text note below.
42 USC 1396f. Observance of religious beliefs
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
Nothing in this subchapter shall be construed to require any State
which has a plan approved under this subchapter to compel any person to
undergo any medical screening, examination, diagnosis, or treatment or
to accept any other health care or services provided under such plan for
any purpose (other than for the purpose of discovering and preventing
the spread of infection or contagious disease or for the purpose of
protecting environmental health), if such person objects (or, in case
such person is a child, his parent or guardian objects) thereto on
religious grounds.
(Aug. 14, 1935, ch. 531, title XIX, 1907, as added Jan. 2, 1968,
Pub. L. 90-248, title II, 232, 81 Stat. 905.)
42 USC 1396g. State programs for licensing of administrators of
nursing homes
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Nature of State program
For purposes of section 1396a(a)(29) of this title, a ''State program
for the licensing of administrators of nursing homes'' is a program
which provides that no nursing home within the State may operate except
under the supervision of an administrator licensed in the manner
provided in this section.
(b) Licensing by State agency or board representative of concerned
professions and institutions
Licensing of nursing home administrators shall be carried out by the
agency of the State responsible for licensing under the healing arts
licensing act of the State, or, in the absence of such act or such an
agency, a board representative of the professions and institutions
concerned with care of chronically ill and infirm aged patients and
established to carry out the purposes of this section.
(c) Functions and duties of State agency or board
It shall be the function and duty of such agency or board to --
(1) develop, impose, and enforce standards which must be met by
individuals in order to receive a license as a nursing home
administrator, which standards shall be designed to insure that nursing
home administrators will be individuals who are of good character and
are otherwise suitable, and who, by training or experience in the field
of institutional administration, are qualified to serve as nursing home
administrators;
(2) develop and apply appropriate techniques, including examinations
and investigations, for determining whether an individual meets such
standards;
(3) issue licenses to individuals determined, after the application
of such techniques, to meet such standards, and revoke or suspend
licenses previously issued by the board in any case where the individual
holding any such license is determined substantially to have failed to
conform to the requirements of such standards;
(4) establish and carry out procedures designed to insure that
individuals licensed as nursing home administrators will, during any
period that they serve as such, comply with the requirements of such
standards;
(5) receive, investigate, and take appropriate action with respect
to, any charge or complaint filed with the board to the effect that any
individual licensed as a nursing home administrator has failed to comply
with the requirements of such standards; and
(6) conduct a continuing study and investigation of nursing homes and
administrators of nursing homes within the State with a view to the
improvement of the standards imposed for the licensing of such
administrators and of procedures and methods for the enforcement of such
standards with respect to administrators of nursing homes who have been
licensed as such.
(d) Waiver of standards other than good character or suitability
standards
No State shall be considered to have failed to comply with the
provisions of section 1396a(a)(29) of this title because the agency or
board of such State (established pursuant to subsection (b) of this
section) shall have granted any waiver, with respect to any individual
who, during all of the three calendar years immediately preceding the
calendar year in which the requirements prescribed in section
1396a(a)(29) of this title are first met by the State, has served as a
nursing home administrator, of any of the standards developed, imposed,
and enforced by such agency or board pursuant to subsection (c) of this
section.
(e) ''Nursing home'' and ''nursing home administrator'' defined
As used in this section, the term --
(1) ''nursing home'' means any institution or facility defined as
such for licensing purposes under State law, or, if State law does not
employ the term nursing home, the equivalent term or terms as determined
by the Secretary, but does not include a Christian Science sanatorium
operated, or listed and certified, by the First Church of Christ,
Scientist, Boston, Massachusetts; and
(2) ''nursing home administrator'' means any individual who is
charged with the general administration of a nursing home whether or not
such individual has an ownership interest in such home and whether or
not his functions and duties are shared with one or more other
individuals.
(Aug. 14, 1935, ch. 531, title XIX, 1908, as added Jan. 2, 1968,
Pub. L. 90-248, title II, 236(b), 81 Stat. 908, and amended Oct. 30,
1972, Pub. L. 92-603, title II, 268(b), 269, 274(b), 86 Stat. 1451,
1452; Dec. 31, 1973, Pub. L. 93-233, 18(y)(3), 87 Stat. 973.)
Pub. L. 101-508, title IV, 4801(e)(11), Nov. 5, 1990, 104 Stat.
1388-217, provided that, effective on the date on which the Secretary
promulgates standards regarding the qualifications of nursing facility
administrators under section 1396r(f)(4) of this title, this section is
repealed.
1973 -- Subsec. (d). Pub. L. 93-233 struck out second sentence
reading substantially the same as the first sentence but containing the
following additional text reading ''other than such standards as relate
to good character or suitability if --
''(1) such waiver is for a period which ends after being in effect
for two years or on June 30, 1972, whichever is earlier, and
''(2) there is provided in the State (during all of the period for
which waiver is in effect), a program of training and instruction
designed to enable all individuals with respect to whom any such waiver
is granted, to attain the qualifications necessary in order to meet such
standards'' and also ''calendar year'' instead of ''three calendar
years'' and reference to ''subsection (c)(1) of this section'' instead
of ''subsection (c) of this section''.
Subsec. (e). Pub. L. 93-233 redesignated subsec. (g) as (e), and
repealed prior subsec. (e) relating to authorization of appropriations
for fiscal years 1968 through 1972 and to limitation of grants.
Subsec. (f). Pub. L. 93-233 repealed subsec. (f) providing for
creation of National Advisory Council on Nursing Home Administration and
for its composition, appointment of members, the Chairman,
representation of interests, functions and duties, compensation and
travel expenses, technical assistance, availability of assistance and
data, and termination date of Dec. 31, 1971.
Subsec. (g). Pub. L. 93-233, redesignated subsec. (g) as (e).
1972 -- Subsec. (d). Pub. L. 92-603, 269, 274(b), inserted
references to the grant of waivers to individuals who, during all of the
three calendar years immediately preceding the calendar year in which
the requirements prescribed in section 1396a(a)(29) of this title are
first met by the State, have served as nursing home administrators and
substituted ''subsection (c)(1)'' for ''subsection (b)(1)''.
Subsec. (g)(1). Pub. L. 92-603, 268(b), inserted '', but does not
include a Christian Science sanatorium operated, or listed and
certified, by the First Church of Christ, Scientist, Boston,
Massachusetts'' after ''Secretary''.
Amendment by section 268(b) of Pub. L. 92-603 effective Oct. 30,
1972, see section 268(c) of Pub. L. 92-603, set out as a note under
section 1396a of this title.
Section 236(c) of Pub. L. 90-248 provided that: ''Except as
otherwise specified in the text thereof, the amendments made by this
section (enacting this section and amending section 1396a of this title)
shall take effect on July 1, 1970.''
42 USC 1396h. Transferred
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
Section, act Aug. 14, 1935, ch. 531, title XIX, 1909, as added and
amended Oct. 30, 1972, Pub. L. 92-603, title II, 242(c), 278(b)(9),
86 Stat. 1419, 1454; Oct. 25, 1977, Pub. L. 95-142, 4(b), 91 Stat.
1181; Dec. 5, 1980, Pub. L. 96-499, title IX, 917, 94 Stat. 2625;
Aug. 18, 1987, Pub. L. 100-93, 4(a)-(c), 101 Stat. 688, 689, which
related to criminal penalties for acts involving Medicare and State
health care programs, was renumbered section 1128B of title XI of act
Aug. 14, 1935, by section 4(d) of Pub. L. 100-93 and transferred to
section 1320a-7b of this title.
42 USC 1396i. Certification and approval of rural health clinics and
intermediate care facilities for mentally retarded
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a)(1) Whenever the Secretary certifies a facility in a State to be
qualified as a rural health clinic under subchapter XVIII of this
chapter, such facility shall be deemed to meet the standards for
certification as a rural health clinic for purposes of providing rural
health clinic services under this title.
(2) The Secretary shall notify the State agency administering the
medical assistance plan of his approval or disapproval of any facility
in that State which has applied for certification by him as a qualified
rural health clinic.
(b)(1) The Secretary may cancel approval of any intermediate care
facility for the mentally retarded at any time if he finds on the basis
of a determination made by him as provided in section 1396a(a)(33)(B) of
this title that a facility fails to meet the requirements contained in
section 1396a(a)(31) of this title or section 1396d(d) of this title, or
if he finds grounds for termination of his agreement with the facility
pursuant to section 1395cc(b) of this title. In that event the
Secretary shall notify the State agency and the intermediate care
facility for the mentally retarded that approval of eligibility of the
facility to participate in the programs established by this subchapter
and subchapter XVIII of this chapter shall be terminated at a time
specified by the Secretary. The approval of eligibility of any such
facility to participate in such programs may not be reinstated unless
the Secretary finds that the reason for termination has been removed and
there is reasonable assurance that it will not recur.
(2) Any intermediate care facility for the mentally retarded which is
dissatisfied with a determination by the Secretary that it no longer
qualifies as a /1/ intermediate care facility for the mentally retarded
for purposes of this subchapter, shall be entitled to a hearing by the
Secretary to the same extent as is provided in section 405(b) of this
title and to judicial review of the Secretary's final decision after
such hearing as is provided in section 405(g) of this title. Any
agreement between such facility and the State agency shall remain in
effect until the period for filing a request for a hearing has expired
or, if a request has been filed, until a decision has been made by the
Secretary; except that the agreement shall not be extended if the
Secretary makes a written determination, specifying the reasons
therefor, that the continuation of provider status constitutes an
immediate and serious threat to the health and safety of patients, and
the Secretary certifies that the facility has been notified of its
deficiencies and has failed to correct them.
(Aug. 14, 1935, ch. 531, title XIX, 1910, as added and amended Oct.
30, 1972, Pub. L. 92-603, title II, 249A(a), 278(b)(12), 86 Stat.
1426, 1454; Dec. 13, 1977, Pub. L. 95-210, 2(d), 91 Stat. 1489; Dec.
5, 1980, Pub. L. 96-499, title IX, 916(b)(2), 94 Stat. 2624; Dec. 22,
1987, Pub. L. 100-203, title IV, 4212(e)(3), 101 Stat. 1330-213; July
1, 1988, Pub. L. 100-360, title IV, 411(l)(6)(F), as added Oct. 13,
1988, Pub. L. 100-485, title VI, 608(d)(27)(J), 102 Stat. 2423; Dec.
19, 1989, Pub. L. 101-239, title VI, 6901(d)(5), 103 Stat. 2301.)
1989 -- Pub. L. 101-239, 6901(d)(5)(A), substituted ''rural health
clinics and intermediate care facilities for the mentally retarded'' for
''rural health clinics'' in section catchline.
Subsec. (b)(1). Pub. L. 101-239, 6901(d)(5)(B)-(D), substituted
''any intermediate care facility for the mentally retarded'' for ''any
skilled nursing or intermediate care facility'', ''section 1396a(a)(31)
of this title or section 1396d(d) of this title'' for ''section
1396a(a)(28) of this title or section 1396r of this title or section
1396d(c) of this title'', and ''the intermediate care facility for the
mentally retarded'' for ''the skilled nursing facility or intermediate
care facility''.
Subsec. (b)(2). Pub. L. 101-239, 6901(d)(5)(D), substituted
''intermediate care facility for the mentally retarded'' for ''skilled
nursing facility or intermediate care facility'' in two places.
1988 -- Subsec. (b)(1). Pub. L. 100-360, 411(l)(6)(F), as added by
Pub. L. 100-485, 608(d)(27)(J), inserted ''or section 1396r of this
title'' after ''1396a(a)(28) of this title''.
1987 -- Pub. L. 100-203 struck out ''skilled nursing facilities
and'' before ''of rural'' in section catchline, redesignated subsecs.
(b) and (c) as (a) and (b), respectively, and struck out former subsec.
(a) which related to certification and approval of skilled nursing
facilities.
1980 -- Subsec. (c). Pub. L. 96-499 added subsec. (c).
1977 -- Pub. L. 95-210 redesignated existing subsecs. (a) and (b)
as (a)(1) and (2), respectively, and added subsec. (b).
Amendment by Pub. L. 101-239 effective as if included in the
enactment of the Omnibus Budget Reconciliation Act of 1987, Pub. L.
100-203, see section 6901(d)(6) of Pub. L. 101-239, set out as a note
under section 1395i-3 of this title.
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
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.
Amendment by Pub. L. 100-203 applicable to nursing facility services
furnished on or after Oct. 1, 1990, without regard to whether
regulations implementing such amendment are promulgated by such date,
except as otherwise specifically provided in section 1396r of this
title, with transitional rule, see section 4214(a), (b)(2) of Pub. L.
100-203, as amended, set out as an Effective Date note under section
1396r of this title.
Amendment by Pub. L. 95-210 applicable to medical assistance
provided, under a State plan approved under subchapter XIX of this
chapter, on and after first day of first calendar quarter that begins
more than six months after Dec. 13, 1977, with exception for plans
requiring State legislation, see section 2(f) of Pub. L. 95-210, set
out as a note under section 1395cc of this title.
Section effective with respect to agreements filed with Secretary
under section 1395cc of this title by skilled nursing facilities before,
on, or after Oct. 30, 1972, but accepted by him on or after such date,
see section 249A(e) of Pub. L. 92-603, set out as an Effective Date of
1972 Amendment note under section 1395cc of this title.
/1/ So in original. Probably should be ''an''.
42 USC 1396j. Indian health service facilities
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Eligibility for reimbursement for medical assistance
A facility of the Indian Health Service (including a hospital,
nursing facility, or any other type of facility which provides services
of a type otherwise covered under the State plan), whether operated by
such Service or by an Indian tribe or tribal organization (as those
terms are defined in section 1603 of title 25), shall be eligible for
reimbursement for medical assistance provided under a State plan if and
for so long as it meets all of the conditions and requirements which are
applicable generally to such facilities under this subchapter.
(b) Facilities deemed to meet requirements upon submission of
acceptable plan for achieving compliance
Notwithstanding subsection (a) of this section, a facility of the
Indian Health Service (including a hospital, nursing facility, or any
other type of facility which provides services of a type otherwise
covered under the State plan) which does not meet all of the conditions
and requirements of this title which are applicable generally to such
facility, but which submits to the Secretary within six months after
September 30, 1976, an acceptable plan for achieving compliance with
such conditions and requirements, shall be deemed to meet such
conditions and requirements (and to be eligible for reimbursement under
this subchapter), without regard to the extent of its actual compliance
with such conditions and requirements, during the first twelve months
after the month in which such plan is submitted.
(c) Agreement to reimburse State agency for providing care and
services
The Secretary is authorized to enter into agreements with the State
agency for the purpose of reimbursing such agency for health care and
services provided in Indian Health Service facilities to Indians who are
eligible for medical assistance under the State plan.
(Aug. 14, 1935, ch. 531, title XIX, 1911, as added Sept. 30, 1976,
Pub. L. 94-437, title IV, 402(a), 90 Stat. 1409, and amended Dec. 22,
1987, Pub. L. 100-203, title IV, 4118(f)(1), 4211(h)(8), 101 Stat.
1330-155, 1330-206; July 1, 1988, Pub. L. 100-360, title IV,
411(k)(10)(E), 102 Stat. 796.)
1988 -- Subsecs. (a), (b). Pub. L. 100-360, 411(k)(10)(E), made
technical correction to directory language of Pub. L. 100-203,
4118(f)(1)(A), see 1987 Amendment note below.
1987 -- Subsecs. (a), (b). Pub. L. 100-203, 4118(f)(1)(A), as
amended by Pub. L. 100-360, 411(k)(10)(E), substituted '', nursing
facility, or any other type of facility which provides services of a
type otherwise covered under the State plan'' for ''or nursing
facility''.
Pub. L. 100-203, 4211(h)(8), substituted ''or nursing facility'' for
'', intermediate care facility, or skilled nursing facility'' wherever
appearing.
Subsec. (c). Pub. L. 100-203, 4118(f)(1)(B), added subsec. (c).
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.
Section 4118(f)(2) of Pub. L. 100-203 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
health care services performed on or after the date of the enactment of
this Act (Dec. 22, 1987).''
Amendment by section 4211(h)(8) of Pub. L. 100-203 applicable to
nursing facility services furnished on or after Oct. 1, 1990, without
regard to whether regulations implementing such amendment are
promulgated by such date, except as otherwise specifically provided in
section 1396r of this title, with transitional rule, see section
4214(a), (b)(2) of Pub. L. 100-203, as amended, set out as an Effective
Date note under section 1396r of this title.
Pub. L. 94-437, title IV, 402(b), Sept. 30, 1976, 90 Stat. 1409,
which authorized Secretary to enter into agreements to reimburse State
agencies for health care and services provided in Service facilities to
Indians eligible for medical assistance under this subchapter, was
repealed by Pub. L. 100-713, title IV, 401(b), Nov. 23, 1988, 102
Stat. 4818, applicable to services performed on or after the Nov. 23,
1988.
Compliance by Secretary
Section 402(c) of Pub. L. 94-437, as amended by Pub. L. 100-713,
title IV, 401(a), Nov. 23, 1988, 102 Stat. 4818, provided that:
''Notwithstanding any other provision of law, payments to which any
facility of the Indian Health Service (including a hospital,
intermediate care facility, skilled nursing facility, or any other type
of facility which provides services of a type otherwise covered under a
State plan for medical assistance approved under title XIX of the Social
Security Act (this subchapter)) is entitled under such a State plan by
reason of section 1911 of such Act (this section) shall be placed in a
special fund to be held by the Secretary and used by him (to such extent
or in such amounts as are provided in appropriation Acts) exclusively
for the purpose of making any improvements in the facilities of such
Service which may be necessary to achieve compliance with the applicable
conditions and requirements of such title (this subchapter). In making
payments from such fund, the Secretary shall ensure that each service
unit of the Indian Health Service receives at least 50 percent of the
amounts to which the facilities of the Indian Health Service, for which
such service unit makes collections, are entitled by reason of section
1911 of the Social Security Act, if such amount is necessary for the
purpose of making improvements in such facilities in order to achieve
compliance with the conditions and requirements of title XIX of the
Social Security Act. This subsection shall cease to apply when the
Secretary determines and certifies that substantially all of the health
facilities of such Service in the United States are in compliance with
such conditions and requirements.''
(Pub. L. 100-713, title IV, 401(c), Nov. 23, 1988, 102 Stat. 4818,
provided that: ''The amendments made by this section (amending section
402(c) of Pub. L. 94-437 and repealing section 402(b) of Pub. L.
94-437, set out as notes under this section) shall apply to services
performed on or after the date of the enactment of this Act (Nov. 23,
1988).''
Section 402(d) of Pub. L. 94-437 provided that: ''Any payments
received for services provided recipients hereunder (under this section)
shall not be considered in determining appropriations for the provision
of health care and services to Indians.''
42 USC 1396k. Assignment, enforcement, and collection of rights of
payments for medical care; establishment of procedures pursuant to
State plan; amounts retained by State
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) For the purpose of assisting in the collection of medical support
payments and other payments for medical care owed to recipients of
medical assistance under the State plan approved under this subchapter,
a State plan for medical assistance shall --
(1) provide that, as a condition of eligibility for medical
assistance under the State plan to an individual who has the legal
capacity to execute an assignment for himself, the individual is
required --
(A) to assign the State any rights, of the individual or of any other
person who is eligible for medical assistance under this subchapter and
on whose behalf the individual has the legal authority to execute an
assignment of such rights, to support (specified as support for the
purpose of medical care by a court or administrative order) and to
payment for medical care from any third party;
(B) to cooperate with the State (i) in establishing the paternity of
such person (referred to in subparagraph (A)) if the person is a child
born out of wedlock, and (ii) in obtaining support and payments
(described in subparagraph (A)) for himself and for such person, unless
(in either case) the individual is described in section 1396a(l)(1)(A)
of this title or the individual is found to have good cause for refusing
to cooperate as determined by the State agency in accordance with
standards prescribed by the Secretary, which standards shall take into
consideration the best interests of the individuals involved; and
(C) to cooperate with the State in identifying, and providing
information to assist the State in pursuing, any third party who may be
liable to pay for care and services available under the plan, unless
such individual has good cause for refusing to cooperate as determined
by the State agency in accordance with standards prescribed by the
Secretary, which standards shall take into consideration the best
interests of the individuals involved; and
(2) provide for entering into cooperative arrangements (including
financial arrangements), with any appropriate agency of any State
(including, with respect to the enforcement and collection of rights of
payment for medical care by or through a parent, with a State's agency
established or designated under section 654(3) of this title) and with
appropriate courts and law enforcement officials, to assist the agency
or agencies administering the State plan with respect to (A) the
enforcement and collection of rights to support or payment assigned
under this section and (B) any other matters of common concern.
(b) Such part of any amount collected by the State under an
assignment made under the provisions of this section shall be retained
by the State as is necessary to reimburse it for medical assistance
payments made on behalf of an individual with respect to whom such
assignment was executed (with appropriate reimbursement of the Federal
Government to the extent of its participation in the financing of such
medical assistance), and the remainder of such amount collected shall be
paid to such individual.
(Aug. 14, 1935, ch. 531, title XIX, 1912, as added Oct. 25, 1977,
Pub. L. 95-142, 11(b), 91 Stat. 1196, and amended July 18, 1984, Pub.
L. 98-369, div. B, title III, 2367(b), 98 Stat. 1109; Apr. 7, 1986,
Pub. L. 99-272, title IX, 9503(e), 100 Stat. 207; Nov. 5, 1990, Pub.
L. 101-508, title IV, 4606(a), 104 Stat. 1388-170.)
1990 -- Subsec. (a)(1)(B). Pub. L. 101-508 inserted ''the individual
is described in section 1396a(l)(1)(A) of this title or'' after ''unless
(in either case)''.
1986 -- Subsec. (a)(1)(C). Pub. L. 99-272 added subpar. (C).
1984 -- Subsec. (a). Pub. L. 98-369 substituted ''State plan for
medical assistance shall'' for ''State plan for medical assistance
may''.
Section 4606(b) of Pub. L. 101-508 provided that: ''The amendment
made by subsection (a) (amending this section) shall take effect on the
date of the enactment of this Act (Nov. 5, 1990).''
Amendment by Pub. L. 99-272 applicable to calendar quarters
beginning on or after Apr. 7, 1986, except as otherwise provided, see
section 9503(g)(1), (2) of Pub. L. 99-272, set out as a note under
section 1396a of this title.
Amendment by Pub. L. 98-369 effective Oct. 1, 1984, except as
otherwise provided, see section 2367(c) of Pub. L. 98-369, set out as a
note under section 1396a of this title.
42 USC 1396l. Hospital providers of nursing facility services
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Notwithstanding any other provision of this subchapter, payment
may be made, in accordance with this section, under a State plan
approved under this subchapter for nursing facility services furnished
by a hospital which has in effect an agreement under section 1395tt of
this title and which, with respect to the provision of such services,
meets the requirements of subsections (b) through (d) of section 1396r
of this title.
(b)(1) Except as provided in paragraph (3), payment to any such
hospital, for any nursing facility services furnished pursuant to
subsection (a) of this section, shall be at a rate equal to the average
rate per patient-day paid for routine services during the previous
calendar year under the State plan to nursing facilities, respectively,
/1/ located in the State in which the hospital is located. The
reasonable cost of ancillary services shall be determined in the same
manner as the reasonable cost of ancillary services provided for
inpatient hospital services.
(2) With respect to any period for which a hospital has an agreement
under section 1395tt of this title, in order to allocate routine costs
between hospital and long-term care services, the total reimbursement
for routine services due from all classes of long-term care patients
(including subchapter XVIII of this chapter, this subchapter, and
private pay patients) shall be subtracted from the hospital total
routine costs before calculations are made to determine reimbursement
for routine hospital services under the State plan.
(3) Payment to all such hospitals, for any nursing facility services
furnished pursuant to subsection (a) of this section, may be made at a
payment rate established by the State in accordance with the
requirements of section 1396a(a)(13)(A) of this title.
(Aug. 14, 1935, ch. 531, title XIX, 1913, as added Dec. 5, 1980,
Pub. L. 96-499, title IX, 904(b), 94 Stat. 2617, and amended July 18,
1984, Pub. L. 98-369, div. B, title III, 2369(a), 98 Stat. 1110; Dec.
22, 1987, Pub. L. 100-203, title IV, 4211(h)(9), 101 Stat. 1330-206.)
1987 -- Pub. L. 100-203, 4211(h)(9)(A), substituted ''nursing
facility services'' for ''skilled nursing and intermediate care
services'' in section catchline.
Subsec. (a). Pub. L. 100-203, 4211(h)(9)(B), substituted ''nursing
facility services'' for ''skilled nursing facility services and
intermediate care facility services'' and inserted ''and which, with
respect to the provision of such services, meets the requirements of
subsections (b) through (d) of section 1396r of this title'' before
period at end.
Subsec. (b)(1). Pub. L. 100-203, 4211(h)(9)(C), substituted
''nursing facility services'' for ''skilled nursing or intermediate care
facility services'' and ''nursing facilities'' for ''skilled nursing and
intermediate care facilities''.
Subsec. (b)(3). Pub. L. 100-203, 4211(h)(9)(D), substituted
''nursing facility services'' for ''skilled nursing or intermediate care
facility services''.
1984 -- Subsec. (b)(1). Pub. L. 98-369, 2369(a)(1), substituted
''Except as provided in paragraph (3), payment'' for ''Payment''.
Subsec. (b)(3). Pub. L. 98-369, 2369(a)(2), added par. (3).
Amendment by Pub. L. 100-203 applicable to nursing facility services
furnished on or after Oct. 1, 1990, without regard to whether
regulations implementing such amendment are promulgated by such date,
except as otherwise specifically provided in section 1396r of this
title, with transitional rule, see section 4214(a), (b)(2) of Pub. L.
100-203, as amended, set out as an Effective Date note under section
1396r of this title.
Section 2369(b) of Pub. L. 98-369 provided that: ''The amendments
made by this section (amending this section) shall apply to payments for
services furnished after the date of the enactment of this Act (July 18,
1984).''
Section effective on date on which final regulations to implement the
section are first issued, see section 904(d) of Pub. L. 96-499, set out
as an Effective Date note under section 1395tt of this title.
/1/ So in original, '', respectively,'' probably should not appear.
42 USC 1396m. Withholding of Federal share of payments for certain
medicare providers
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Adjustment of Federal matching payments
The Secretary may adjust, in accordance with this section, the
Federal matching payment to a State with respect to expenditures for
medical assistance for care or services furnished in any quarter by --
(1) an institution (A) which has or previously had in effect an
agreement with the Secretary under section 1395cc of this title; and
(B)(i) from which the Secretary has been unable to recover overpayments
made under subchapter XVIII of this chapter, or (ii) from which the
Secretary has been unable to collect the information necessary to enable
him to determine the amount (if any) of the overpayments made to such
institution under subchapter XVIII of this chapter; and
(2) any person (A) who (i) has previously accepted payment on the
basis of an assignment under section 1395u(b)(3)(B)(ii) of this title,
and (ii) during the annual period immediately preceding such quarter
submitted no claims for payment under subchapter XVIII of this chapter,
or submitted claims for payment under subchapter XVIII of this chapter
which aggregated less than the amount of overpayments made to him, and
(B)(i) from whom the Secretary has been unable to recover overpayments
received in violation of the terms of such assignment, or (ii) from whom
the Secretary has been unable to collect the information necessary to
enable him to determine the amount (if any) of the overpayments made to
such person under subchapter XVIII of this chapter.
(b) Reductions in payments to and by States
The Secretary may (subject to the remaining provisions of this
section) reduce payment to a State under this subchapter for any quarter
by an amount equal to the lesser of the Federal matching share of
payments to any institution or person specified in subsection (a) of
this section, or the total overpayments to such institution or person
under subchapter XVIII of this chapter, and may require the State to
reduce its payment to such institution or person by such amount.
(c) Notice
The Secretary shall not make any adjustment in the payment to a
State, nor require any adjustment in the payment to an institution or
person, pursuant to subsection (b) of this section until after he has
provided adequate notice (which shall be not less than 60 days) to the
State agency and the institution or person.
(d) Regulations
The Secretary shall by regulation provide procedures for
implementation of this section, which procedures shall (1) determine the
amount of the Federal payment to which the institution or person would
otherwise be entitled under this section which shall be treated as a
setoff against overpayments under subchapter XVIII of this chapter, and
(2) assure the restoration to the institution or person of amounts
withheld under this section which are ultimately determined to be in
excess of overpayments under subchapter XVIII of this chapter and to
which the institution or person would otherwise be entitled under this
subchapter.
(e) Restoration to trust funds of recovered amounts
The Secretary shall restore to the trust funds established under
sections 1395i and 1395t of this title, as appropriate, amounts
recovered under this section as setoffs against overpayments under
subchapter XVIII of this chapter.
(f) Liability of States for withheld payments
Notwithstanding any other provision of this subchapter, an
institution or person shall not be entitled to recover from any State
any amount in payment for medical care and services under this
subchapter which is withheld by the State agency pursuant to an order by
the Secretary under subsection (b) of this section.
(Aug. 14, 1935, ch. 531, title XIX, 1914, as added Dec. 5, 1980,
Pub. L. 96-499, title IX, 905(d), 94 Stat. 2618.)
42 USC 1396n. Compliance with State plan and payment provisions
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Activities deemed as compliance
A State shall not be deemed to be out of compliance with the
requirements of paragraphs (1), (10), or (23) of section 1396a(a) of
this title solely by reason of the fact that the State (or any political
subdivision thereof) --
(1) has entered into --
(A) a contract with an organization which has agreed to provide care
and services in addition to those offered under the State plan to
individuals eligible for medical assistance who reside in the geographic
area served by such organization and who elect to obtain such care and
services from such organization, or by reason of the fact that the plan
provides for payment for rural health clinic services only if those
services are provided by a rural health clinic; or
(B) arrangements through a competitive bidding process or otherwise
for the purchase of laboratory services referred to in section
1396d(a)(3) of this title or medical devices if the Secretary has found
that --
(i) adequate services or devices will be available under such
arrangements, and
(ii) any such laboratory services will be provided only through
laboratories --
(I) which meet the applicable requirements of section 1395x(e)(9) of
this title or paragraphs (15) and (16) of section 1395x(s) of this
title, and such additional requirements as the Secretary may require,
and
(II) no more than 75 percent of whose charges for such services are
for services provided to individuals who are entitled to benefits under
this subchapter or under part A or part B of subchapter XVIII of this
chapter; or
(2) restricts for a reasonable period of time the provider or
providers from which an individual (eligible for medical assistance for
items or services under the State plan) can receive such items or
services, if --
(A) the State has found, after notice and opportunity for a hearing
(in accordance with procedures established by the State), that the
individual has utilized such items or services at a frequency or amount
not medically necessary (as determined in accordance with utilization
guidelines established by the State), and
(B) under such restriction, individuals eligible for medical
assistance for such services have reasonable access (taking into account
geographic location and reasonable travel time) to such services of
adequate quality.
(b) Waivers to promote cost-effectiveness and efficiency
The Secretary, to the extent he finds it to be cost-effective and
efficient and not inconsistent with the purposes of this subchapter, may
waive such requirements of section 1396a of this title (other than
subsection (s)) (other than sections 1396a(a)(13)(E) and 1396a(a)(10)(A)
of this title insofar as it requires provision of the care and services
described in section 1396d(a)(2)(C) of this title) as may be necessary
for a State --
(1) to implement a primary care case-management system or a specialty
physician services arrangement which restricts the provider from (or
through) whom an individual (eligible for medical assistance under this
subchapter) can obtain medical care services (other than in emergency
circumstances), if such restriction does not substantially impair access
to such services of adequate quality where medically necessary,
(2) to allow a locality to act as a central broker in assisting
individuals (eligible for medical assistance under this subchapter) in
selecting among competing health care plans, if such restriction does
not substantially impair access to services of adequate quality where
medically necessary,
(3) to share (through provision of additional services) with
recipients of medical assistance under the State plan cost savings
resulting from use by the recipient of more cost-effective medical care,
and
(4) to restrict the provider from (or through) whom an individual
(eligible for medical assistance under this subchapter) can obtain
services (other than in emergency circumstances) to providers or
practitioners who undertake to provide such services and who meet,
accept, and comply with the reimbursement, quality, and utilization
standards under the State plan, which standards shall be consistent with
the requirements of section 1396r-4 of this title and are consistent
with access, quality, and efficient and economic provision of covered
care and services, if such restriction does not discriminate among
classes of providers on grounds unrelated to their demonstrated
effectiveness and efficiency in providing those services and if
providers under such restriction are paid on a timely basis in the same
manner as health care practitioners must be paid under section
1396a(a)(37)(A) of this title.
No waiver under this subsection may restrict the choice of the
individual in receiving services under section 1396d(a)(4)(C) of this
title.
(c) Waiver respecting medical assistance requirement in State plan;
scope, etc.; ''habilitation services'' defined; imposition of certain
regulatory limits prohibited; computation of expenditures for certain
disabled patients; coordinated services; substitution of participants
(1) The Secretary may by waiver provide that a State plan approved
under this subchapter may include as ''medical assistance'' under such
plan payment for part or all of the cost of home or community-based
services (other than room and board) approved by the Secretary which are
provided pursuant to a written plan of care to individuals with respect
to whom there has been a determination that but for the provision of
such services the individuals would require the level of care provided
in a hospital or a nursing facility or intermediate care facility for
the mentally retarded the cost of which could be reimbursed under the
State plan. For purposes of this subsection, the term ''room and
board'' shall not include an amount established under a method
determined by the State to reflect the portion of costs of rent and food
attributable to an unrelated personal caregiver who is residing in the
same household with an individual who, but for the assistance of such
caregiver, would require admission to a hospital, nursing facility, or
intermediate care facility for the mentally retarded.
(2) A waiver shall not be granted under this subsection unless the
State provides assurances satisfactory to the Secretary that --
(A) necessary safeguards (including adequate standards for provider
participation) have been taken to protect the health and welfare of
individuals provided services under the waiver and to assure financial
accountability for funds expended with respect to such services;
(B) the State will provide, with respect to individuals who --
(i) are entitled to medical assistance for inpatient hospital
services, nursing facility services, or services in an intermediate care
facility for the mentally retarded under the State plan,
(ii) may require such services, and
(iii) may be eligible for such home or community-based care under
such waiver,
for an evaluation of the need for inpatient hospital services,
nursing facility services, or services in an intermediate care facility
for the mentally retarded;
(C) such individuals who are determined to be likely to require the
level of care provided in a hospital, nursing facility, or intermediate
care facility for the mentally retarded are informed of the feasible
alternatives, if available under the waiver, at the choice of such
individuals, to the provision of inpatient hospital services, nursing
facility services, or services in an intermediate care facility for the
mentally retarded;
(D) under such waiver the average per capita expenditure estimated by
the State in any fiscal year for medical assistance provided with
respect to such individuals does not exceed 100 percent of the average
per capita expenditure that the State reasonably estimates would have
been made in that fiscal year for expenditures under the State plan for
such individuals if the waiver had not been granted; and
(E) the State will provide to the Secretary annually, consistent with
a data collection plan designed by the Secretary, information on the
impact of the waiver granted under this subsection on the type and
amount of medical assistance provided under the State plan and on the
health and welfare of recipients.
(3) A waiver granted under this subsection may include a waiver of
the requirements of section 1396a(a)(1) of this title (relating to
statewideness), section 1396a(a)(10)(B) of this title (relating to
comparability), and section 1396a(a)(10)(C)(i)(III) of this title
(relating to income and resource rules applicable in the community). A
waiver under this subsection shall be for an initial term of three years
and, upon the request of a State, shall be extended for additional
five-year periods unless the Secretary determines that for the previous
waiver period the assurances provided under paragraph (2) have not been
met. A waiver may provide, with respect to post-eligibility treatment
of income of all individuals receiving services under that waiver, that
the maximum amount of the individual's income which may be disregarded
for any month for the maintenance needs of the individual may be an
amount greater than the maximum allowed for that purpose under
regulations in effect on July 1, 1985.
(4) A waiver granted under this subsection may, consistent with
paragraph (2) --
(A) limit the individuals provided benefits under such waiver to
individuals with respect to whom the State has determined that there is
a reasonable expectation that the amount of medical assistance provided
with respect to the individual under such waiver will not exceed the
amount of such medical assistance provided for such individual if the
waiver did not apply, and
(B) provide medical assistance to individuals (to the extent
consistent with written plans of care, which are subject to the approval
of the State) for case management services, homemaker/home health aide
services and personal care services, adult day health services,
habilitation services, respite care, and such other services requested
by the State as the Secretary may approve and for day treatment or other
partial hospitalization services, psychosocial rehabilitation services,
and clinic services (whether or not furnished in a facility) for
individuals with chronic mental illness.
Except as provided under paragraph (2)(D), the Secretary may not
restrict the number of hours or days of respite care in any period which
a State may provide under a waiver under this subsection.
(5) For purposes of paragraph (4)(B), the term ''habilitation
services'', with respect to individuals who receive such services after
discharge from a nursing facility or intermediate care facility for the
mentally retarded --
(A) means services designed to assist individuals in acquiring,
retaining, and improving the self-help, socialization, and adaptive
skills necessary to reside successfully in home and community based
settings; and
(B) includes (except as provided in subparagraph (C)) prevocational,
educational, and supported employment services; but
(C) does not include --
(i) special education and related services (as defined in paragraphs
(16) and (17) of section 1401(a) of title 20) which otherwise are
available to the individual through a local educational agency; and
(ii) vocational rehabilitation services which otherwise are available
to the individual through a program funded under section 730 of title
29.
(6) The Secretary may not require, as a condition of approval of a
waiver under this section under paragraph (2)(D), that the actual total
expenditures for home and community-based services under the waiver (and
a claim for Federal financial participation in expenditures for the
services) cannot exceed the approved estimates for these services. The
Secretary may not deny Federal financial payment with respect to
services under such a waiver on the ground that, in order to comply with
paragraph (2)(D), a State has failed to comply with such a requirement.
(7)(A) In making estimates under paragraph (2)(D) in the case of a
waiver that applies only to individuals with a particular illness or
condition who are inpatients in, or who would require the level of care
provided in, hospitals, nursing facilities, or intermediate care
facilities for the mentally retarded, the State may determine the
average per capita expenditure that would have been made in a fiscal
year for those individuals under the State plan separately from the
expenditures for other individuals who are inpatients in, or who would
require the level of care provided in, those respective facilities.
(B) In making estimates under paragraph (2)(D) in the case of a
waiver that applies only to individuals with developmental disabilities
who are inpatients in a nursing facility and whom the State has
determined, on the basis of an evaluation under paragraph (2)(B), to
need the level of services provided by an intermediate care facility for
the mentally retarded, the State may determine the average per capita
expenditures that would have been made in a fiscal year for those
individuals under the State plan on the basis of the average per capita
expenditures under the State plan for services to individuals who are
inpatients in an intermediate care facility for the mentally retarded,
without regard to the availability of beds for such inpatients.
(C) In making estimates under paragraph (2)(D) in the case of a
waiver to the extent that it applies to individuals with mental
retardation or a related condition who are resident in an intermediate
care facility for the mentally retarded the participation of which under
the State plan is terminated, the State may determine the average per
capita expenditures that would have been made in a fiscal year for those
individuals without regard to any such termination.
(8) The State agency administering the plan under this subchapter
may, whenever appropriate, enter into cooperative arrangements with the
State agency responsible for administering the program for children with
special health care needs under subchapter V of this chapter in order to
assure improved access to coordinated services to meet the needs of such
children.
(9) In the case of any waiver under this subsection which contains a
limit on the number of individuals who shall receive home or
community-based services, the State may substitute additional
individuals to receive such services to replace any individuals who die
or become ineligible for services under the State plan.
(10) The Secretary shall not limit to fewer than 200 the number of
individuals in the State who may receive home and community-based
services under a waiver under this subsection.
(d) Home and community-based services for elderly
(1) Subject to paragraph (2), the Secretary shall grant a waiver to
provide that a State plan approved under this subchapter shall include
as ''medical assistance'' under such plan payment for part or all of the
cost of home or community-based services (other than room and board)
which are provided pursuant to a written plan of care to individuals 65
years of age or older with respect to whom there has been a
determination that but for the provision of such services the
individuals would be likely to require the level of care provided in a
skilled nursing facility or intermediate care facility the cost of which
could be reimbursed under the State plan. For purposes of this
subsection, the term ''room and board'' shall not include an amount
established under a method determined by the State to reflect the
portion of costs of rent and food attributable to an unrelated personal
caregiver who is residing in the same household with an individual who,
but for the assistance of such caregiver, would require admission to a
hospital, nursing facility, or intermediate care facility for the
mentally retarded.
(2) A waiver shall not be granted under this subsection unless the
State provides assurances satisfactory to the Secretary that --
(A) necessary safeguards (including adequate standards for provider
participation) have been taken to protect the health and welfare of
individuals provided services under the waiver and to assure financial
accountability for funds expended with respect to such services;
(B) with respect to individuals 65 years of age or older who --
(i) are entitled to medical assistance for skilled nursing or
intermediate care facility services under the State plan,
(ii) may require such services, and
(iii) may be eligible for such home or community-based services under
such waiver,
the State will provide for an evaluation of the need for such skilled
nursing facility or intermediate care facility services; and
(C) such individuals who are determined to be likely to require the
level of care provided in a skilled nursing facility or intermediate
care facility are informed of the feasible alternatives to the provision
of skilled nursing facility or intermediate care facility services,
which such individuals may choose if available under the waiver.
Each State with a waiver under this subsection shall provide to the
Secretary annually, consistent with a reasonable data collection plan
designed by the Secretary, information on the impact of the waiver
granted under this subsection on the type and amount of medical
assistance provided under the State plan and on the health and welfare
of recipients.
(3) A waiver granted under this subsection may include a waiver of
the requirements of section 1396a(a)(1) of this title (relating to
statewideness), section 1396a(a)(10)(B) of this title (relating to
comparability), and section 1396a(a)(10)(C)(i)(III) of this title
(relating to income and resource rules applicable in the community).
Subject to a termination by the State (with notice to the Secretary) at
any time, a waiver under this subsection shall be for an initial term of
3 years and, upon the request of a State, shall be extended for
additional 5-year periods unless the Secretary determines that for the
previous waiver period the assurances provided under paragraph (2) have
not been met. A waiver may provide, with respect to post-eligibility
treatment of income of all individuals receiving services under the
waiver, that the maximum amount of the individual's income which may be
disregarded for any month is equal to the amount that may be allowed for
that purpose under a waiver under subsection (c) of this section.
(4) A waiver under this subsection may, consistent with paragraph
(2), provide medical assistance to individuals for case management
services, homemaker/home health aide services and personal care
services, adult day health services, respite care, and other medical and
social services that can contribute to the health and well-being of
individuals and their ability to reside in a community-based care
setting.
(5)(A) In the case of a State having a waiver approved under this
subsection, notwithstanding any other provision of section 1396b of this
title to the contrary, the total amount expended by the State for
medical assistance with respect to skilled nursing facility services,
intermediate care facility services, and home and community-based
services under the State plan for individuals 65 years of age or older
during a waiver year under this subsection may not exceed the projected
amount determined under subparagraph (B).
(B) For purposes of subparagraph (A), the projected amount under this
subparagraph is the sum of the following:
(i) The aggregate amount of the State's medical assistance under this
subchapter for skilled nursing facility services and intermediate care
facility services furnished to individuals who have attained the age of
65 for the base year increased by a percentage which is equal to the
lesser of 7 percent times the number of years (rounded to the nearest
quarter of a year) beginning after the base year and ending at the end
of the waiver year involved or the sum of --
(I) the percentage increase (based on an appropriate market-basket
index representing the costs of elements of such services) between the
beginning of the base year and the beginning of the waiver year
involved, plus
(II) the percentage increase between the beginning of the base year
and the beginning of the waiver year involved in the number of residents
in the State who have attained the age of 65, plus
(III) 2 percent for each year (rounded to the nearest quarter of a
year) beginning after the base year and ending at the end of the waiver
year.
(ii) The aggregate amount of the State's medical assistance under
this subchapter for home and community-based services for individuals
who have attained the age of 65 for the base year increased by a
percentage which is equal to the lesser of 7 percent times the number of
years (rounded to the nearest quarter of a year) beginning after the
base year and ending at the end of the waiver year involved or the sum
of --
(I) the percentage increase (based on an appropriate market-basket
index representing the costs of elements of such services) between the
beginning of the base year and the beginning of the waiver year
involved, plus
(II) the percentage increase between the beginning of the base year
and the beginning of the waiver year involved in the number of residents
in the State who have attained the age of 65, plus
(III) 2 percent for each year (rounded to the nearest quarter of a
year) beginning after the base year and ending at the end of the waiver
year.
(iii) The Secretary shall develop and promulgate by regulation (by
not later than October 1, 1989) --
(I) a method, based on an index of appropriately weighted indicators
of changes in the wages and prices of the mix of goods and services
which comprise both skilled nursing facility services and intermediate
care facility services (regardless of the source of payment for such
services), for projecting the percentage increase for purposes of clause
(i)(I);
(II) a method, based on an index of appropriately weighted indicators
of changes in the wages and prices of the mix of goods and services
which comprise home and community-based services (regardless of the
source of payment for such services), for projecting the percentage
increase for purposes of clause (ii)(I); and
(III) a method for projecting, on a State specific basis, the
percentage increase in the number of residents in each State who are
over 65 years of age for any period.
The Secretary shall develop (by not later than October 1, 1989) a
method for projecting, on a State-specific basis, the percentage
increase in the number of residents in each State who are over 75 years
of age for any period. Effective on and after the date the Secretary
promulgates the regulation under clause (iii), any reference in this
subparagraph to the ''lesser of 7 percent'' shall be deemed to be a
reference to the ''greater of 7 percent''.
(iv) If there is enacted after December 22, 1987, an Act which amends
this subchapter whose provisions become effective on or after such date
and which results in an increase in the aggregate amount of medical
assistance under this subchapter for nursing facility services and home
and community-based services for individuals who have attained the age
of 65 years, the Secretary, at the request of a State with a waiver
under this subsection for a waiver year or years and in close
consultation with the State, shall adjust the projected amount computed
under this subparagraph for the waiver year or years to take into
account such increase.
(C) In this paragraph:
(i) The term ''home and community-based services'' includes services
described in sections 1396d(a)(7) and 1396d(a)(8) of this title,
services described in subsection (c)(4)(B) of this section, services
described in paragraph (4), and personal care services.
(ii)(I) Subject to subclause (II), the term ''base year'' means the
most recent year (ending before December 22, 1987) for which actual
final expenditures under this subchapter have been reported to, and
accepted by, the Secretary.
(II) For purposes of subparagraph (C), in the case of a State that
does not report expenditures on the basis of the age categories
described in such subparagraph for a year ending before December 22,
1987, the term ''base year'' means fiscal year 1989.
(iii) The term ''intermediate care facility services'' does not
include services furnished in an institution certified in accordance
with section 1396d(d) of this title.
(6)(A) A determination by the Secretary to deny a request for a
waiver (or extension of waiver) under this subsection shall be subject
to review to the extent provided under section 1316(b) of this title.
(B) Notwithstanding any other provision of this chapter, if the
Secretary denies a request of the State for an extension of a waiver
under this subsection, any waiver under this subsection in effect on the
date such request is made shall remain in effect for a period of not
less than 90 days after the date on which the Secretary denies such
request (or, if the State seeks review of such determination in
accordance with subparagraph (A), the date on which a final
determination is made with respect to such review).
(e) Waiver for children infected with AIDS or drug dependent at birth
(1)(A) Subject to paragraph (2), the Secretary shall grant a waiver
to provide that a State plan approved under this subchapter shall
include as ''medical assistance'' under such plan payment for part or
all of the cost of nursing care, respite care, physicians' services,
prescribed drugs, medical devices and supplies, transportation services,
and such other services requested by the State as the Secretary may
approve which are provided pursuant to a written plan of care to a child
described in subparagraph (B) with respect to whom there has been a
determination that but for the provision of such services the infants
would be likely to require the level of care provided in a hospital or
nursing facility the cost of which could be reimbursed under the State
plan.
(B) Children described in this subparagraph are individuals under 5
years of age who --
(i) at the time of birth were infected with (or tested positively
for) the etiologic agent for acquired immune deficiency syndrome (AIDS),
(ii) have such syndrome, or
(iii) at the time of birth were dependent on heroin, cocaine, or
phencyclidine,
and with respect to whom adoption or foster care assistance is (or
will be) made available under part E of subchapter IV of this chapter.
(2) A waiver shall not be granted under this subsection unless the
State provides assurances satisfactory to the Secretary that --
(A) necessary safeguards (including adequate standards for provider
participation) have been taken to protect the health and welfare of
individuals provided services under the waiver and to assure financial
accountability for funds expended with respect to such services;
(B) under such waiver the average per capita expenditure estimated by
the State in any fiscal year for medical assistance provided with
respect to such individuals does not exceed 100 percent of the average
per capita expenditure that the State reasonably estimates would have
been made in that fiscal year for expenditures under the State plan for
such individuals if the waiver had not been granted; and
(C) the State will provide to the Secretary annually, consistent with
a data collection plan designed by the Secretary, information on the
impact of the waiver granted under this subsection on the type and
amount of medical assistance provided under the State plan and on the
health and welfare of recipients.
(3) A waiver granted under this subsection may include a waiver of
the requirements of section 1396a(a)(1) of this title (relating to
statewideness) and section 1396a(a)(10)(B) of this title (relating to
comparability). A waiver under this subsection shall be for an initial
term of 3 years and, upon the request of a State, shall be extended for
additional five-year periods unless the Secretary determines that for
the previous waiver period the assurances provided under paragraph (2)
have not been met.
(4) The provisions of paragraph (6) of subsection (d) of this section
shall apply to this subsection in the same manner as it applies to
subsection (d) of this section.
(f) Monitor of implementation of waivers; termination of waiver for
noncompliance; time limitation for action on requests for plan
approval, amendments, or waivers
(1) The Secretary shall monitor the implementation of waivers granted
under this section to assure that the requirements for such waiver are
being met and shall, after notice and opportunity for a hearing,
terminate any such waiver where he finds noncompliance has occurred.
(2) A request to the Secretary from a State for approval of a
proposed State plan or plan amendment or a waiver of a requirement of
this subchapter submitted by the State pursuant to a provision of this
subchapter shall be deemed granted unless the Secretary, within 90 days
after the date of its submission to the Secretary, either denies such
request in writing or informs the State agency in writing with respect
to any additional information which is needed in order to make a final
determination with respect to the request. After the date the Secretary
receives such additional information, the request shall be deemed
granted unless the Secretary, within 90 days of such date, denies such
request.
(g) Optional targeted case management services
(1) A State may provide, as medical assistance, case management
services under the plan without regard to the requirements of section
1396a(a)(1) of this title and section 1396a(a)(10)(B) of this title.
The provision of case management services under this subsection shall
not restrict the choice of the individual to receive medical assistance
in violation of section 1396a(a)(23) of this title. A State may limit
the provision of case management services under this subsection to
individuals with acquired immune deficiency syndrome (AIDS), or with
AIDS-related conditions, or with either, and a State may limit the
provision of case management services under this subsection to
individuals with chronic mental illness. The State may limit the case
managers available with respect to case management services for eligible
individuals with developmental disabilities or with chronic mental
illness in order to ensure that the case managers for such individuals
are capable of ensuring that such individuals receive needed services.
(2) For purposes of this subsection, the term ''case management
services'' means services which will assist individuals eligible under
the plan in gaining access to needed medical, social, educational, and
other services.
(h) Period of waivers; continuations
No waiver under this section (other than a waiver under subsection
(c), (d), or (e) of this section) may extend over a period of longer
than two years unless the State requests continuation of such waiver,
and such request shall be deemed granted unless the Secretary, within 90
days after the date of its submission to the Secretary, either denies
such request in writing or informs the State agency in writing with
respect to any additional information which is needed in order to make a
final determination with respect to the request. After the date the
Secretary receives such additional information, the request shall be
deemed granted unless the Secretary, within 90 day /2/ of such date,
denies such request.
(Aug. 14, 1935, ch. 531, title XIX, 1915, as added Aug. 13, 1981,
Pub. L. 97-35, title XXI, 2175(b), 95 Stat. 809, and amended Aug. 13,
1981, Pub. L. 97-35, title XXI, 2176, 2177(a), 95 Stat. 812, 813;
Sept. 3, 1982, Pub. L. 97-248, title I, 137(b)(19)(A), (20)-(25), 96
Stat. 380; Jan. 12, 1983, Pub. L. 97-448, title III, 309(b)(17), 96
Stat. 2409; July 18, 1984, Pub. L. 98-369, div. B, title III,
2373(b)(21), 98 Stat. 1112; Apr. 7, 1986, Pub. L. 99-272, title IX,
9502(a)-(e), (g)-(i), 9508(a), 100 Stat. 202-204, 210; Oct. 21, 1986,
Pub. L. 99-509, title IX, 9320(h)(3), 9411(a)-(d), 100 Stat. 2016,
2061, 2062; Aug. 18, 1987, Pub. L. 100-93, 8(h)(2), 101 Stat. 694;
Dec. 22, 1987, Pub. L. 100-203, title IV, 4072(d), 4102(a)(1), (b)(2),
4118(a)(1), (b), (i)(1), (k), (l)(1), (p)(10), 4211(h)(10), 101 Stat.
1330-117, 1330-143, 1330-146, 1330-154 to 1330-157, 1330-160, 1330-206;
July 1, 1988, Pub. L. 100-360, title II, 204(d)(3), title IV,
411(k)(3), (10)(A), (H), (I), (17)(A), (l)(3)(G), 102 Stat. 729, 791,
794, 796, 799, 803; Oct. 13, 1988, Pub. L. 100-485, title VI,
608(d)(26)(M), (f)(2), 102 Stat. 2422, 2424; Nov. 10, 1988, Pub. L.
100-647, title VIII, 8432(a), (b), 8437(a), 102 Stat. 3804, 3806;
Dec. 13, 1989, Pub. L. 101-234, title II, 201(a), 103 Stat. 1981; Dec.
19, 1989, Pub. L. 101-239, title VI, 6115(c), 6411(c)(2), 103 Stat.
2219, 2270; Nov. 5, 1990, Pub. L. 101-508, title IV, 4604(c),
4704(b)(3), 4741, 4742(a), (c)(1), (d)(1), 104 Stat. 1388-169, 1388-172,
1388-197, 1388-198; Oct. 7, 1991, Pub. L. 102-119, 26(i)(2), 105 Stat.
607.)
For contingent effective date of amendment by section 4072(d) of Pub.
L. 100-203, see section 4072(e) of Pub. L. 100-203, set out as an
Effective Date of 1987 Amendment note under section 1395x of this title.
Parts A and B of subchapter XVIII of this chapter, referred to in
subsec. (a)(1)(B)(ii)(II), are classified to sections 1395c et seq.
and 1395j et seq., respectively, of this title.
Part E of subchapter IV of this chapter, referred to in subsec.
(e)(1)(B), is classified to section 670 et seq. of this title.
1991 -- Subsec. (c)(5)(C)(i). Pub. L. 102-119 substituted ''(as
defined in paragraphs (16) and (17) of section 1401(a) of title 20)''
for ''(as defined in section 1401(16) and (17) of title 20)''. The
reference to section 1401 of title 20 includes the substitution of
''Individuals with Disabilities Education Act'' for ''Education of the
Handicapped Act'' in the original.
1990 -- Subsec. (b). Pub. L. 101-508, 4704(b)(3), inserted ''(other
than sections 1396a(a)(13)(E) and 1396a(a)(10)(A) of this title insofar
as it requires provision of the care and services described in section
1396d(a)(2)(C) of this title)'' after ''section 1396a of this title'' in
introductory provisions.
Pub. L. 101-508, 4604(c), which directed amendment of subsec. (b)
by inserting ''(other than subsection (s))'' after ''Section 1396a of
this title'', was executed by inserting the new language after ''section
1396a of this title'' to reflect the probable intent of Congress.
Subsec. (b)(4). Pub. L. 101-508, 4742(a), inserted before period at
end ''and if providers under such restriction are paid on a timely basis
in the same manner as health care practitioners must be paid under
section 1396a(a)(37)(A) of this title''.
Subsec. (c)(1). Pub. L. 101-508, 4741(a), inserted at end ''For
purposes of this subsection, the term 'room and board' shall not include
an amount established under a method determined by the State to reflect
the portion of costs of rent and food attributable to an unrelated
personal caregiver who is residing in the same household with an
individual who, but for the assistance of such caregiver, would require
admission to a hospital, nursing facility, or intermediate care facility
for the mentally retarded.''
Subsec. (c)(4). Pub. L. 101-508, 4742(d)(1), inserted at end
''Except as provided under paragraph (2)(D), the Secretary may not
restrict the number of hours or days of respite care in any period which
a State may provide under a waiver under this subsection.''
Subsec. (c)(7)(C). Pub. L. 101-508, 4742(c)(1), added subpar. (C).
Subsec. (d)(1). Pub. L. 101-508, 4741(a), inserted at end ''For
purposes of this subsection, the term 'room and board' shall not include
an amount established under a method determined by the State to reflect
the portion of costs of rent and food attributable to an unrelated
personal caregiver who is residing in the same household with an
individual who, but for the assistance of such caregiver, would require
admission to a hospital, nursing facility, or intermediate care facility
for the mentally retarded.''
Subsec. (d)(5)(B)(iv). Pub. L. 101-508, 4741(b), substituted ''this
subchapter whose provisions become effective on or after such date'' for
first reference to ''this subchapter''.
1989 -- Subsec. (a)(1)(B)(ii)(I). Pub. L. 101-239, 6115(c),
substituted ''paragraphs (15) and (16)'' for ''paragraphs (14) and
(15)''.
Pub. L. 101-234 repealed Pub. L. 100-360, 204(d)(3), and provided
that the provisions of law amended or repealed by such section are
restored or revived as if such section had not been enacted, see 1988
Amendment note below.
Subsec. (b)(4). Pub. L. 101-239, 6411(c)(2), inserted ''shall be
consistent with the requirements of section 1396r-4 of this title and''
after ''which standards''.
1988 -- Subsec. (a)(1)(B)(ii)(I). Pub. L. 100-360, 204(d)(3),
substituted ''paragraphs (14) and (15)'' for ''paragraphs (13) and
(14)''.
Subsec. (a)(2). Pub. L. 100-485, 608(f)(2), substituted
''restricts'' for ''Restricts'' in introductory provisions.
Subsec. (c)(7). Pub. L. 100-360, 411(l)(3)(G), amended Pub. L.
100-203, 4211(h)(10)(G), see 1987 Amendment note below.
Subsec. (c)(7)(A). Pub. L. 100-647, 8437(a), substituted ''who are
inpatients in, or who would require the level of care provided in,
hospitals,'' for ''who are inpatients in hospitals,'' and ''who are
inpatients in, or who would require the level of care provided in, those
respective facilities'' for ''who are inpatients of those respective
facilities''.
Subsec. (c)(7)(B). Pub. L. 100-360, 411(k)(10)(H), inserted '',
without regard to the availability of beds for such inpatients'' before
period at end.
Subsec. (c)(10). Pub. L. 100-360, 411(k)(10)(A), substituted ''The
Secretary shall not limit to fewer than 200'' for ''No waiver under this
subsection shall limit by an amount less than 200'' and ''under a waiver
under this subsection'' for ''under such waiver''.
Subsec. (d)(5)(B)(i), (ii). Pub. L. 100-647, 8432(b), in
introductory provisions, substituted ''the number of years (rounded to
the nearest quarter of a year) beginning after the base year and ending
at the end of the waiver year'' for ''the number of years beginning
after the base year and ending before the waiver year'', in subcls. (I)
and (II), substituted ''between the beginning of the base year and the
beginning of the waiver year'' for ''between the base year and the
waiver year'', and in subcl. (III), inserted ''(rounded to the nearest
quarter of a year)'' after ''for each year'' and substituted ''at the
end of the waiver year'' for ''before the waiver year''.
Subsec. (d)(5)(B)(iii). Pub. L. 100-360, 411(k)(3)(A)(ii), inserted
before last sentence ''The Secretary shall develop (by not later than
October 1, 1989) a method for projecting, on a State-specific basis, the
percentage increase in the number of residents in each State who are
over 75 years of age for any period.''
Subsec. (d)(5)(B)(iii)(III). Pub. L. 100-360, 411(k)(3)(A)(i),
substituted ''65'' for ''75''.
Subsec. (d)(5)(B)(iv). Pub. L. 100-647, 8432(a), added cl. (iv).
Subsec. (d)(5)(C)(i). Pub. L. 100-360, 411(k)(3)(B), substituted
''paragraph (4), and personal care services'' for ''paragraph (4)(B),
personal care services, and services furnished pursuant to a waiver
under subsection (c) of this section''.
Subsec. (e). Pub. L. 100-360, 411(k)(17)(A)(ii), (iii), added
subsec. (e), redesignated former subsec. (e)(1) as (f)(1), and struck
out former subsec. (e)(2) which read as follows: ''The Secretary shall
report, not later than September 30, 1984, to Congress on waivers
granted under this section.''
Subsec. (f)(1). Pub. L. 100-360, 411(k)(17)(A)(ii), redesignated
former subsec. (e)(1) as (f)(1).
Subsec. (f)(2). Pub. L. 100-360, 411(k)(17)(A)(i), redesignated
former subsec. (f) as subsec. (f)(2).
Subsec. (h). Pub. L. 100-360, 411(k)(10)(I), made technical
amendment to directory language of Pub. L. 100-203, 4118(l)(1), see
1987 Amendment note below.
Pub. L. 100-360, 411(k)(17)(A)(iv), as amended by Pub. L. 100-485,
608(d)(26)(M), substituted '', (d), or (e)'' for ''or (d)''.
1987 -- Subsec. (a)(1)(B)(ii)(I). Pub. L. 100-203, 4072(d),
substituted ''paragraphs (13) and (14)'' for ''paragraphs (12) and
(13)''.
Subsec. (a)(2). Pub. L. 100-93 amended par. (2) generally. Prior to
amendment, par. (2) read as follows: ''restricts --
''(A) for a reasonable period of time the provider or providers from
which an individual (eligible for medical assistance for items or
services under the State plan) can receive such items or services, if
the State has found, after notice and opportunity for a hearing (in
accordance with procedures established by the State), that the
individual has utilized such items or services at a frequency or amount
not medically necessary (as determined in accordance with utilization
guidelines established by the State), or
''(B) (through suspension or otherwise) for a reasonable period of
time the participation of a provider of items or services under the
State plan, if the State has found, after notice and opportunity for a
hearing (in accordance with procedures established by the State), that
the provider has (in a significant number or proportion of cases)
provided such items or services either (i) at a frequency or amount not
medically necessary (as determined in accordance with utilization
guidelines established by the State), or (ii) of a quality which does
not meet professionally recognized standards of health care,
if, under such restriction, individuals eligible for medical
assistance for such services have reasonable access (taking into account
geographic location and reasonable travel time) to such services of
adequate quality.''
Subsec. (c)(1). Pub. L. 100-203, 4211(h)(10)(A), substituted
''nursing facility or intermediate care facility for the mentally
retarded'' for ''skilled nursing facility or intermediate care
facility''.
Subsec. (c)(2)(B). Pub. L. 100-203, 4211(h)(10)(C), in closing
provisions, substituted ''need for inpatient hospital services, nursing
facility services, or services in an intermediate care facility for the
mentally retarded'' for ''need for such inpatient hospital, skilled
nursing facility or intermediate care facility services''.
Pub. L. 100-203, 4118(p)(10), in closing provisions inserted
''such'' after ''need for''.
Subsec. (c)(2)(B)(i). Pub. L. 100-203, 4211(h)(10)(B), substituted
''services, nursing facility services, or services in an intermediate
care facility for the mentally retarded'' for '', skilled nursing
facility, or intermediate care facility services''.
Subsec. (c)(2)(C). Pub. L. 100-203, 4211(h)(10)(D), (E), substituted
'', nursing facility, or intermediate care facility for the mentally
retarded'' for ''or skilled nursing facility or intermediate care
facility'' and '', nursing facility services, or services in an
intermediate care facility for the mentally retarded'' for ''or skilled
nursing facility or intermediate care facility services''.
Subsec. (c)(3). Pub. L. 100-203, 4118(a)(1), substituted '', section
1396a(a)(10)(B) of this title (relating to comparability), and section
1396a(a)(10)(C)(i)(III) of this title (relating to income and resource
rules applicable in the community)'' for ''and section 1396a(a)(10)(B)
of this title (relating to comparability)''.
Subsec. (c)(5). Pub. L. 100-203, 4211(h)(10)(F), substituted
''nursing facility or intermediate care facility for the mentally
retarded'' for ''skilled nursing facility or intermediate care
facility''.
Subsec. (c)(7). Pub. L. 100-203, 4211(h)(10)(G), as amended by Pub.
L. 100-360, 411(l)(3)(G), substituted '', nursing facilities, or
intermediate care facilities for the mentally retarded'' for ''or in
skilled nursing or intermediate care facilities'' in subpar. (A) and
''nursing facility'' for ''skilled nursing facility or intermediate care
facility'' in subpar. (B).
Pub. L. 100-203, 4118(k), designated existing provisions as subpar.
(A) and added subpar. (B).
Subsec. (c)(10). Pub. L. 100-203, 4118(b), added par. (10).
Subsec. (d). Pub. L. 100-203, 4102(a)(1), added subsec. (d).
Former subsec. (d) redesignated (h).
Subsec. (g)(1). Pub. L. 100-203, 4118(i)(1), inserted at end ''The
State may limit the case managers available with respect to case
management services for eligible individuals with developmental
disabilities or with chronic mental illness in order to ensure that the
case managers for such individuals are capable of ensuring that such
individuals receive needed services.''
Subsec. (h). Pub. L. 100-203, 4118(l)(1), as amended by Pub. L.
100-360, 411(k)(10)(I), substituted '', within 90 days after the date
of its submission to the Secretary, either denies such request in
writing or informs the State agency in writing with respect to any
additional information which is needed in order to make a final
determination with respect to the request. After the date the Secretary
receives such additional information, the request shall be deemed
granted unless the Secretary, within 90 day of such date, denies such
request.'' for ''denies such request in writing within 90 days after the
date of its submission to the Secretary.''
Pub. L. 100-203, 4102(b)(2), substituted ''subsection (c) or (d) of
this section'' for ''subsection (c) of this section''.
Pub. L. 100-203, 4102(a)(1)(A), redesignated former subsec. (d) as
(h).
1986 -- Subsec. (a)(1)(B)(ii)(I). Pub. L. 99-509, 9320(h)(3),
substituted ''paragraphs (12) and (13)'' for ''paragraphs (11) and
(12)''.
Subsec. (b). Pub. L. 99-272, 9508(a)(2), inserted provision,
following par. (4), that no waiver under this subsection may restrict
the choice of the individual in receiving services under section
1396d(a)(4)(C) of this title.
Subsec. (c)(1). Pub. L. 99-509, 9411(a)(1), inserted ''a hospital
or'' after ''level of care provided in'', and struck out provision added
by Pub. L. 99-272, 9502(b)(1).
Pub. L. 99-272, 9502(b)(1), inserted provision relating to
individuals with respect to whom there has been a determination that but
for the provision of such services the individuals would continue to
receive inpatient hospital services, skilled nursing facility services,
or intermediate care facility services because they are dependent on
ventilator support the cost of which is reimbursed under the State plan.
Subsec. (c)(2)(B). Pub. L. 99-509, 9411(a)(2), substituted
''inpatient hospital, skilled nursing facility, or'' for ''skilled
nursing facility or'' in cl. (i) and inserted ''inpatient hospital,''
after ''need for'' in concluding provision following cl. (iii).
Subsec. (c)(2)(C). Pub. L. 99-272, 9502(b)(2), inserted ''hospital
or'' after ''provided in a'', and ''inpatient hospital services or''
after ''the provision of''.
Subsec. (c)(2)(D). Pub. L. 99-272, 9502(c)(1), inserted ''100
percent of'' after ''does not exceed''.
Subsec. (c)(3). Pub. L. 99-509, 9411(c), substituted ''and section
1396a(a)(10)(B) of this title (relating to comparability)'' for ''and
section 1396a(a)(10) of this title''.
Pub. L. 99-272, 9502(g), substituted ''additional five-year
periods'' for ''additional three-year periods'', and ''previous waiver
period'' for ''previous three-year period''.
Pub. L. 99-272, 9502(e), inserted at end ''A waiver may provide,
with respect to post-eligibility treatment of income of all individuals
receiving services under that waiver, that the maximum amount of the
individual's income which may be disregarded for any month for the
maintenance needs of the individual may be an amount greater than the
maximum allowed for that purpose under regulations in effect on July 1,
1985.''
Subsec. (c)(4)(B). Pub. L. 99-509, 9411(d), inserted before the
period ''and for day treatment or other partial hospitalization
services, psychosocial rehabilitation services, and clinic services
(whether or not furnished in a facility) for individuals with chronic
mental illness''.
Subsec. (c)(5). Pub. L. 99-272, 9502(a), added par. (5).
Subsec. (c)(6). Pub. L. 99-272, 9502(c)(2), added par. (6).
Subsec. (c)(7). Pub. L. 99-509, 9411(a)(3), amended par. (7)
generally. Prior to amendment, par. (7) read as follows: ''In making
estimates under paragraph (2)(D) in the case of a waiver which applies
only to physically disabled individuals who are inpatients in skilled
nursing or intermediate care facilities, the State may determine the
average per capita expenditure which would have been made in a fiscal
year for those individuals under the State plan separately from the
expenditure for other individuals who are inpatients of those
facilities.''
Pub. L. 99-272, 9502(d), added par. (7).
Subsec. (c)(8). Pub. L. 99-272, 9502(h), added par. (8).
Subsec. (c)(9). Pub. L. 99-272, 9502(i), added par. (9).
Subsec. (g). Pub. L. 99-272, 9508(a)(1), added subsec. (g).
Subsec. (g)(1). Pub. L. 99-509, 9411(b), inserted provision at end
allowing a State to limit case management services to AIDS victims or to
individuals with chronic mental illness.
1984 -- Subsec. (c)(1). Pub. L. 98-369 substituted ''under this
subchapter'' for ''under this part''.
1983 -- Subsec. (c)(2)(B). Pub. L. 97-448 substituted ''need for
such skilled nursing facility or intermediate care facility services''
for ''need for such services'' in provisions following cl. (iii).
1982 -- Subsec. (b). Pub. L. 97-248, 137(b)(19)(A), struck out
''and section 1396b(m) of this title'' after ''section 1396a of this
title''.
Subsec. (b)(1). Pub. L. 97-248, 137(b)(20), inserted ''primary
care'' before ''case-management system'', and substituted ''medical care
services'' for ''primary care services''.
Subsec. (c)(1). Pub. L. 97-248, 137(b)(21), inserted ''payment for
part or all of the cost of'' after ''may include as 'medical assistance'
under such plan''.
Subsec. (c)(2)(B). Pub. L. 97-248, 137(b)(22), redesignated existing
provisions as cls. (i) and (ii) and added cl. (iii).
Subsec. (c)(3). Pub. L. 97-248, 137(b)(23), substituted ''section
1396a(a)(1) of this title'' for ''subsection (a)(1) of this section''
and ''section 1396a(a)(10) of this title'' for ''subsection (a)(10) of
section 1396a of this title''.
Subsec. (c)(4). Pub. L. 97-248, 137(b)(24), substituted ''this
subsection'' for ''this section''.
Subsec. (f). Pub. L. 97-248, 137(b)(25), inserted ''approval of''
before ''a proposed State plan''.
1981 -- Subsecs. (c) to (e). Pub. L. 97-35, 2176, added subsec.
(c), redesignated former subsec. (c) as (d) and inserted ''(other than
a waiver under subsection (c) of this section)'', and redesignated
former subsec. (d) as (e).
Subsec. (f). Pub. L. 97-35, 2177(a), added subsec. (f).
Amendment by section 4604(c) of Pub. L. 101-508 effective with
respect to payments under this subchapter for calendar quarters
beginning on or after July 1, 1991, without regard to whether or not
final regulations to carry out the amendments by section 4604 of Pub.
L. 101-508 have been promulgated by such date, see section 4604(d) of
Pub. L. 101-508, set out as a note under section 1396a of this title.
Amendment by section 4704(b)(3) of Pub. L. 101-508 effective as if
included in the enactment of the Omnibus Budget Reconciliation Act of
1989, Pub. L. 101-239, see section 4704(f) of Pub. L. 101-508, set out
as a note under section 1396a of this title.
Section 4742(b) of Pub. L. 101-508 provided that: ''The amendment
made by subsection (a) (amending this section) shall take effect as of
the first calendar quarter beginning more than 30 days after the date of
the enactment of this Act (Nov. 5, 1990).''
Section 4742(c)(2) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply as
if included in the enactment of the Omnibus Budget Reconciliation Act of
1981 (Pub. L. 97-35), but shall only apply to facilities the
participation of which under a State plan under title XIX of the Social
Security Act (this subchapter) is terminated on or after the date of the
enactment of this Act (Nov. 5, 1990).''
Section 4742(d)(2) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply as
if included in the enactment of the Omnibus Budget Reconciliation Act of
1981 (Pub. L. 97-35).''
Amendment by section 6115(c) of Pub. L. 101-239 applicable to
screening pap smears performed on or after July 1, 1990, see section
6115(d) of Pub. L. 101-239, set out as a note under section 1395x of
this title.
Section 6411(c)(4) of Pub. L. 101-239 provided that: ''The
amendment made by paragraph (2) (amending this section) shall be
effective as if included in the enactment of the Omnibus Budget
Reconciliation Act of 1987 (Pub. L. 100-203).''
Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section
201(c) of Pub. L. 101-234, set out as a note under section 1320a-7a of
this title.
Section 8432(c) of Pub. L. 100-647 provided that: ''The amendments
made by this section (amending this section) shall apply to waiver years
beginning during or after fiscal year 1989.''
Section 8437(b) of Pub. L. 100-647 provided that: ''The amendment
made by subsection (a) (amending this section) shall apply with respect
to waiver applications submitted before, on, or after the date of the
enactment of this Act (Nov. 10, 1988).''
Amendment by section 608(d)(26)(M) of Pub. L. 100-485 effective as
if included in the enactment of the Medicare Catastrophic Coverage Act
of 1988, Pub. L. 100-360, see section 608(g)(1) of Pub. L. 100-485,
set out as a note under section 704 of this title.
Amendment by section 608(f)(2) of Pub. L. 100-485 effective Oct.
13, 1988, see section 608(g)(2) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 204(d)(3) of Pub. L. 100-360 applicable to
screening mammography performed on or after Jan. 1, 1990, see section
204(e) of Pub. L. 100-360, set out as a note under section 1395m of
this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(k)(3), (10)(A), (H), (I), (17)(A), (l)(3)(G) of
Pub. L. 100-360, as it relates to a provision in the Omnibus Budget
Reconciliation Act of 1987, Pub. L. 100-203, effective as if included
in the enactment of that provision in Pub. L. 100-203, see section
411(a) of Pub. L. 100-360, set out as a Reference to OBRA; Effective
Date note under section 106 of Title 1, General Provisions.
For contingent effective date of amendment by section 4072(d) of Pub.
L. 100-203, see section 4072(e) of Pub. L. 100-203, set out as a note
under section 1395x of this title.
Section 4102(a)(2) of Pub. L. 100-203 provided that: ''The
amendments made by paragraph (1) (amending this section) shall become
effective on January 1, 1988.''
Section 4118(a)(2) of Pub. L. 100-203 provided that: ''The
amendment made by paragraph (1) (amending this section) shall be
effective as if included in the enactment of the Omnibus Budget
Reconciliation Act of 1986 (Pub. L. 99-509).''
Section 4118(i)(2) of Pub. L. 100-203 provided that: ''The
amendment made by paragraph (1) (amending this section) shall take
effect as though it were included in the enactment of the Consolidated
Omnibus Budget Reconciliation Act of 1985 (Pub. L. 99-272).''
Section 4118(l)(2) of Pub. L. 100-203 provided that: ''The
amendment made by paragraph (1) (amending this section) shall apply to
requests for continuation of waivers received after the date of the
enactment of this Act (Dec. 22, 1987).''
Section 4118(p)(10) of Pub. L. 100-203 provided that the amendment
made by that section is effective as if included in the enactment of
Pub. L. 99-509.
Amendment by section 4211(h)(10) of Pub. L. 100-203 applicable to
nursing facility services furnished on or after Oct. 1, 1990, without
regard to whether regulations implementing such amendment are
promulgated by such date, except as otherwise specifically provided in
section 1396r of this title, with transitional rule, see section
4214(a), (b)(2) of Pub. L. 100-203, as amended, set out as an Effective
Date note under section 1396r of this title.
Amendment by Pub. L. 100-93 effective at end of fourteen-day period
beginning Aug. 18, 1987, and inapplicable to administrative proceedings
commenced before end of such period, see section 15(a) of Pub. L.
100-93, set out as a note under section 1320a-7 of this title.
Amendment by section 9320(h)(3) of Pub. L. 99-509 applicable to
services furnished on or after Jan. 1, 1989, with exceptions for
hospitals located in rural areas which meet certain requirements related
to certified registered nurse anesthetists, see section 9320(i), (k) of
Pub. L. 99-509, as amended, set out as notes under section 1395k of
this title.
Section 9411(e) of Pub. L. 99-509 provided that: ''The amendments
made by this section (amending this section) shall apply to applications
for waivers (or renewals thereof) approved on or after the date of the
enactment of this Act (Oct. 21, 1986).''
Section 9502(j) of Pub. L. 99-272, as amended by Pub. L. 99-509,
title IX, 9435(a), Oct. 21, 1986, 100 Stat. 2069; Pub. L. 100-203,
title IV, 4118(j), Dec. 22, 1987, 101 Stat. 1330-156, provided that:
''(1) Habilitation services. -- The amendment made by subsection (a)
(amending this section) shall be effective for services furnished on or
after the date of the enactment of this Act (Apr. 7, 1986) to
individuals eligible for services under a waiver granted under section
1915(c) of the Social Security Act (subsec. (c) of this section),
without regard to whether such individuals were receiving institutional
services before their participation in the waiver.
''(2) Hospitalized patients. -- The amendments made by subsection (b)
(amending this section) shall be effective for services furnished on or
after October 1, 1985.
''(3) Prohibition of regulatory limits and treatment of certain
physically disabled individuals. -- The amendments made by subsections
(c) and (d) (amending this section) shall apply to applications for
waivers (or renewals thereof) filed before, on, or after, the date of
the enactment of this Act (Apr. 7, 1986) and for services furnished on
or after August 13, 1981.
''(4) Income standards. -- The amendment made by subsection (e)
(amending this section) shall apply to waivers (or renewals thereof)
approved before, on, or after the date of the enactment of this Act
(Apr. 7, 1986).
''(5) Waiver extensions. -- Subsection (f) (enacting provisions set
out below) shall apply to waivers expiring on or after September 30,
1985, and before September 30, 1986.
''(6) Waiver renewals. -- The amendments made by subsection (g)
(amending this section) shall become effective on September 30, 1986.
''(7) Coordinated services and substitution of participants. -- The
amendments made by subsections (h) and (i) (amending this section) shall
become effective on the date of the enactment of this Act (Apr. 7,
1986).''
Section 9508(b) of Pub. L. 99-272, as amended by Pub. L. 99-509,
title IX, 9435(d)(1), Oct. 21, 1986, 100 Stat. 2070, provided that:
''The amendments made by this section (amending this section) shall
apply to services furnished on or after the date of the enactment of
this Act (Apr. 7, 1986), without regard to whether or not regulations to
carry out the amendments have been promulgated by that date.''
(Section 4118(j) of Pub. L. 100-203 provided that the amendment made
by that section to section 9502(j)(1) of Pub. L. 99-272, set out above,
is effective as if included in the enactment of section 9502 of Pub. L.
99-272.)
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.
Section 137(b)(19)(B) of Pub. L. 97-248 provided that: ''The
amendment made by subparagraph (A) (amending this section) shall not
apply with respect to any waiver if such waiver was granted, and the
arrangement covered by the waiver was in place, prior to August 10,
1982.''
Amendment by section 137(b)(20)-(25) of Pub. L. 97-248 effective as
if originally included as part of this section as this section was
amended by the Omnibus Budget Reconciliation Act of 1981, Pub. L.
97-35, see section 137(d)(2) of Pub. L. 97-248, set out as a note under
section 1396a of this title.
Section 2177(b) of Pub. L. 97-35 provided that: ''The amendment
made by this section (amending this section) shall become effective 90
days after the date of the enactment of this Act (Aug. 13, 1981)''.
Section 4742(e) of Pub. L. 101-508 provided that: ''In the case of
a waiver under section 1915(c) of the Social Security Act (subsec. (c)
of this section) for individuals with mental retardation or a related
condition in a State, the Secretary of Health and Human Services shall
permit the State to adjust the estimate of average per capita
expenditures submitted under paragraph (2)(D) of such section, with
respect to such expenditures made on or after January 1, 1989, to take
into account increases in expenditures for, or utilization of,
intermediate care facilities for the mentally retarded resulting from
implementation of section 1919(e)(7)(A) of such Act (section
1396r(e)(7)(A) of this title).''
Section 4102(c) of Pub. L. 100-203 provided that: ''In the case of
a State which, as of December 1, 1987, has a waiver approved with
respect to elderly individuals under section 1915(c) of the Social
Security Act (subsec. (c) of this section), which waiver is scheduled to
expire before July 1, 1988, if the State notifies the Secretary of
Health and Human Services of the State's intention to file an
application for a waiver under section 1915(d) of such Act (as amended
by subsection (a) of this section), the Secretary shall extend approval
of the State's waiver, under section 1915(c) of such Act, on the same
terms and conditions through September 30, 1988.''
Section 9502(f) of Pub. L. 99-272 provided that: ''The Secretary of
Health and Human Services shall extend, upon request of the State, any
waiver under section 1915(c) of the Social Security Act (subsec. (c) of
this section) which expires on or after September 30, 1985, and before
September 30, 1986. Such extension shall be for a period of not less
than one year nor more than five years, subject to section 1915(e)(1) of
such Act.''
/2/ So in original. Probably should be ''days''.
42 USC 1396o. Use of enrollment fees, premiums, deductions, cost
sharing, and similar charges
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Imposition of certain charges under plan in case of individuals
described in section 1396a(a)(10)(A) or (E)
The State plan shall provide that in the case of individuals
described in subparagraph (A) or (E)(i) of section 1396a(a)(10) of this
title who are eligible under the plan --
(1) no enrollment fee, premium, or similar charge will be imposed
under the plan (except for a premium imposed under subsection (c) of
this section);
(2) no deduction, cost sharing or similar charge will be imposed
under the plan with respect to --
(A) services furnished to individuals under 18 years of age (and, at
the option of the State, individuals under 21, 20, or 19 years of age,
or any reasonable category of individuals 18 years of age or over),
(B) services furnished to pregnant women, if such services relate to
the pregnancy or to any other medical condition which may complicate the
pregnancy (or, at the option of the State, any services furnished to
pregnant women),
(C) services furnished to any individual who is an inpatient in a
hospital, nursing facility, intermediate care facility for the mentally
retarded, or other medical institution, if such individual is required,
as a condition of receiving services in such institution under the State
plan, to spend for costs of medical care all but a minimal amount of his
income required for personal needs,
(D) emergency services (as defined by the Secretary), family planning
services and supplies described in section 1396d(a)(4)(C) of this title,
or services furnished to such an individual by a health maintenance
organization (as defined in section 1396b(m) of this title) in which he
is enrolled, or
(E) services furnished to an individual who is receiving hospice care
(as defined in section 1396d(o) of this title); and
(3) any deduction, cost sharing, or similar charge imposed under the
plan with respect to other such individuals or other care and services
will be nominal in amount (as determined by the Secretary in regulations
which shall, if the definition of ''nominal'' under the regulations in
effect on July 1, 1982 is changed, take into account the level of cash
assistance provided in such State and such other criteria as the
Secretary determines to be appropriate); except that a deduction,
cost-sharing, or similar charge of up to twice the nominal amount
established for outpatient services may be imposed by a State under a
waiver granted by the Secretary for services received at a hospital
emergency room if the services are not emergency services (referred to
in paragraph (2)(D)) and the State has established to the satisfaction
of the Secretary that individuals eligible for services under the plan
have actually available and accessible to them alternative sources of
nonemergency, outpatient services.
(b) Imposition of certain charges under plan in case of individuals
other than those described in section 1396a(a)(10)(A) or (E)
The State plan shall provide that in the case of individuals other
than those described in subparagraph (A) or (E) of section 1396a(a)(10)
of this title who are eligible under the plan --
(1) there may be imposed an enrollment fee, premium, or similar
charge, which (as determined in accordance with standards prescribed by
the Secretary) is related to the individual's income,
(2) no deduction, cost sharing, or similar charge will be imposed
under the plan with respect to --
(A) services furnished to individuals under 18 years of age (and, at
the option of the State, individuals under 21, 20, or 19 years of age,
or any reasonable category of individuals 18 years of age or over),
(B) services furnished to pregnant women, if such services relate to
the pregnancy or to any other medical condition which may complicate the
pregnancy (or, at the option of the State, any services furnished to
pregnant women),
(C) services furnished to any individual who is an inpatient in a
hospital, nursing facility, intermediate care facility for the mentally
retarded, or other medical institution, if such individual is required,
as a condition of receiving services in such institution under the State
plan, to spend for costs of medical care all but a minimal amount of his
income required for personal needs,
(D) emergency services (as defined by the Secretary), family planning
services and supplies described in section 1396d(a)(4)(C) of this title,
or (at the option of the State) services furnished to such an individual
by a health maintenance organization (as defined in section 1396b(m) of
this title) in which he is enrolled, or
(E) services furnished to an individual who is receiving hospice care
(as defined in section 1396d(o) of this title); and
(3) any deduction, cost sharing, or similar charge imposed under the
plan with respect to other such individuals or other care and services
will be nominal in amount (as determined by the Secretary in regulations
which shall, if the definition of ''nominal'' under the regulations in
effect on July 1, 1982 is changed, take into account the level of cash
assistance provided in such State and such other criteria as the
Secretary determines to be appropriate); except that a deduction,
cost-sharing, or similar charge of up to twice the nominal amount
established for outpatient services may be imposed by a State under a
waiver granted by the Secretary for services received at a hospital
emergency room if the services are not emergency services (referred to
in paragraph (2)(D)) and the State has established to the satisfaction
of the Secretary that individuals eligible for services under the plan
have actually available and accessible to them alternative sources of
nonemergency, outpatient services.
(c) Imposition of monthly premium; persons affected; amount;
prepayment; failure to pay; use of funds from other programs
(1) The State plan of a State may at the option of the State provide
for imposing a monthly premium (in an amount that does not exceed the
limit established under paragraph (2)) with respect to an individual
described in subparagraph (A) or (B) of section 1396a(l)(1) of this
title who is receiving medical assistance on the basis of section
1396a(a)(10)(A)(ii)(IX) of this title and whose family income (as
determined in accordance with the methodology specified in section
1396a(l)(3) of this title) equals or exceeds 150 percent of the income
official poverty line (as defined by the Office of Management and
Budget, and revised annually in accordance with section 9902(2) of this
title) applicable to a family of the size involved.
(2) In no case may the amount of any premium imposed under paragraph
(1) exceed 10 percent of the amount by which the family income (less
expenses for the care of a dependent child) of an individual exceeds 150
percent of the line described in paragraph (1).
(3) A State shall not require prepayment of a premium imposed
pursuant to paragraph (1) and shall not terminate eligibility of an
individual for medical assistance under this subchapter on the basis of
failure to pay any such premium until such failure continues for a
period of not less than 60 days. The State may waive payment of any
such premium in any case where the State determines that requiring such
payment would create an undue hardship.
(4) A State may permit State or local funds available under other
programs to be used for payment of a premium imposed under paragraph
(1). Payment of a premium with such funds shall not be counted as
income to the individual with respect to whom such payment is made.
(d) Premiums for qualified disabled and working individuals described
in section 1396d(s)
With respect to a qualified disabled and working individual described
in section 1396d(s) of this title whose income (as determined under
paragraph (3) of that section) exceeds 150 percent of the official
poverty line referred to in that paragraph, the State plan of a State
may provide for the charging of a premium (expressed as a percentage of
the medicare cost-sharing described in section 1396d(p)(3)(A)(i) of this
title provided with respect to the individual) according to a sliding
scale under which such percentage increases from 0 percent to 100
percent, in reasonable increments (as determined by the Secretary), as
the individual's income increases from 150 percent of such poverty line
to 200 percent of such poverty line.
(e) Prohibition of denial of services on basis of individual's
inability to pay certain charges
The State plan shall require that no provider participating under the
State plan may deny care or services to an individual eligible for such
care or services under the plan on account of such individual's
inability to pay a deduction, cost sharing, or similar charge. The
requirements of this subsection shall not extinguish the liability of
the individual to whom the care or services were furnished for payment
of the deduction, cost sharing, or similar charge.
(f) Charges imposed under waiver authority of Secretary
No deduction, cost sharing, or similar charge may be imposed under
any waiver authority of the Secretary, except as provided in subsections
(a)(3) and (b)(3) of this section, unless such waiver is for a
demonstration project which the Secretary finds after public notice and
opportunity for comment --
(1) will test a unique and previously untested use of copayments,
(2) is limited to a period of not more than two years,
(3) will provide benefits to recipients of medical assistance which
can reasonably be expected to be equivalent to the risks to the
recipients,
(4) is based on a reasonable hypothesis which the demonstration is
designed to test in a methodologically sound manner, including the use
of control groups of similar recipients of medical assistance in the
area, and
(5) is voluntary, or makes provision for assumption of liability for
preventable damage to the health of recipients of medical assistance
resulting from involuntary participation.
(Aug. 14, 1935, ch. 531, title XIX, 1916, as added Sept. 3, 1982,
Pub. L. 97-248, title I, 131(b), 96 Stat. 367, and amended Jan. 12,
1983, Pub. L. 97-448, title III, 309(b)(18)-(20), 96 Stat. 2409, 2410;
Apr. 7, 1986, Pub. L. 99-272, title IX, 9505(c)(2), 100 Stat. 209;
Oct. 21, 1986, Pub. L. 99-509, title IX, 9403(g)(4)(B), 100 Stat. 2056;
Dec. 22, 1987, Pub. L. 100-203, title IV, 4101(d)(1), 4211(h)(11),
101 Stat. 1330-142, 1330-207; July 1, 1988, Pub. L. 100-360, title IV,
411(k)(2), 102 Stat. 791; Dec. 19, 1989, Pub. L. 101-239, title VI,
6408(d)(3), 103 Stat. 2269.)
1989 -- Subsec. (a). Pub. L. 101-239, 6408(d)(3)(A), substituted
''subparagraph (A) or (E)(i)'' for ''subparagraph (A) or (E)'' in
introductory provisions.
Subsecs. (d) to (f). Pub. L. 101-239, 6408(d)(3)(B), (C), added
subsec. (d) and redesignated former subsecs. (d) and (e) as (e) and
(f), respectively.
1988 -- Subsec. (c)(1). Pub. L. 100-360 struck out ''nonfarm'' after
''150 percent of the''.
1987 -- Subsec. (a)(1). Pub. L. 100-203, 4101(d)(1)(A), inserted
''(except for a premium imposed under subsection (c) of this section)''
after ''plan''.
Subsecs. (a)(2)(C), (b)(2)(C). Pub. L. 100-203, 4211(h)(11),
substituted ''nursing facility, intermediate care facility for the
mentally retarded'' for ''skilled nursing facility, intermediate care
facility''.
Subsecs. (c) to (e). Pub. L. 100-203, 4101(d)(1)(B), (C), added
subsec. (c) and redesignated former subsecs. (c) and (d) as (d) and
(e), respectively.
1986 -- Subsec. (a). Pub. L. 99-509 substituted ''subparagraph (A)
or (E) of section 1396a(a)(10) of this title'' for ''section
1396a(a)(10)(A) of this title''.
Subsec. (a)(2)(E). Pub. L. 99-272 added subpar. (E).
Subsec. (b). Pub. L. 99-509 substituted ''subparagraph (A) or (E) of
section 1396a(a)(10) of this title'' for ''section 1396a(a)(10)(A) of
this title''.
Subsec. (b)(2)(E). Pub. L. 99-272 added subpar. (E).
1983 -- Subsec. (c). Pub. L. 97-448, 309(b)(18), substituted
''subsection'' for ''subparagraph''.
Subsec. (d). Pub. L. 97-448, 309(b)(19), (20), substituted in
introductory text '', except as provided in subsections (a)(3) and
(b)(3) of this section'' for ''unless authorized under this section'',
and in cl. (5) substituted ''is voluntary, or makes provision'' for
''in which participation is voluntary, or in which provision is made''.
Amendment by Pub. L. 101-239 applicable, except as otherwise
provided, to payments under this subchapter for calendar quarters
beginning on or after July 1, 1990, without regard to whether or not
final regulations have been promulgated by such date, see section
6408(d)(5) of Pub. L. 101-239, set out as a note under section 1396a 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.
Section 4101(d)(2) of Pub. L. 100-203 provided that: ''The
amendments made by paragraph (1) (amending this section) shall become
effective on July 1, 1988.''
Amendment by section 4211(h)(11) of Pub. L. 100-203 applicable to
nursing facility services furnished on or after Oct. 1, 1990, without
regard to whether regulations implementing such amendment are
promulgated by such date, except as otherwise specifically provided in
section 1396r of this title, with transitional rule, see section
4214(a), (b)(2) of Pub. L. 100-203, as amended, set out as an Effective
Date note under section 1396r of this title.
Amendment by Pub. L. 99-509 applicable to payments under this
subchapter for calendar quarters beginning on or after July 1, 1987,
without regard to whether or not final regulations to carry out such
amendments have been promulgated by such date, see section 9403(h) of
Pub. L. 99-509, set out as a note under section 1396a of this title.
Amendment by Pub. L. 99-272 applicable to medical assistance
provided for hospice care furnished on or after Apr. 7, 1986, see
section 9505(e) of Pub. L. 99-272, set out as a note under section
1396a of this title.
Amendment by Pub. L. 97-448 effective as if originally included as a
part of this section as this section was added 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.
Section 131(d), formerly 131(c), of Pub. L. 97-248, redesignated by
section 309(a)(8) of Pub. L. 97-448, provided that:
''(1) Except as provided in paragraph (2), the amendments made by
this section (enacting this section and amending section 1396a of this
title) shall become effective on October 1, 1982.
''(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act (this subchapter) which the Secretary of
Health and Human Services determines requires State legislation in order
for the plan to meet the additional requirements imposed by the
amendments made by this section, the State plan shall not be regarded as
failing to comply with the requirements of such title solely on the
basis of its failure to meet these additional requirements before the
first day of the first calendar quarter beginning after the close of the
first regular session of the State legislature that begins after the
date of the enactment of this Act (Sept. 3, 1982).''
1255a.
42 USC 1396p. Liens, adjustments and recoveries, and transfers of
assets
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Imposition of lien against property of an individual on account
of medical assistance rendered to him under a State plan
(1) No lien may be imposed against the property of any individual
prior to his death on account of medical assistance paid or to be paid
on his behalf under the State plan, except --
(A) pursuant to the judgment of a court on account of benefits
incorrectly paid on behalf of such individual, or
(B) in the case of the real property of an individual --
(i) who is an inpatient in a nursing facility, intermediate care
facility for the mentally retarded, or other medical institution, if
such individual is required, as a condition of receiving services in
such institution under the State plan, to spend for costs of medical
care all but a minimal amount of his income required for personal needs,
and
(ii) with respect to whom the State determines, after notice and
opportunity for a hearing (in accordance with procedures established by
the State), that he cannot reasonably be expected to be discharged from
the medical institution and to return home,
except as provided in paragraph (2).
(2) No lien may be imposed under paragraph (1)(B) on such
individual's home if --
(A) the spouse of such individual,
(B) such individual's child who is under age 21, or (with respect to
States eligible to participate in the State program established under
subchapter XVI of this chapter) is blind or permanently and totally
disabled, or (with respect to States which are not eligible to
participate in such program) is blind or disabled as defined in section
1382c of this title, or
(C) a sibling of such individual (who has an equity interest in such
home and who was residing in such individual's home for a period of at
least one year immediately before the date of the individual's admission
to the medical institution),
is lawfully residing in such home.
(3) Any lien imposed with respect to an individual pursuant to
paragraph (1)(B) shall dissolve upon that individual's discharge from
the medical institution and return home.
(b) Adjustment or recovery of medical assistance correctly paid under
a State plan
(1) No adjustment or recovery of any medical assistance correctly
paid on behalf of an individual under the State plan may be made, except
--
(A) in the case of an individual described in subsection (a)(1)(B) of
this section, from his estate or upon sale of the property subject to a
lien imposed on account of medical assistance paid on behalf of such
individual, and
(B) in the case of any other individual who was 65 years of age or
older when he received such assistance, from his estate.
(2) Any adjustment or recovery under paragraph (1) may be made only
after the death of the individual's surviving spouse, if any, and only
at a time --
(A) when he has no surviving child who is under age 21, or (with
respect to States eligible to participate in the State program
established under subchapter XVI of this chapter) is blind or
permanently and totally disabled, or (with respect to States which are
not eligible to participate in such program) is blind or disabled as
defined in section 1382c of this title; and
(B) in the case of a lien on an individual's home under subsection
(a)(1)(B) of this section, when --
(i) no sibling of the individual (who was residing in the
individual's home for a period of at least one year immediately before
the date of the individual's admission to the medical institution), and
(ii) no son or daughter of the individual (who was residing in the
individual's home for a period of at least two years immediately before
the date of the individual's admission to the medical institution, and
who establishes to the satisfaction of the State that he or she provided
care to such individual which permitted such individual to reside at
home rather than in an institution),
is lawfully residing in such home who has lawfully resided in such
home on a continuous basis since the date of the individual's admission
to the medical institution.
(c) Taking into account certain transfers of assets
(1) In order to meet the requirements of this subsection (for
purposes of section 1396a(a)(51)(B) of this title), the State plan must
provide for a period of ineligibility for nursing facility services and
for a level of care in a medical institution equivalent to that of
nursing facility services and for services under section 1396n(c) of
this title in the case of an institutionalized individual (as defined in
paragraph (3)) who, or whose spouse, at any time during or after the
30-month period immediately before the date the individual becomes an
institutionalized individual (if the individual is entitled to medical
assistance under the State plan on such date) or, if the individual is
not so entitled, the date the individual applies for such assistance
while an institutionalized individual, disposed of resources for less
than fair market value. The period of ineligibility shall begin with
the month in which such resources were transferred and the number of
months in such period shall be equal to the lesser of --
(A) 30 months, or
(B)(i) the total uncompensated value of the resources so transferred,
divided by (ii) the average cost, to a private patient at the time of
the application, of nursing facility services in the State or, at State
option, in the community in which the individual is institutionalized.
(2) An individual shall not be ineligible for medical assistance by
reason of paragraph (1) to the extent that --
(A) the resources transferred were a home and title to the home was
transferred to --
(i) the spouse of such individual;
(ii) a child of such individual who (I) is under age 21, or (II)
(with respect to States eligible to participate in the State program
established under subchapter XVI of this chapter) is blind or
permanently and totally disabled, or (with respect to States which are
not eligible to participate in such program) is blind or disabled as
defined in section 1382c of this title;
(iii) a sibling of such individual who has an equity interest in such
home and who was residing in such individual's home for a period of at
least one year immediately before the date the individual becomes an
institutionalized individual; or
(iv) a son or daughter of such individual (other than a child
described in clause (ii)) who was residing in such individual's home for
a period of at least two years immediately before the date the
individual becomes an institutionalized individual, and who (as
determined by the State) provided care to such individual which
permitted such individual to reside at home rather than in such an
institution or facility;
(B) the resources were transferred (i) to or from (or to another for
the sole benefit of) the individual's spouse, or (ii) to the
individual's child described in subparagraph (A)(ii)(II);
(C) a satisfactory showing is made to the State (in accordance with
any regulations promulgated by the Secretary) that (i) the individual
intended to dispose of the resources either at fair market value, or for
other valuable consideration, or (ii) the resources were transferred
exclusively for a purpose other than to qualify for medical assistance;
or
(D) the State determines that denial of eligibility would work an
undue hardship.
(3) In this subsection, the term ''institutionalized individual''
means an individual who is an inpatient in a nursing facility, who is an
inpatient in a medical institution and with respect to whom payment is
made based on a level of care provided in a nursing facility, or who is
described in section 1396a(a)(10)(A)(ii)(VI) of this title.
(4) A State (including a State which has elected treatment under
section 1396a(f) of this title) may not provide for any period of
ineligibility for an individual due to transfer of resources for less
than fair market value except in accordance with this subsection.
(5) In this subsection, the term ''resources'' has the meaning given
such term in section 1382b of this title, without regard to the
exclusion described in subsection (a)(1) thereof.
(Aug. 14, 1935, ch. 531, title XIX, 1917, as added Sept. 3, 1982,
Pub. L. 97-248, title I, 132(b), 96 Stat. 370, and amended Jan. 12,
1983, Pub. L. 97-448, title III, 309(b)(21), (22), 96 Stat. 2410; Dec.
22, 1987, Pub. L. 100-203, title IV, 4211(h)(12), 101 Stat. 1330-207;
July 1, 1988, Pub. L. 100-360, title III, 303(b), title IV,
411(l)(3)(I), 102 Stat. 760, 803; Oct. 13, 1988, Pub. L. 100-485,
title VI, 608(d)(16)(B), 102 Stat. 2417; Dec. 19, 1989, Pub. L.
101-239, title VI, 6411(e)(1), 103 Stat. 2271.)
1989 -- Subsec. (c)(1). Pub. L. 101-239, 6411(e)(1)(A), inserted
''or whose spouse,'' after ''an institutionalized individual (as defined
in paragraph (3)) who,''.
Subsec. (c)(2)(B)(i). Pub. L. 101-239, 6411(e)(1)(B)(i), amended cl.
(i) generally. Prior to amendment, cl. (i) read as follows: ''to (or
to another for the sole benefit of) the community spouse, as defined in
section 1396r-5(h)(2) of this title,,''.
Subsec. (c)(2)(B)(ii), (iii). Pub. L. 101-239, 6411(e)(1)(B)(ii),
struck out '', or'' after ''subparagraph (A)(ii)(II)'' in cl. (ii) and
struck out cl. (iii) which read as follows: ''to (or to another for
the sole benefit of) the individual's spouse if such spouse does not
transfer such resources to another person other than the spouse for less
than fair market value''.
1988 -- Subsec. (c). Pub. L. 100-360, 303(b), amended subsec. (c)
generally, substituting pars. (1) to (4) relating to taking into
account certain transfers of assets, for former pars. (1) to (3)
relating to denial of medical assistance, period of eligibility, and
exceptions.
Subsec. (c)(1). Pub. L. 100-485, 608(d)(16)(B)(i), substituted
''period of ineligibility for nursing facility services and for a level
of care in a medical institution equivalent to that of nursing facility
services and for services under section 1396n(c) of this title in the
case of an institutionalized individual (as defined in paragraph (3))
who, at any time during or after the 30-month period immediately before
the date the individual becomes an institutionalized individual (if the
individual is entitled to medical assistance under the State plan on
such date) or, if the individual is not so entitled, the date the
individual applies for such assistance while an institutionalized
individual'' for ''period of ineligibility in the case of an
institutionalized individual (as defined in paragraph (3)) who, at any
time during the 30-month period immediately before the individual's
application for medical assistance under the State plan''.
Subsec. (c)(2)(A)(ii). Pub. L. 100-485, 608(d)(16)(B)(ii), inserted
subcl. (I) and (II) designations.
Subsec. (c)(2)(A)(iii). Pub. L. 100-485, 608(d)(16)(B)(iii),
substituted ''the individual becomes an institutionalized individual''
for ''of the individual's admission to the medical institution or
nursing facility''.
Subsec. (c)(2)(A)(iv). Pub. L. 100-485, 608(d)(16)(B)(iv),
substituted ''the individual becomes an institutionalized individual''
for ''of such individual's admission to the medical institution or
nursing facility''.
Subsec. (c)(2)(B). Pub. L. 100-485, 608(d)(16)(B)(v), inserted cl.
(i) designation, substituted ''section 1396r-5(h)(2) of this title,,''
for ''section 1396r-5(h)(2) of this title, or the individual's child who
is blind or permanently and totally disabled'', and added cl. (ii).
Subsec. (c)(2)(B)(ii). Pub. L. 100-360, 411(l)(3)(I), amended Pub.
L. 100-203, 4211(h)(12)(B), see 1987 Amendment note below.
Subsec. (c)(3). Pub. L. 100-485, 608(d)(16)(B)(vi), substituted ''in
a nursing facility, who is an inpatient in a medical institution and
with respect to whom payment is made based on a level of care provided
in a nursing facility, or who is described in section
1396a(a)(10)(A)(ii)(VI) of this title'' for ''in a medical institution
or nursing facility''.
Subsec. (c)(5). Pub. L. 100-485, 608(d)(16)(B)(vii), added par.
(5).
1987 -- Subsecs. (a)(1)(B)(i), (c)(2)(B)(i). Pub. L. 100-203,
4211(h)(12)(A), substituted ''nursing facility, intermediate care
facility for the mentally retarded'' for ''skilled nursing facility,
intermediate care facility''.
Subsec. (c)(2)(B)(ii). Pub. L. 100-203, 4211(h)(12)(B), as amended
by Pub. L. 100-360, 411(l)(3)(I), substituted ''a nursing facility''
for ''a skilled nursing facility'' in two places each in subcls. (I)
and (II).
1983 -- Subsec. (b)(2)(B). Pub. L. 97-448, 309(b)(21), substituted
''who'' for ''and'' before ''has lawfully resided''.
Subsec. (c)(2)(B)(iii). Pub. L. 97-448, 309(b)(22), substituted in
subcl. (I) ''can'' for ''cannot'' and struck out from subcl. (IV) the
introductory word ''if''.
Amendment by Pub. L. 101-239 applicable to transfers occurring after
Dec. 19, 1989, see section 6411(e)(4) of Pub. L. 101-239, set out as a
note under section 1396a of this title.
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 303(b) of Pub. L. 100-360 applicable to
payments under this subchapter for calendar quarters beginning on or
after July 1, 1988 (except in certain situations requiring State
legislative action), without regard to whether or not final regulations
to carry out such amendment have been promulgated by such date, and
subsection (c) of this section, as amended by section 303(b) of Pub. L.
100-360, applicable to resources disposed of on or after July 1, 1988,
but not applicable with respect to inter-spousal transfers occurring
before Oct. 1, 1989, see section 303(g)(2), (5) of Pub. L. 100-360,
set out as an Effective Date note under section 1396r-5 of this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(l)(3)(I) 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.
Amendment by Pub. L. 100-203 applicable to nursing facility services
furnished on or after Oct. 1, 1990, without regard to whether
regulations implementing such amendment are promulgated by such date,
except as otherwise specifically provided in section 1396r of this
title, with transitional rule, see section 4214(a), (b)(2) of Pub. L.
100-203, as amended, set out as an Effective Date note under section
1396r of this title.
Amendment by Pub. L. 97-448 effective as if originally included as a
part of this section as this section was added 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.
Section 132(d) of Pub. L. 97-248 provided that: ''The amendments
made by this section (enacting this section and amending section 1396a
of this title) shall become effective on the date of the enactment of
this Act (Sept. 3, 1982), but the provisions of section 1917(c)(2)(B) of
the Social Security Act (subsec. (c)(2)(B) of this section) shall not
apply with respect to a transfer of assets which took place prior to
such date of enactment.''
42 USC 1396q. Application of provisions of subchapter II relating to
subpoenas
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
The provisions of subsections (d) and (e) of section 405 of this
title shall apply with respect to this subchapter to the same extent as
they are applicable with respect to subchapter II of this chapter.
(Aug. 14, 1935, ch. 531, title XIX, 1918, as added July 18, 1984,
Pub. L. 98-369, div. B, title III, 2370(a), 98 Stat. 1110.)
Section 2370(b) of Pub. L. 98-369 provided that: ''The amendment
made by this section (enacting this section) shall become effective on
the date of the enactment of this Act (July 18, 1984).''
42 USC 1396r. Requirements for nursing facilities
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) ''Nursing facility'' defined
In this subchapter, the term ''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,
(B) rehabilitation services for the rehabilitation of injured,
disabled, or sick persons, or
(C) on a regular basis, health-related care and services to
individuals who because of their mental or physical condition require
care and services (above the level of room and board) which can be made
available to them only through institutional facilities,
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 nursing facility described in
subsections (b), (c), and (d) of this section.
Such term also includes any facility which is located in a State on
an Indian reservation and is certified by the Secretary as meeting the
requirements of paragraph (1) and subsections (b), (c), and (d) of this
section.
(b) Requirements relating to provision of services
(1) Quality of life
(A) In general
A 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 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 nursing facility must provide services and activities 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 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
Such an assessment must be conducted --
(I) promptly upon (but no later than /1/ not later than 14 days after
the date of) admission for each individual admitted on or after October
1, 1990, and by not later than October 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 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.
(F) Requirements relating to preadmission screening for mentally ill
and mentally retarded individuals
Except as provided in clauses (ii) and (iii) of subsection (e)(7)(A)
of this section, a nursing facility must not admit, on or after January
1, 1989, any new resident who --
(i) is mentally ill (as defined in subsection (e)(7)(G)(i) of this
section) unless the State mental health authority has determined (based
on an independent physical and mental evaluation performed by a person
or entity other than the State mental health authority) prior to
admission that, because of the physical and mental condition of the
individual, the individual requires the level of services provided by a
nursing facility, and, if the individual requires such level of
services, whether the individual requires specialized services for
mental illness, or
(ii) is mentally retarded (as defined in subsection (e)(7)(G)(ii) of
this section) unless the State mental retardation or developmental
disability authority has determined prior to admission that, because of
the physical and mental condition of the individual, the individual
requires the level of services provided by a nursing facility, and, if
the individual requires such level of services, whether the individual
requires specialized services for mental retardation.
A State mental health authority and a State mental retardation or
developmental disability authority may not delegate (by subcontract or
otherwise) their responsibilities under this subparagraph to a nursing
facility (or to an entity that has a direct or indirect affiliation or
relationship with such a facility).
(4) Provision of services and activities
(A) In general
To the extent needed to fulfill all plans of care described in
paragraph (2), a nursing facility must provide (or arrange for the
provision of) --
(i) nursing and related 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 dental services (to the extent covered under the State
plan) 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.
(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; facility waivers
(i) General requirements
With respect to nursing facility services provided on or after
October 1, 1990, a nursing facility --
(I) except as provided in clause (ii), must provide 24-hour licensed
nursing services which are sufficient to meet the nursing needs of its
residents, and
(II) except as provided in clause (ii), must use the services of a
registered professional nurse for at least 8 consecutive hours a day, 7
days a week.
(ii) Waiver by State
To the extent that a facility is unable to meet the requirements of
clause (i), a State may waive such requirements with respect to the
facility if --
(I) the facility demonstrates to the satisfaction of the State that
the facility has been unable, despite diligent efforts (including
offering wages at the community prevailing rate for nursing facilities),
to recruit appropriate personnel,
(II) the State determines that a waiver of the requirement will not
endanger the health or safety of individuals staying in the facility,
(III) the State finds that, for any such periods in which licensed
nursing services are not available, a registered professional nurse or a
physician is obligated to respond immediately to telephone calls from
the facility,
(IV) the State agency granting a waiver of such requirements provides
notice of the waiver to the State long-term care ombudsman (established
under section 3027(a)(12) of this title) and the protection and advocacy
system in the State for the mentally ill and the mentally retarded, and
(V) the nursing facility that is granted such a waiver by a State
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 clause shall be subject to annual review and
to the review of the Secretary and subject to clause (iii) shall be
accepted by the Secretary for purposes of this subchapter to the same
extent as is the State's certification of the facility. In granting or
renewing a waiver, a State may require the facility to use other
qualified, licensed personnel.
(iii) Assumption of waiver authority by Secretary
If the Secretary determines that a State has shown a clear pattern
and practice of allowing waivers in the absence of diligent efforts by
facilities to meet the staffing requirements, the Secretary shall assume
and exercise the authority of the State to grant waivers.
(5) Required training of nurse aides
(A) In general
(i) Except as provided in clause (ii), a 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 nursing facility must not use on a temporary, per diem,
leased, or on any other 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 nursing facility must provide, for individuals used as a nurse aide
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 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 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 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, or licensed or
certified social worker.
(6) Physician supervision and clinical records
A nursing facility must --
(A) require that the health care of every resident be provided under
the supervision of a physician (or, at the option of a State, under the
supervision of a nurse practitioner, clinical nurse specialist, or
physician assistant who is not an employee of the facility but who is
working in collaboration with 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)), as well as the results of any
pre-admission screening conducted under subsection (e)(7) of this
section.
(7) Required social services
In the case of a 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.
(c) Requirements relating to residents' rights
(1) General rights
(A) Specified rights
A 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 not a skilled nursing facility (for purposes of
subchapter XVIII of this chapter) to a portion of the facility that is
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
medical assistance under this subchapter or a State's entitlement to
Federal medical assistance under this subchapter with respect to
services furnished to such a resident.
(B) Notice of rights
A 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 and of the requirements and procedures for
establishing eligibility for medical assistance under this subchapter,
including the right to request an assessment under section
1396r-5(c)(1)(B) of this title;
(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 subsection (e)(6) of this section;
(iii) inform each resident who is entitled to medical assistance
under this subchapter --
(I) at the time of admission to the facility or, if later, at the
time the resident becomes eligible for such assistance, of the items and
services (including those specified under section 1396a(a)(28)(B) of
this title) that are included in nursing facility services under the
State plan and for which the resident may not be charged (except as
permitted in section 1396o of this title), and of those other items and
services that the facility offers and for which the resident may be
charged and the amount of the charges for such items and services, and
(II) of changes in the items and services described in subclause (I)
and of changes in the charges imposed for items and services described
in that subclause; and
(iv) 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 subchapter XVIII of
this chapter 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.
(2) Transfer and discharge rights
(A) In general
A 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 XVIII 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 (iv), 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 case
described in clause (iv) the documentation must be made by a physician.
For purposes of clause (v), in the case of a resident who becomes
eligible for assistance under this subchapter after admission to the
facility, only charges which may be imposed under this subchapter shall
be considered to be allowable.
(B) Pre-transfer and pre-discharge notice
(i) In general
Before effecting a transfer or discharge of a resident, a nursing
facility must --
(I) notify the resident (and, if known, an immediate 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, 1989,
notice of the resident's right to appeal the transfer or discharge under
the State process established under subsection (e)(3) of this section;
(II) the name, mailing address, and telephone number of the State
long-term care ombudsman (established under section 3027(a)(12) of this
title);
(III) in the case of residents with developmental disabilities, the
mailing address and telephone number of the agency responsible for the
protection and advocacy system for developmentally disabled individuals
established under part C of the Developmental Disabilities Assistance
and Bill of Rights Act (42 U.S.C. 6041 et seq.); and
(IV) in the case of mentally ill residents (as defined in subsection
(e)(7)(G)(i) of this section), the mailing address and telephone number
of the agency responsible for the protection and advocacy system for
mentally ill individuals established under the Protection and Advocacy
for Mentally Ill Individuals Act (42 U.S.C. 10801 et seq.).
(C) Orientation
A nursing facility must provide sufficient preparation and
orientation to residents to ensure safe and orderly transfer or
discharge from the facility.
(D) Notice on bed-hold policy and readmission
(i) Notice before transfer
Before a resident of a nursing facility is transferred for
hospitalization or therapeutic leave, a nursing facility must provide
written information to the resident and an immediate family member or
legal representative concerning --
(I) the provisions of the State plan under this subchapter regarding
the period (if any) during which the resident will be permitted under
the State plan to return and resume residence in the facility, and
(II) the policies of the facility regarding such a period, which
policies must be consistent with clause (iii).
(ii) Notice upon transfer
At the time of transfer of a resident to a hospital or for
therapeutic leave, a nursing facility must provide written notice to the
resident and an immediate family member or legal representative of the
duration of any period described in clause (i).
(iii) Permitting resident to return
A nursing facility must establish and follow a written policy under
which a resident --
(I) who is eligible for medical assistance for nursing facility
services under a State plan,
(II) who is transferred from the facility for hospitalization or
therapeutic leave, and
(III) whose hospitalization or therapeutic leave exceeds a period
paid for under the State plan for the holding of a bed in the facility
for the resident,
will be permitted to be readmitted to the facility immediately
upon the first availability of a bed in a semiprivate room in the
facility if, at the time of readmission, the resident requires the
services provided by the facility.
(E) Information respecting advance directives
A nursing facility must comply with the requirement of section
1396a(w) of this title (relating to maintaining written policies and
procedures respecting advance directives).
(3) Access and visitation rights
A 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 or
agency described in subclause (II), (III), or (IV) of paragraph
(2)(B)(iii), 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) In general
A nursing facility must establish and maintain identical policies and
practices regarding transfer, discharge, and the provision of services
required under the State plan for all individuals regardless of source
of payment.
(B) Construction
(i) Nothing prohibiting any charges for non-medicaid patients
Subparagraph (A) shall not be construed as prohibiting a nursing
facility from charging any amount for services furnished, consistent
with the notice in paragraph (1)(B) describing such charges.
(ii) No additional services required
Subparagraph (A) shall not be construed as requiring a State to offer
additional services on behalf of a resident than are otherwise provided
under the State plan.
(5) Admissions policy
(A) Admissions
With respect to admissions practices, a 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
subchapter XVIII 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 subchapter XVIII of this chapter,
and (III) prominently display in the facility written information, and
provide to such individuals oral and written information, about how to
apply for and use such benefits and how to receive refunds for previous
payments covered by such benefits;
(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; and
(iii) in the case of an individual who is entitled to medical
assistance for nursing facility services, not charge, solicit, accept,
or receive, in addition to any amount otherwise required to be paid
under the State plan under this subchapter, any gift, money, donation,
or other consideration as a precondition of admitting (or expediting the
admission of) the individual to the facility or as a requirement for the
individual's 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 the State plan with respect to admissions practices of
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.
(iii) Charges for additional services requested
Subparagraph (A)(iii) shall not be construed as preventing a facility
from charging a resident, eligible for medical assistance under the
State plan, for items or services the resident has requested and
received and that are not specified in the State plan as included in the
term ''nursing facility services''.
(iv) Bona fide contributions
Subparagraph (A)(iii) shall not be construed as prohibiting a nursing
facility from soliciting, accepting, or receiving a charitable,
religious, or philanthropic contribution from an organization or from a
person unrelated to the resident (or potential resident), but only to
the extent that such contribution is not a condition of admission,
expediting admission, or continued stay in the facility.
(6) Protection of resident funds
(A) In general
The 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
$50 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 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) Notice of certain balances
The facility must notify each resident receiving medical assistance
under the State plan under this subchapter when the amount in the
resident's account reaches $200 less than the dollar amount determined
under section 1382(a)(3)(B) of this title and the fact that if the
amount in the account (in addition to the value of the resident's other
nonexempt resources) reaches the amount determined under such section
the resident may lose eligibility for such medical assistance or for
benefits under subchapter XVI of this chapter.
(iv) 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 XVIII of this chapter.
(7) Limitation on charges in case of medicaid-eligible individuals
(A) In general
A nursing facility may not impose charges, for certain
medicaid-eligible individuals for nursing facility services covered by
the State under its plan under this subchapter, that exceed the payment
amounts established by the State for such services under this
subchapter.
(B) ''Certain medicaid-eligible individual'' defined
In subparagraph (A), the term ''certain medicaid-eligible
individual'' means an individual who is entitled to medical assistance
for nursing facility services in the facility under this subchapter but
with respect to whom such benefits are not being paid because, in
determining the amount of the individual's income to be applied monthly
to payment for the costs of such services, the amount of such income
exceeds the payment amounts established by the State for such services
under this subchapter.
(8) Posting of survey results
A nursing facility must post in a place readily accessible to
residents, and family members and legal representatives of residents,
the results of the most recent survey of the facility conducted under
subsection (g) of this section.
(d) Requirements relating to administration and other matters
(1) Administration
(A) In general
A 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, 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 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) Nursing facility administrator
The administrator of a 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 nursing facility must be licensed under applicable State and local
law.
(B) Life Safety Code
A 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 nursing facilities.
(3) Sanitary and infection control and physical environment
A 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 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 /2/ and
with accepted professional standards and principles which apply to
professionals providing services in such a facility.
(B) Other
A nursing facility must meet such other requirements relating to the
health and safety of residents or relating to the physical facilities
thereof as the Secretary may find necessary.
(e) State requirements relating to nursing facility requirements
As a condition of approval of its plan under this subchapter, a State
must provide for the following:
(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. 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 nursing facilities
effected on or after October 1, 1989, must provide for a fair mechanism,
meeting the guidelines established under subsection (f)(3) of this
section, for hearing appeals on transfers and discharges of residents of
such facilities; but the failure of the Secretary to establish such
guidelines under such subsection shall not relieve any State of its
responsibility under this paragraph.
(4) Nursing facility administrator standards
By not later than July 1, 1989, the State must have implemented and
enforced the nursing facility administrator standards developed under
subsection (f)(4) of this section respecting the qualification of
administrators of 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.
(6) Notice of medicaid rights
Each State, as a condition of approval of its plan under this
subchapter, effective April 1, 1988, must develop (and periodically
update) a written notice of the rights and obligations of residents of
nursing facilities (and spouses of such residents) under this
subchapter.
(7) State requirements for preadmission screening and resident review
(A) Preadmission screening
(i) In general
Effective January 1, 1989, the State must have in effect a
preadmission screening program, for making determinations (using any
criteria developed under subsection (f)(8) of this section) described in
subsection (b)(3)(F) of this section for mentally ill and mentally
retarded individuals (as defined in subparagraph (G)) who are admitted
to nursing facilities on or after January 1, 1989. The failure of the
Secretary to develop minimum criteria under subsection (f)(8) of this
section shall not relieve any State of its responsibility to have a
preadmission screening program under this subparagraph or to perform
resident reviews under subparagraph (B).
(ii) Clarification with respect to certain readmissions
The preadmission screening program under clause (i) need not provide
for determinations in the case of the readmission to a nursing facility
of an individual who, after being admitted to the nursing facility, was
transferred for care in a hospital.
(iii) Exception for certain hospital discharges
The preadmission screening program under clause (i) shall not apply
to the admission to a nursing facility of an individual --
(I) who is admitted to the facility directly from a hospital after
receiving acute inpatient care at the hospital,
(II) who requires nursing facility services for the condition for
which the individual received care in the hospital, and
(III) whose attending physician has certified, before admission to
the facility, that the individual is likely to require less than 30 days
of nursing facility services.
(B) State requirement for annual resident review
(i) For mentally ill residents
As of April 1, 1990, in the case of each resident of a nursing
facility who is mentally ill, the State mental health authority must
review and determine (using any criteria developed under subsection
(f)(8) of this section and based on an independent physical and mental
evaluation performed by a person or entity other than the State mental
health authority) --
(I) whether or not the resident, because of the resident's physical
and mental condition, requires the level of services provided by a
nursing facility or requires the level of services of an inpatient
psychiatric hospital for individuals under age 21 (as described in
section 1396d(h) of this title) or of an institution for mental diseases
providing medical assistance to individuals 65 years of age or older;
and
(II) whether or not the resident requires specialized services for
mental illness.
(ii) For mentally retarded residents
As of April 1, 1990, in the case of each resident of a nursing
facility who is mentally retarded, the State mental retardation or
developmental disability authority must review and determine (using any
criteria developed under subsection (f)(8) of this section) --
(I) whether or not the resident, because of the resident's physical
and mental condition, requires the level of services provided by a
nursing facility or requires the level of services of an intermediate
care facility described under section 1396d(d) of this title; and
(II) whether or not the resident requires specialized services for
mental retardation.
(iii) Frequency of reviews
Except as provided in subclauses (II) and (III), the reviews and
determinations under clauses (i) and (ii) must be conducted with respect
to each mentally ill or mentally retarded resident not less often than
annually.
In the case of a resident subject to a preadmission review under
subsection (b)(3)(F) of this section, the review and determination under
clause (i) or (ii) need not be done until the resident has resided in
the nursing facility for 1 year.
The reviews and determinations under clauses (i) and (ii) must first
be conducted (for each resident not subject to preadmission review under
subsection (b)(3)(F) of this section) by not later than April 1, 1990.
(iv) Prohibition of delegation
A State mental health authority, a State mental retardation or
developmental disability authority, and a State may not delegate (by
subcontract or otherwise) their responsibilities under this subparagraph
to a nursing facility (or to an entity that has a direct or indirect
affiliation or relationship with such a facility).
(C) Response to preadmission screening and resident review
As of April 1, 1990, the State must meet the following requirements:
(i) Long-term residents not requiring nursing facility services, but
requiring specialized services
In the case of a resident who is determined, under subparagraph (B),
not to require the level of services provided by a nursing facility, but
to require specialized services for mental illness or mental
retardation, and who has continuously resided in a nursing facility for
at least 30 months before the date of the determination, the State must,
in consultation with the resident's family or legal representative and
care-givers --
(I) inform the resident of the institutional and noninstitutional
alternatives covered under the State plan for the resident,
(II) offer the resident the choice of remaining in the facility or of
receiving covered services in an alternative appropriate institutional
or noninstitutional setting,
(III) clarify the effect on eligibility for services under the State
plan if the resident chooses to leave the facility (including its effect
on readmission to the facility), and
(IV) regardless of the resident's choice, provide for (or arrange for
the provision of) such specialized services for the mental illness or
mental retardation.
A State shall not be denied payment under this subchapter for
nursing facility services for a resident described in this clause
because the resident does not require the level of services provided by
such a facility, if the resident chooses to remain in such a facility.
(ii) Other residents not requiring nursing facility services, but
requiring specialized services
In the case of a resident who is determined, under subparagraph (B),
not to require the level of services provided by a nursing facility, but
to require specialized services for mental illness or mental
retardation, and who has not continuously resided in a nursing facility
for at least 30 months before the date of the determination, the State
must, in consultation with the resident's family or legal representative
and care-givers --
(I) arrange for the safe and orderly discharge of the resident from
the facility, consistent with the requirements of subsection (c)(2) of
this section,
(II) prepare and orient the resident for such discharge, and
(III) provide for (or arrange for the provision of) such specialized
services for the mental illness or mental retardation.
(iii) Residents not requiring nursing facility services and not
requiring specialized services
In the case of a resident who is determined, under subparagraph (B),
not to require the level of services provided by a nursing facility and
not to require specialized services for mental illness or mental
retardation, the State must --
(I) arrange for the safe and orderly discharge of the resident from
the facility, consistent with the requirements of subsection (c)(2) of
this section, and
(II) prepare and orient the resident for such discharge.
(iv) Annual report
Each State shall report to the Secretary annually concerning the
number and disposition of residents described in each of clauses (ii)
and (iii).
(D) Denial of payment
(i) For failure to conduct preadmission screening or annual review
No payment may be made under section 1396b(a) of this title with
respect to nursing facility services furnished to an individual for whom
a determination is required under subsection (b)(3)(F) of this section
or subparagraph (B) but for whom the determination is not made.
(ii) For certain residents not requiring nursing facility level of
services
No payment may be made under section 1396b(a) of this title with
respect to nursing facility services furnished to an individual (other
than an individual described in subparagraph (C)(i)) who does not
require the level of services provided by a nursing facility.
(E) Permitting alternative disposition plans
With respect to residents of a nursing facility who are mentally
retarded or mentally ill and who are determined under subparagraph (B)
not to require the level of services of such a facility, but who require
specialized services for mental illness or mental retardation, a State
and the nursing facility shall be considered to be in compliance with
the requirements of subparagraphs (A) through (C) of this paragraph if,
before April 1, 1989, the State and the Secretary have entered into an
agreement relating to the disposition of such residents of the facility
and the State is in compliance with such agreement. Such an agreement
may provide for the disposition of the residents after the date
specified in subparagraph (C). The State may revise such an agreement,
subject to the approval of the Secretary, before October 1, 1991, but
only if, under the revised agreement, all residents subject to the
agreement who do not require the level of services of such a facility
are discharged from the facility by not later than April 1, 1994.
(F) Appeals procedures
Each State, as a condition of approval of its plan under this
subchapter, effective January 1, 1989, must have in effect an appeals
process for individuals adversely affected by determinations under
subparagraph (A) or (B).
(G) Definitions
In this paragraph and in subsection (b)(3)(F) of this section:
(i) An individual is considered to be ''mentally ill'' if the
individual has a serious mental illness (as defined by the Secretary in
consultation with the National Institute of Mental Health) and does not
have a primary diagnosis of dementia (including Alzheimer's disease or a
related disorder) or a diagnosis (other than a primary diagnosis) of
dementia and a primary diagnosis that is not a serious mental illness.
(ii) An individual is considered to be ''mentally retarded'' if the
individual is mentally retarded or a person with a related condition (as
described in section 1396d(d) of this title).
(iii) The term ''specialized services'' has the meaning given such
term by the Secretary in regulations, but does not include, in the case
of a resident of a nursing facility, services within the scope of
services which the facility must provide or arrange for its residents
under subsection (b)(4) of this section.
(f) Responsibilities of Secretary relating to 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 nursing facilities
under State plans approved 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, and 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 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, 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) shall prohibit approval of such a program --
(I) offered by or in a nursing facility which, within the previous 2
years --
(a) has operated under a waiver under subsection (b)(4)(C)(ii) of
this section that was granted on the basis of a demonstration that the
facility is unable to provide the nursing care required under subsection
(b)(4)(C)(i) of this section for a period in excess of 48 hours during a
week;
(b) has been subject to an extended (or partial extended) survey
under section 1395i-3(g)(2)(B)(i) of this title or subsection
(g)(2)(B)(i) of this section; or
(c) has been assessed a civil money penalty described in section
1395i-3(h)(2)(B)(ii) of this title or subsection (h)(2)(A)(ii) of this
section of not less than $5,000, or has been subject to a remedy
described in subsection (h)(1)(B)(i) of this section, clauses /3/ (i),
(iii), or (iv) of subsection (h)(2)(A) of this section, clauses /3/ (i)
or (iii) of section 1395i-3(h)(2)(B) of this title, or section
1395i-3(h)(4) of this title, or
(II) offered by or in a 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 nursing facilities.
A State may not delegate (through subcontract or otherwise) its
responsibility under clause (iii)(II) to the nursing facility.
(3) Federal guidelines for State appeals process for transfers and
discharges
For purposes of subsections (c)(2)(B)(iii) 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 nursing facilities.
(4) Secretarial standards 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, 1988, standards to
be applied in assuring the qualifications of administrators of nursing
facilities.
(5) Criteria for administration
The Secretary shall establish criteria for assessing a 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 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 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 nursing facilities who are
individuals receiving medical assistance with respect to nursing
facility services under this subchapter and those costs which are to be
included in the payment amount under this subchapter for nursing
facility 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 that subparagraph, in the case of
a resident of a nursing facility who is eligible to receive benefits for
nursing facility services under this subchapter, for purposes of section
1396a(a)(28)(B) of this title, the Secretary shall be deemed to have
promulgated regulations under this paragraph which provide that 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)
include, at a minimum, the costs for routine personal hygiene items and
services furnished by the facility.
(8) Federal minimum criteria and monitoring for preadmission
screening and resident review
(A) Minimum criteria
The Secretary shall develop, by not later than October 1, 1988,
minimum criteria for States to use in making determinations under
subsections (b)(3)(F) and (e)(7)(B) of this section and in permitting
individuals adversely affected to appeal such determinations, and shall
notify the States of such criteria.
(B) Monitoring compliance
The Secretary shall review, in a sufficient number of cases to allow
reasonable inferences, each State's compliance with the requirements of
subsection (e)(7)(C)(ii) of this section (relating to discharge and
placement for active treatment of certain residents).
(9) Criteria for monitoring State waivers
The Secretary shall develop, by not later than October 1, 1988,
criteria and procedures for monitoring State performances in granting
waivers pursuant to subsection (b)(4)(C)(ii) of this section.
(g) Survey and certification process
(1) State and Federal responsibility
(A) In general
Under each State plan under this subchapter, the State shall be
responsible for certifying, in accordance with surveys conducted under
paragraph (2), the compliance of 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 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 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 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. 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) 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) Annual standard survey
(i) In general
Each 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 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 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
Each 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 a nursing facility shall not exceed 12 months.
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 nursing facility,
or 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 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 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 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 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 nursing facilities surveyed by the State in the year, but in
no case less than 5 nursing facilities in the State.
(C) Reduction in administrative costs 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 may provide for the training of survey teams in the State
and shall provide for a reduction of the payment otherwise made to the
State under section 1396b(a)(2)(D) of this title with respect to a
quarter equal to 33 percent multiplied by a fraction, the denominator of
which is equal to the total number of residents in nursing facilities
surveyed by the Secretary that quarter and the numerator of which is
equal to the total number of residents in nursing facilities which were
found pursuant to such surveys to be not in compliance with any of the
requirements of subsections (b), (c), and (d) of this section. A State
that is dissatisfied with the Secretary's findings under this
subparagraph may obtain reconsideration and review of the findings under
section 1316 of this title in the same manner as a State may seek
reconsideration and review under that section of the Secretary's
determination under section 1316(a)(1) of this title.
(D) Special surveys of compliance
Where the Secretary has reason to question the compliance of a
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 nursing facility meets
such requirements.
(4) Investigation of complaints and monitoring nursing facility
compliance
Each State shall maintain procedures and adequate staff to --
(A) investigate complaints of violations of requirements by nursing
facilities, and
(B) monitor, on-site, on a regular, as needed basis, a 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
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 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 under subchapter XVIII 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 section 3027(a)(12) of this title) 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 nursing facility under paragraphs /4/ (1), (2), or (3) of
subsection (h) of this section, with respect to a nursing facility in
the State.
(C) Notice to physicians and nursing facility administrator licensing
board
If a State finds that a 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) any State board responsible for the licensing of the nursing
facility administrator of 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 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 take immediate action to remove the jeopardy and correct the
deficiencies through the remedy specified in paragraph (2)(A)(iii), or
terminate the facility's participation under the State plan and may
provide, in addition, for one or more of the other remedies described in
paragraph (2); or
(B) do not immediately jeopardize the health or safety of its
residents, the State may --
(i) terminate the facility's participation under the State plan,
(ii) provide for one or more of the remedies described in paragraph
(2), or
(iii) do both.
Nothing in this paragraph shall be construed as restricting the
remedies available to a State to remedy a nursing facility's
deficiencies. If a State finds that a 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
provide for a civil money penalty under paragraph (2)(A)(ii) for the
days in which it finds that the facility was not in compliance with such
requirements.
(2) Specified remedies
(A) Listing
Except as provided in subparagraph (B)(ii), each State shall
establish by law (whether statute or regulation) at least the following
remedies:
(i) Denial of payment under the State plan with respect to any
individual admitted to the nursing facility involved after such notice
to the public and to the facility as may be provided for by the State.
(ii) A civil money penalty assessed and collected, with interest, for
each day in which the facility is or was out of compliance with a
requirement of subsection (b), (c), or (d) of this section. Funds
collected by a State as a result of imposition of such a penalty (or as
a result of the imposition by the State of a civil money penalty for
activities described in subsections (b)(3)(B)(ii)(I), (b)(3)(B)(ii)(II),
or (g)(2)(A)(i) of this section) shall be applied to the protection of
the health or property of residents of nursing facilities that the State
or the Secretary finds deficient, including payment for the costs of
relocation of residents to other facilities, maintenance of operation of
a facility pending correction of deficiencies or closure, and
reimbursement of residents for personal funds lost.
(iii) The appointment of 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 State 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.
(iv) The authority, in the case of an emergency, to close the
facility, to transfer residents in that facility to other facilities, or
both.
The State also 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
State may provide for other specified remedies, such as directed plans
of correction.
(B) Deadline and guidance
(i) Except as provided in clause (ii), as a condition for approval of
a State plan for calendar quarters beginning on or after October 1,
1989, each State shall establish the remedies described in clauses (i)
through (iv) of subparagraph (A) by not later than October 1, 1989. The
Secretary shall provide, through regulations by not later than October
1, 1988, guidance to States in establishing such remedies; but the
failure of the Secretary to provide such guidance shall not relieve a
State of the responsibility for establishing such remedies.
(ii) A State may establish alternative remedies (other than
termination of participation) other than those described in clauses (i)
through (iv) of subparagraph (A), if the State demonstrates to the
Secretary's satisfaction that the alternative remedies are as effective
in deterring noncompliance and correcting deficiencies as those
described in subparagraph (A).
(C) Assuring prompt compliance
If a 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 State shall impose the remedy described in
subparagraph (A)(i) for all individuals who are admitted to the facility
after such date.
(D) Repeated noncompliance
In the case of a 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 State shall
(regardless of what other remedies are provided) --
(i) impose the remedy described in subparagraph (A)(i), and
(ii) monitor the facility under subsection (g)(4)(B) of this section,
until the facility has demonstrated, to the satisfaction of the
State, 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.
(E) Funding
The reasonable expenditures of a State to provide for temporary
management and other expenses associated with implementing the remedies
described in clauses (iii) and (iv) of subparagraph (A) shall be
considered, for purposes of section 1396b(a)(7) of this title, to be
necessary for the proper and efficient administration of the State plan.
(F) Incentives for high quality care
In addition to the remedies specified in this paragraph, a State may
establish a program to reward, through public recognition, incentive
payments, or both, nursing facilities that provide the highest quality
care to residents who are entitled to medical assistance under this
subchapter. For purposes of section 1396b(a)(7) of this title, proper
expenses incurred by a State in carrying out such a program shall be
considered to be expenses necessary for the proper and efficient
administration of the State plan under this subchapter.
(3) Secretarial authority
(A) For State nursing facilities
With respect to a State nursing facility, the Secretary shall have
the authority and duties of a State under this subsection, including the
authority to impose remedies described in clauses (i), (ii), and (iii)
of paragraph (2)(A).
(B) Other nursing facilities
With respect to any other nursing facility in a State, if the
Secretary finds that a 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 (C)(iii),
or terminate the facility's participation under the State plan and may
provide, in addition, for one or more of the other remedies described in
subparagraph (C); or
(ii) do not immediately jeopardize the health or safety of its
residents, the Secretary may impose any of the remedies described in
subparagraph (C).
Nothing in this subparagraph shall be construed as restricting the
remedies available to the Secretary to remedy a nursing facility's
deficiencies. If the Secretary finds that a 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 (C)(ii) for the days on which he finds that the facility
was not in compliance with such requirements.
(C) 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 to the State for medical
assistance furnished by the facility to all individuals in the facility
or to 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.
(D) 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 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 State 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.
(4) Effective period of denial of payment
A finding to deny payment under this subsection shall terminate when
the State or Secretary (or both, as the case may be) finds that the
facility is in substantial compliance with all the requirements of
subsections (b), (c), and (d) of this section.
(5) Immediate termination of participation for facility where State
or Secretary finds noncompliance and immediate jeopardy
If either the State or the Secretary finds that a 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 State or the Secretary, respectively /5/
shall notify the other of such finding, and the State or the Secretary,
respectively, shall take immediate action to remove the jeopardy and
correct the deficiencies through the remedy specified in paragraph
(2)(A)(iii) or (3)(C)(iii), or terminate the facility's participation
under the State plan. If the facility's participation in the State plan
is terminated by either the State or the Secretary, the State shall
provide for the safe and orderly transfer of the residents eligible
under the State plan consistent with the requirements of subsection
(c)(2) of this section.
(6) Special rules where State and Secretary do not agree on finding
of noncompliance
(A) State finding of noncompliance and no Secretarial finding of
noncompliance
If the Secretary finds that a nursing facility has met all the
requirements of subsections (b), (c), and (d) of this section, but a
State finds that the facility has not met such requirements and the
failure does not immediately jeopardize the health or safety of its
residents, the State's findings shall control and the remedies imposed
by the State shall be applied.
(B) Secretarial finding of noncompliance and no State finding of
noncompliance
If the Secretary finds that a nursing facility has not met all the
requirements of subsections (b), (c), and (d) of this section, and that
the failure does not immediately jeopardize the health or safety of its
residents, but the State has not made such a finding, the Secretary --
(i) may impose any remedies specified in paragraph (3)(C) with
respect to the facility, and
(ii) shall (pending any termination by the Secretary) permit
continuation of payments in accordance with paragraph (3)(D).
(7) Special rules for timing of termination of participation where
remedies overlap
If both the Secretary and the State find that a nursing facility has
not met all the requirements of subsections (b), (c), and (d) of this
section, and neither finds that the failure immediately jeopardizes the
health or safety of its residents --
(A)(i) if both find that the facility's participation under the State
plan should be terminated, the State's timing of any termination shall
control so long as the termination date does not occur later than 6
months after the date of the finding to terminate;
(ii) if the Secretary, but not the State, finds that the facility's
participation under the State plan should be terminated, the Secretary
shall (pending any termination by the Secretary) permit continuation of
payments in accordance with paragraph (3)(D); or
(iii) if the State, but not the Secretary, finds that the facility's
participation under the State plan should be terminated, the State's
decision to terminate, and timing of such termination, shall control;
and
(B)(i) if the Secretary or the State, but not both, establishes one
or more remedies which are additional or alternative to the remedy of
terminating the facility's participation under the State plan, such
additional or alternative remedies shall also be applied, or
(ii) if both the Secretary and the State establish one or more
remedies which are additional or alternative to the remedy of
terminating the facility's participation under the State plan, only the
additional or alternative remedies of the Secretary shall apply.
(8) 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), (iii), and (iv) of paragraph (2)(A) may be imposed during
the pendency of any hearing. The provisions of this subsection shall
apply to a nursing facility (or portion thereof) notwithstanding that
the facility (or portion thereof) also is a skilled nursing facility for
purposes of subchapter XVIII of this chapter.
(9) Sharing of information
Notwithstanding any other provision of law, all information
concerning 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 XVIII 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 1395i-3 of this title, the fulfillment of
those requirements or obligations under section 1395i-3 of this title
shall be considered to be the fulfillment of the corresponding
requirements or obligations under this section.
(Aug. 14, 1935, ch. 531, title XIX, 1919, as added and amended Dec.
22, 1987, Pub. L. 100-203, title IV, 4211(a)(3), (c), 4212(a), (b),
4213(a), 4216, 101 Stat. 1330-182, 1330-196, 1330-207, 1330-213,
1330-220, as amended July 1, 1988, Pub. L. 100-360, title IV,
411(l)(3)(C)(ii), (6)(B), (8)(A), 102 Stat. 803-805; July 1, 1988, Pub.
L. 100-360, title III, 303(a)(2), title IV, 411(l)(2)(A)-(D), (F)-(K),
(L)(ii), (3)(A), (B), (C)(iii), (D), (5), (6)(A), (7), (8)(B), 102 Stat.
760, 801-805, as amended Oct. 13, 1988, Pub. L. 100-485, title VI,
608(d)(27)(C)-(E), (I), 102 Stat. 2423; Dec. 19, 1989, Pub. L. 101-239,
title VI, 6901(b)(1), (3), (4)(A), (d)(1), (4), 103 Stat. 2298-2301;
Nov. 5, 1990, Pub. L. 101-508, title IV, 4751(b)(2),
4801(a)(2)-(6)(A), (7), (b)(2)-(5)(A), (6)-(8), (d)(1), (e)(2)-(7)(A),
(8)-(10), (12)-(15), (18), 104 Stat. 1388-205, 1388-211 to 1388-219.)
The Developmental Disabilities Assistance and Bill of Rights Act,
referred to in subsec. (c)(2)(B)(iii)(III), is title I of Pub. L.
88-164, as added by Pub. L. 98-527, 2, Oct. 19, 1984, 98 Stat. 2662,
as amended. Part C of the Developmental Disabilities Assistance and
Bill of Rights Act is classified generally to subchapter III ( 6041 et
seq.) of chapter 75 of this title. For complete classification of this
Act to the Code, see Short Title note set out under section 6000 of this
title and Tables.
The Protection and Advocacy for Mentally Ill Individuals Act,
referred to in subsec. (c)(2)(B)(iii)(IV), probably means the
Protection and Advocacy for Mentally Ill Individuals Act of 1986, Pub.
L. 99-319, May 23, 1986, 100 Stat. 478, as amended, which is classified
generally to chapter 114 ( 10801 et seq.) of this title. For complete
classification of this Act to the Code, see Short Title note set out
under section 10801 of this title and Tables.
Section 6901(b)(4)(B)-(D) of the Omnibus Budget Reconciliation Act of
1989, referred to in subsec. (e)(2)(A), is section 6901(b)(4)(B)-(D) of
Pub. L. 101-239, which is set out as a note under section 1395i-3 of
this title.
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.
A prior section 1919 of act Aug. 14, 1935, was renumbered section
1922, by Pub. L. 100-203, and is classified to section 1396r-3 of this
title.
1990 -- Subsec. (b)(1)(B). Pub. L. 101-508, 4801(e)(2), 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, 4801(e)(3), substituted
''not later than 14 days'' for ''4 days''.
Subsec. (b)(3)(F). Pub. L. 101-508, 4801(b)(8), substituted
''specialized services'' for ''active treatment'' in cls. (i) and (ii).
Pub. L. 101-508, 4801(b)(4)(A), inserted at end ''A State mental
health authority and a State mental retardation or developmental
disability authority may not delegate (by subcontract or otherwise)
their responsibilities under this subparagraph to a nursing facility (or
to an entity that has a direct or indirect affiliation or relationship
with such a facility).''
Pub. L. 101-508, 4801(b)(2)(A), substituted ''Except as provided in
clauses (ii) and (iii) of subsection (e)(7)(A) of this section, a
nursing facility'' for ''A nursing facility'' in introductory
provisions.
Subsec. (b)(4)(A)(vii). Pub. L. 101-508, 4801(e)(4), added cl.
(vii).
Subsec. (b)(4)(C)(ii). Pub. L. 101-508, 4801(e)(5)(A), substituted
''To the extent that a facility is unable to meet the requirements of
clause (i), a State may waive such requirements with respect to the
facility if'' for ''A State may waive the requirement of subclause (I)
or (II) of clause (i) with respect to a facility if'' in introductory
provisions.
Subsec. (b)(4)(C)(ii)(IV), (V). Pub. L. 101-508, 4801(e)(5)(B)-(D),
which directed amendment of cl. (ii) by adding subcls. (IV) and (V) at
the end, was executed by adding subcls. (IV) and (V) after subcl.
(III) and before concluding provisions to reflect the probable intent of
Congress.
Subsec. (b)(5)(A). Pub. L. 101-508, 4801(a)(2), designated existing
provision as cl. (i), substituted ''Except as provided in clause (ii),
a nursing facility'' for ''A 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, 4801(a)(3), 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, 4801(a)(4), inserted before
period at end '', or a new competency evaluation program''.
Subsec. (b)(5)(F)(i). Pub. L. 101-508, 4801(e)(6), substituted
''(G)) or a registered dietician'' for ''(G))''.
Subsec. (b)(6)(A). Pub. L. 101-508, 4801(d)(1), inserted before
semicolon at end ''(or, at the option of a State, under the supervision
of a nurse practitioner, clinical nurse specialist, or physician
assistant who is not an employee of the facility but who is working in
collaboration with a physician)''.
Subsec. (c)(1)(A). Pub. L. 101-508, 4801(e)(8)(B), 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 medical
assistance under this subchapter or a State's entitlement to Federal
medical assistance under this subchapter with respect to services
furnished to such a resident.''
Subsec. (c)(1)(A)(iv). Pub. L. 101-508, 4801(e)(9), 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, 4801(e)(8)(A), added
cl. (x) and redesignated former cl. (x) as (xi).
Subsec. (c)(1)(B)(ii). Pub. L. 101-508, 4801(e)(10), inserted
''including the notice (if any) of the State developed under subsection
(e)(6) of this section'' after ''in such rights)''.
Subsec. (c)(2)(E). Pub. L. 101-508, 4751(b)(2), added subpar. (E).
Subsec. (c)(7), (8). Pub. L. 101-508, 4801(e)(7)(A), added par.
(7) and redesignated former par. (7) as (8).
Subsec. (e)(1)(A). Pub. L. 101-508, 4801(e)(18), substituted ''under
subsection (f)(2) of this section'' for ''under clause (i) or (ii) of
subsection (f)(2)(A) of this section''.
Subsec. (e)(2)(A). Pub. L. 101-508, 4801(e)(12)(A), inserted '', 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'' after ''in the State''.
Subsec. (e)(2)(C). Pub. L. 101-508, 4801(e)(12)(B), added subpar.
(C).
Subsec. (e)(7)(A). Pub. L. 101-508, 4801(b)(2)(B), designated
existing provision as cl. (i), inserted cl. (i) heading, and added
cls. (ii) and (iii).
Subsec. (e)(7)(B)(i)(II), (ii)(II). Pub. L. 101-508, 4801(b)(8),
substituted ''specialized services'' for ''active treatment''.
Subsec. (e)(7)(B)(iv). Pub. L. 101-508, 4801(b)(4)(B), added cl.
(iv).
Subsec. (e)(7)(C)(i) to (iii). Pub. L. 101-508, 4801(b)(8),
substituted ''specialized services'' for ''active treatment'' wherever
appearing.
Subsec. (e)(7)(C)(iv). Pub. L. 101-508, 4801(b)(5)(A), added cl.
(iv).
Subsec. (e)(7)(D). Pub. L. 101-508, 4801(b)(3)(A), struck out
''where failure to conduct preadmission screening'' after ''Denial of
payment'' in heading, designated existing provisions as cl. (i),
inserted cl. (i) heading, and added cl. (ii).
Subsec. (e)(7)(E). Pub. L. 101-508, 4801(b)(8), substituted
''specialized services'' for ''active treatment''.
Pub. L. 101-508, 4801(b)(6), inserted at end ''The State may revise
such an agreement, subject to the approval of the Secretary, before
October 1, 1991, but only if, under the revised agreement, all residents
subject to the agreement who do not require the level of services of
such a facility are discharged from the facility by not later than April
1, 1994.''
Pub. L. 101-508, 4801(b)(3)(B), substituted ''the requirements of
subparagraphs (A) through (C) of this paragraph'' for ''the requirement
of this paragraph''.
Subsec. (e)(7)(G)(i). Pub. L. 101-508, 4801(b)(7), substituted
''serious mental illness (as defined by the Secretary in consultation
with the National Institute of Mental Health)'' for ''primary or
secondary diagnosis of mental disorder (as defined in the Diagnostic and
Statistical Manual of Mental Disorders, 3rd edition)'' and inserted
before period at end ''or a diagnosis (other than a primary diagnosis)
of dementia and a primary diagnosis that is not a serious mental
illness''.
Subsec. (e)(7)(G)(iii). Pub. L. 101-508, 4801(b)(8), substituted
''specialized services'' for ''active treatment''.
Subsec. (f)(2)(A)(iv)(II). Pub. L. 101-508, 4801(a)(5)(B), 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''.
Subsec. (f)(2)(A)(iv)(III). Pub. L. 101-508, 4801(a)(5)(A), (C),
(D), added subcl. (III).
Subsec. (f)(2)(B). Pub. L. 101-508, 4801(a)(7), inserted ''(through
subcontract or otherwise)'' after ''may not delegate'' in last sentence.
Subsec. (f)(2)(B)(iii)(I). Pub. L. 101-508, 4801(a)(6)(A), amended
subcl. (I) generally. Prior to amendment, subcl. (I) read as follows:
''offered by or in a 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, 4801(e)(13), 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, 4801(e)(14), 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, 4801(e)(15), substituted ''or of
any adverse action taken against a nursing facility under paragraphs
(1), (2), or (3) of subsection (h) of this section, with respect'' for
''with respect''.
1989 -- Subsec. (b)(5)(A). Pub. L. 101-239, 6901(b)(1)(A),
substituted ''October 1, 1990'' for ''January 1, 1990'' in introductory
provisions.
Subsec. (b)(5)(B). Pub. L. 101-239, 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, 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, 6901(d)(4)(B), substituted
''accommodation'' for ''accommodations''.
Subsec. (f)(2)(A)(i)(I). Pub. L. 101-239, 6901(d)(4)(C), substituted
''and content of the curriculum'' for '', content of the curriculum''.
Pub. L. 101-239, 6901(b)(3)(A), inserted ''care of cognitively
impaired residents,'' after ''social service needs,''.
Subsec. (f)(2)(A)(ii). Pub. L. 101-239, 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, 6901(b)(3)(C), (D), added
cl. (iv).
Subsec. (f)(2)(B)(ii). Pub. L. 101-239, 6901(b)(4)(A), substituted
''July 1, 1989'' for ''January 1, 1989''.
Subsec. (h)(3)(D). Pub. L. 101-239, 6901(d)(4)(D), substituted ''not
longer than 6 months after the effective date of the findings'' for
''not longer than 6 months''.
Subsec. (h)(8). Pub. L. 101-239, 6901(d)(1), inserted at end ''The
provisions of this subsection shall apply to a nursing facility (or
portion thereof) notwithstanding that the facility (or portion thereof)
also is a skilled nursing facility for purposes of subchapter XVIII of
this chapter.''
1988 -- Subsec. (b)(3)(A)(iii). Pub. L. 100-360, 411(l)(2)(B),
struck out ''in the case of a resident eligible for benefits under this
subchapter,'' before ''uses an instrument''.
Subsec. (b)(3)(A)(iv). Pub. L. 100-360, 411(l)(2)(A), as amended by
Pub. L. 100-485, 608(d)(27)(C), struck out ''in the case of a resident
eligible for benefits under part A of subchapter XVIII of this
chapter,'' before ''includes the identification of medical problems''.
Subsec. (b)(3)(B)(ii)(III). Pub. L. 100-360, 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)(4)(C)(i)(II). Pub. L. 100-360, 411(l)(3)(A)(i), inserted
''professional'' after ''registered''.
Subsec. (b)(4)(C)(ii). Pub. L. 100-360, 411(l)(3)(A)(i)-(iv), in
heading, substituted ''(ii) Waiver'' for ''(ii) Facility waivers. -- (i)
Waiver'', in subcl. (III), inserted ''professional'' after
''registered'', and in concluding provisions, substituted ''clause
(iii)'' for ''clause (ii)'' and ''use'' for ''employ''.
Subsec. (b)(4)(C)(iii). Pub. L. 100-360, 411(l)(3)(A)(v), (vi),
substituted ''(iii) Assumption'' for ''(ii) Assumption'' in heading and
''exercise'' for ''excercise'' in text.
Subsec. (b)(5)(A). Pub. L. 100-360, 411(l)(3)(B), which directed
amendment of subpar. (A) by striking ''subparagraph (E)'' and inserting
''subparagraph (F)'', could not be executed because of prior amendment
by Pub. L. 100-360, 411(l)(2)(D)(i), see Amendment note below.
Pub. L. 100-360, 411(l)(2)(D)(i), as amended by Pub. L. 100-485,
608(d)(27)(D), struck out '', who is not a licensed health professional
(as defined in subparagraph (E)),'' after ''any individual'' in
introductory provisions.
Subsec. (b)(5)(A)(ii). Pub. L. 100-360, 411(l)(2)(D)(ii),
substituted ''nursing or nursing-related services'' for ''such
services''.
Subsec. (b)(5)(G). Pub. L. 100-360, 411(l)(2)(D)(iii), inserted
''physical or occupational therapy assistant,'' after ''occupational
therapist,''.
Subsec. (c)(1)(B)(i). Pub. L. 100-360, 303(a)(2), inserted before
semicolon at end ''and of the requirements and procedures for
establishing eligibility for medical assistance under this subchapter,
including the right to request an assessment under section
1396r-5(c)(1)(B) of this title''.
Subsec. (c)(2)(A)(v). Pub. L. 100-360, 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
XVIII of this chapter''.
Subsec. (c)(2)(B)(iii)(III). Pub. L. 100-360, 411(l)(3)(C)(iii), as
added by Pub. L. 100-485, 608(d)(27)(E), substituted ''responsible''
for ''responsibile''.
Subsec. (c)(6). Pub. L. 100-360, 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. (c)(7). Pub. L. 100-360, 411(l)(6)(B), amended Pub. L.
100-203, 4212(b), see 1987 Amendment note below.
Subsec. (e). Pub. L. 100-360, 411(l)(3)(C)(ii), as added by Pub. L.
100-485, 608(d)(27)(E), amended Pub. L. 100-203, 4211, see 1987
Amendment note below.
Subsec. (e)(1). Pub. L. 100-360, 411(l)(3)(D)(i), (ii), substituted
''January 1, 1989'' for ''September 1, 1988'' in subpar. (A) and
''January'' for ''September'' in subpar. (B).
Subsec. (e)(2)(B). Pub. L. 100-360, 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, 411(l)(2)(I), inserted ''and
discharges'' after ''transfers'' in heading and two places in text.
Subsec. (e)(7)(E). Pub. L. 100-360, 411(l)(3)(D)(iii), substituted
''April 1, 1989'' for ''October 1, 1988''.
Subsec. (f). Pub. L. 100-360, 411(l)(3)(C)(ii), as added by Pub. L.
100-485, 608(d)(27)(E), amended Pub. L. 100-203, 4211, see 1987
Amendment note below.
Subsec. (f)(2)(A). Pub. L. 100-360, 411(l)(3)(D)(iv), substituted
''September'' for ''July'' in introductory provisions.
Subsec. (f)(2)(A)(i)(I). Pub. L. 100-360, 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, 411(l)(2)(I), inserted ''and
discharges'' after ''transfers'' in heading and in text.
Subsec. (f)(7)(A). Pub. L. 100-360, 411(l)(2)(K), substituted
''residents'' for ''patients''.
Subsec. (f)(7)(B). Pub. L. 100-360, 411(l)(2)(L)(ii), substituted
''include'' for ''do not include''.
Subsec. (g)(1)(C). Pub. L. 100-360, 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, 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, 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, 411(l)(5)(F), as added by
Pub. L. 100-485, 608(d)(27)(I), substituted ''practicable'' for
''practical''.
Subsec. (g)(3)(C). Pub. L. 100-360, 411(l)(6)(A), redesignated
subpar. (C), relating to special surveys of compliance, as (D).
Subsec. (g)(3)(D). Pub. L. 100-360, 411(l)(5)(G), formerly
411(l)(5)(F), as redesignated by Pub. L. 100-485, 608(d)(27)(I),
substituted ''on the basis of that survey'' for ''on that basis''.
Subsec. (g)(4). Pub. L. 100-360, 411(l)(5)(H), formerly
411(l)(5)(G), as redesignated by Pub. L. 100-485, 608(d)(27)(I),
struck out ''chronically'' after ''enforcement actions against'' in last
sentence.
Subsec. (h). Pub. L. 100-360, 411(l)(8)(A), made technical
correction to directory language of Pub. L. 100-203, 4213(a), see 1987
Amendment note below.
Subsec. (h)(1). Pub. L. 100-360, 411(l)(8)(B)(i), substituted
''paragraph (2)(A)(ii)''for ''paragraph (2)(A)(i)'' in last sentence.
Subsec. (h)(2)(B)(i). Pub. L. 100-360, 411(l)(8)(B)(ii), struck out
''or otherwise'' after ''regulations''.
Subsec. (h)(3)(C)(ii). Pub. L. 100-360, 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, 411(l)(8)(B)(iii), substituted
''State or the Secretary, respectively'' for ''State and the
Secretary''.
Subsec. (h)(9). Pub. L. 100-360, 411(l)(7)(B), inserted ''by such
facilities'' after ''be made available''.
1987 -- Subsec. (c)(7). Pub. L. 100-203, 4212(b), as amended by
Pub. L. 100-360, 411(l)(6)(B), added par. (7).
Subsecs. (e), (f). Pub. L. 100-203, 4211, which contained two
subsecs. (c), the first of which amended this section and the second of
which enacted provisions set out as a note below, was amended by Pub.
L. 100-360, 411(l)(3)(C)(ii), to delete the designation, heading, and
directory language of the first subsec. (c), resulting in subsecs. (e)
and (f) being added by section 4211(a)(3) of Pub. L. 100-203, which
enacted subsecs. (a) to (d) of this section.
Subsec. (g). Pub. L. 100-203, 4212(a), added subsec. (g).
Subsec. (h). Pub. L. 100-203, 4213(a), as amended by Pub. L.
100-360, 411(l)(8)(A), added subsec. (h).
Subsec. (i). Pub. L. 100-203, 4216, added subsec. (i).
Amendment by section 4751(b)(2) of Pub. L. 101-508 applicable with
respect to services furnished on or after the first day of the first
month beginning more than 1 year after Nov. 5, 1990, see section
4751(c) of Pub. L. 101-508, set out as a note under section 1396a of
this title.
Section 4801(a)(6)(B) of Pub. L. 101-508 provided that: ''The
amendments made by subparagraph (A) (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 nursing facility which, pursuant
to any Federal or State law within the 2-year period beginning on
October 1, 1988 --
''(i) had its participation terminated under title XVIII of the
Social Security Act (subchapter XVIII of this chapter) or under the
State plan under title XIX of such Act (this subchapter);
''(ii) was subject to a denial of payment under either such title;
''(iii) was assessed a civil money penalty not less than $5,000 for
deficiencies in nursing facility standards;
''(iv) 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
''(v) pursuant to State action, was closed or had its residents
transferred.''
Amendment by section 4801(a)(2)-(5), (7) of Pub. L. 101-508
effective as if included in the enactment of the Omnibus Budget
Reconciliation Act of 1987, Pub. L. 100-203, see section 4801(a)(9) of
Pub. L. 101-508, set out as a note under section 1396b of this title.
Section 4801(b)(9) of Pub. L. 101-508 provided that:
''(A) In general. -- Except as provided in subparagraph (B), the
amendments made by this subsection (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).
''(B) Exception. -- The amendments made by paragraphs (4), (6), and
(8) (amending this section) shall take effect on the date of the
enactment of this Act (Nov. 5, 1990), without regard to whether or not
regulations to implement such amendments have been promulgated.''
Section 4801(d)(2) of Pub. L. 101-508 provided that: ''The
amendment made by paragraph (1) (amending this section) applies with
respect to nursing facility services furnished on or after October 1,
1990, without regard to whether or not final regulations to carry out
such amendment have been promulgated by such date.''
Section 4801(e)(7)(B) of Pub. L. 101-508 provided that: ''The
amendments made by subparagraph (A) (amending this section) shall take
effect on the date of the enactment of this Act (Nov. 5, 1990), without
regard to whether or not regulations to implement such amendments have
been promulgated.''
Amendment by section 4801(e)(2)-(6), (8)-(10), (12)-(15), and (18) of
Pub. L. 101-508 effective as if included in the enactment of the
Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203, see section
4801(e)(19) of Pub. L. 101-508, set out as a note under section 1396a
of this title.
Amendment by section 6901(b)(1), (4)(A) of Pub. L. 101-239 effective
as if included in the enactment of the Omnibus Budget Reconciliation Act
of 1987, Pub. L. 100-203, and amendment by section 6901(b)(3) of Pub.
L. 101-239 applicable to nurse aide training and competency evaluation
programs, and nurse aide competency evaluation programs, offered on or
after end of 90-day period beginning on Dec. 19, 1989, but not to
affect competency evaluations conducted under programs offered before
end of that period, see section 6901(b)(6) of Pub. L. 101-239, set out
as a note under section 1395i-3 of this title.
Amendment by section 6901(d)(1) of Pub. L. 101-239 effective Dec.
19, 1989, and amendment by section 6901(d)(4) of Pub. L. 101-239
effective as if included in the enactment of the Omnibus Budget
Reconciliation Act of 1987, Pub. L. 100-203, see section 6901(d)(6) of
Pub. L. 101-239, set out as a note under section 1395i-3 of this title.
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 303(a)(2) of Pub. L. 100-360 applicable, except
as otherwise provided, to payments under this subchapter for calendar
quarters beginning on or after Sept. 30, 1989, without regard to
whether or not final regulations to carry out such amendment has been
promulgated by such date, see section 303(g)(1)(A), (5) of Pub. L.
100-360, set out as an Effective Date note under section 1396r-5 of this
title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(l)(2)(A)-(D), (F)-(K), (L)(ii), (3)(A), (B),
(C)(ii), (iii), (D), (5), (6)(A), (B), (7), and (8)(A), (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.
Section 4214 of title IV of Pub. L. 100-203, as amended by Pub. L.
100-360, title IV, 411(l)(10), July 1, 1988, 102 Stat. 806, provided
that:
''(a) New Requirements and Survey and Certification Process. --
Except as otherwise specifically provided in section 1919 of the Social
Security Act (this section), the amendments made by sections 4211
(enacting this section, amending sections 1320a-7b, 1396a, 1396b, 1396d,
1396j, 1396l, 1396n, 1396o, 1396p, 1396r, and 1396s of this title,
redesignating section 1396r of this title as section 1396r-3 of this
title, and amending provisions set out as a note under section 1396r-3
of this title) and 4212 (amending sections 1395cc, 1396a, 1396b, 1396i,
and 1396r of this title) (relating to nursing facility requirements and
survey and certification requirements) shall apply to nursing facility
services furnished on or after October 1, 1990, without regard to
whether regulations to implement such amendments are promulgated by such
date; except that section 1902(a)(28)(B) of the Social Security Act
(section 1396a(a)(28)(B) of this title) (as amended by section 4211(b)
of this Act), relating to requiring State medical assistance plans to
specify the services included in nursing facility services, shall apply
to calendar quarters beginning more than 6 months after the date of the
enactment of this Act (Dec. 22, 1987), without regard to whether
regulations to implement such section are promulgated by such date.
''(b) Enforcement. -- (1) Except as otherwise specifically provided
in section 1919 of the Social Security Act (this section), the
amendments made by section 4213 of this Act (amending this section and
sections 1396a and 1396b of this title) apply to payments under title
XIX of the Social Security Act (this subchapter) for calendar quarters
beginning on or after the date of the enactment of this Act (Dec. 22,
1987), without regard to whether regulations to implement such
amendments are promulgated by such date.
''(2) In applying the amendments made by this part (part 2 of
subtitle C ( 4211-4218) of title IV of Pub. L. 100-203, see Tables for
classification) for services furnished before October 1, 1990 --
''(A) any reference to a nursing facility is deemed a reference to a
skilled nursing facility or intermediate care facility (other than an
intermediate care facility for the mentally retarded), and
''(B) with respect to such a skilled nursing facility or intermediate
care facility, any reference to a requirement of subsection (b), (c), or
(d) of section 1919 of the Social Security Act (subsec. (b), (c), or (d)
of this section), is deemed a reference to the provisions of section
1861(j) or section 1905(c), respectively, of the Social Security Act
(section 1395x(j) or 1396d(c) 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 and implementing the amendments made by this
part.''
Actions
Section 4801(a)(1) of Pub. L. 101-508 provided that: ''The
Secretary of Health and Human Services shall not take (and shall not
continue) any action against a State under section 1904 of the Social
Security Act (section 1396c of this title) on the basis of the State's
failure to meet the requirement of section 1919(e)(1)(A) of such Act
(subsec. (e)(1)(A) of this section) before the effective date of
guidelines, issued by the Secretary, establishing requirements under
section 1919(f)(2)(A) of such Act, if the State demonstrates to the
satisfaction of the Secretary that it has made a good faith effort to
meet such requirement before such effective date.''
Section 4801(b)(1) of Pub. L. 101-508 provided that: ''The
Secretary of Health and Human Services shall not take (and shall not
continue) any action against a State under section 1904 or section
1919(e)(7)(D) of the Social Security Act (section 1396c of this title
and subsec. (e)(7)(D) of this section) on the basis of the State's
failure to meet the requirement of section 1919(e)(7)(A) of such Act
before the effective date of guidelines, issued by the Secretary,
establishing minimum criteria under section 1919(f)(8)(A) of such Act,
if the State demonstrates to the satisfaction of the Secretary that it
has made a good faith effort to meet such requirement before such
effective date.''
Section 4801(c) of Pub. L. 101-508 provided that: ''The Secretary
of Health and Human Services shall not take (and shall not continue) any
action against a State under section 1904 of the Social Security Act
(section 1396c of this title) on the basis of the State's failure to
meet the requirements of section 1919(h)(2) of such Act (subsec. (h)(2)
of this section) before the effective date of guidelines, issued by the
Secretary, regarding the establishment of remedies by the State under
such section, if the State demonstrates to the satisfaction of the
Secretary that it has made a good faith effort to meet such requirements
before such effective date.''
Section 4801(e)(17) of Pub. L. 101-508 provided that:
''(A) Maintaining regulatory standards for certain services. -- Any
regulations promulgated and applied by the Secretary of Health and Human
Services after the date of the enactment of the Omnibus Budget
Reconciliation Act of 1987 (Dec. 22, 1987) with respect to services
described in clauses (ii), (iv), and (v) of section 1919(b)(4)(A) of the
Social Security Act (subsec. (b)(4)(A)(ii), (iv), (v) of this section)
shall include requirements for providers of such services that are at
least as strict as the requirements applicable to providers of such
services prior to the enactment of the Omnibus Budget Reconciliation Act
of 1987.
''(B) Study on staffing requirements in nursing facilities. -- The
Secretary shall conduct a study and report to Congress no later than
January 1, 1992, on the appropriateness of establishing minimum
caregiver to resident ratios and minimum supervisor to caregiver ratios
for skilled nursing facilities serving as providers of services under
title XVIII of the Social Security Act (subchapter XVIII of this
chapter) and nursing facilities receiving payments under a State plan
under title XIX of the Social Security Act (this subchapter), and shall
include in such study recommendations regarding appropriate minimum
ratios.''
For satisfaction of training and competency evaluation requirements
of subsec. (b)(5)(A) of this section and section 1395i-3(b)(5)(A) of
this title and authorization for a State to waive such competency
evaluation requirements, see section 6901(b)(4)(B)-(D) of Pub. L.
101-239, set out as a note under section 1395i-3 of this title.
Section 6901(c) of Pub. L. 101-239 provided that: ''The Secretary
of Health and Human Services shall issue proposed regulations to
establish the criteria described in section 1919(f)(8)(A) of the Social
Security Act (subsec. (f)(8)(A) of this section) by not later than 90
days after the date of the enactment of this Act (Dec. 19, 1989).''
Section 4211(c) of Pub. L. 100-203 provided that: ''The Secretary
of Health and Human Services shall evaluate, and report to Congress by
not later than January 1, 1993, on the implementation of the resident
assessment process for residents of nursing facilities under the
amendments made by this section (enacting this section, amending
sections 1320a-7b, 1396a, 1396b, 1396d, 1396j, 1396l, 1396n, 1396o,
1396p, 1396r, and 1396s of this title, redesignating section 1396r of
this title as section 1396r-3 of this title, and amending provisions set
out as a note under section 1396r-3 of this title).''
Section 4211(k) of Pub. L. 100-203 provided that: ''The Secretary
of Health and Human Services shall report to Congress, by not later than
January 1, 1993, on the progress made in implementing the nursing
facility staffing requirements of subparagraph (C) of section 1919(b)(4)
of the Social Security Act (subsec. (b)(4)(C) of this section) (as
amended by subsection (a) of this section), including the number and
types of waivers approved under subparagraph (C)(ii) of such section and
the number of facilities which have received waivers.''
Section 4215 of Pub. L. 100-203, as amended by Pub. L. 101-508,
title IV, 4801(b)(5)(B), Nov. 5, 1990, 104 Stat. 1388-214, provided
that: ''The Secretary of Health and Human Services shall report to the
Congress annually on the extent to which nursing facilities are
complying with the requirements of subsections (b), (c), and (d) of
section 1919 of the Social Security Act (subsecs. (b), (c), and (d) of
this section) (as added by the amendments made by this part) and the
number and type of enforcement actions taken by States and the Secretary
under section 1919(h) of such Act (as added by section 4213 of this
Act). Each such report shall also include a summary of the information
reported by States under section 1919(e)(7)(C)(iv) of such Act.''
5503.
/1/ So in original. The words ''no later than'' probably should not
appear.
/2/ So in original. Probably should be followed by a closing
parenthesis.
/3/ So in original. Probably should be ''clause''.
/4/ So in original. Probably should be ''paragraph''.
/5/ So in original. Probably should be followed by a comma.
42 USC 1396r-1. Presumptive eligibility for pregnant women
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Ambulatory prenatal care
A State plan approved under section 1396a of this title may provide
for making ambulatory prenatal care available to a pregnant woman during
a presumptive eligibility period.
(b) Definitions
For purposes of this section --
(1) the term ''presumptive eligibility period'' means, with respect
to a pregnant woman, the period that --
(A) begins with the date on which a qualified provider determines, on
the basis of preliminary information, that the family income of the
woman does not exceed the applicable income level of eligibility under
the State plan, and
(B) ends with (and includes) the earlier of --
(i) the day on which a determination is made with respect to the
eligibility of the woman for medical assistance under the State plan, or
(ii) in the case of a woman who does not file an application by the
last day of the month following the month during which the provider
makes the determination referred to in subparagraph (A), such last day;
and
(2) the term ''qualified provider'' means any provider that --
(A) is eligible for payments under a State plan approved under this
subchapter,
(B) provides services of the type described in subparagraph (A) or
(B) of section 1396d(a)(2) of this title or in section 1396d(a)(9) of
this title,
(C) is determined by the State agency to be capable of making
determinations of the type described in paragraph (1)(A), and
(D)(i) receives funds under --
(I) section 254b, 254c, or 256 of this title,
(II) subchapter V of this chapter, or
(III) title V of the Indian Health Care Improvement Act (25 U.S.C.
1651 et seq.);
(ii) participates in a program established under --
(I) section 1786 of this title, or
(II) section 4(a) of the Agriculture and Consumer Protection Act of
1973;
(iii) participates in a State perinatal program; or
(iv) is the Indian Health Service or is a health program or facility
operated by a tribe or tribal organization under the Indian
Self-Determination Act (Public Law 93-638) (25 U.S.C. 450f et seq.).
(c) Duties of State agency, qualified providers, and presumptively
eligible pregnant women
(1) The State agency shall provide qualified providers with --
(A) such forms as are necessary for a pregnant woman to make
application for medical assistance under the State plan, and
(B) information on how to assist such women in completing and filing
such forms.
(2) A qualified provider that determines under subsection (b)(1)(A)
of this section that a pregnant woman is presumptively eligible for
medical assistance under a State plan shall --
(A) notify the State agency of the determination within 5 working
days after the date on which determination is made, and
(B) inform the woman at the time the determination is made that she
is required to make application for medical assistance under the State
plan by not later than the last day of the month following the month
during which the determination is made.
(3) A pregnant woman who is determined by a qualified provider to be
presumptively eligible for medical assistance under a State plan shall
make application for medical assistance under such plan by not later
than the last day of the month following the month during which the
determination is made, which application may be the application used for
the receipt of medical assistance by individuals described in section
1396a(l)(1)(A) of this title.
(d) Ambulatory prenatal care as medical assistance
Notwithstanding any other provision of this subchapter, ambulatory
prenatal care that --
(1) is furnished to a pregnant woman --
(A) during a presumptive eligibility period,
(B) by a provider that is eligible for payments under the State plan;
and
(2) is included in the care and services covered by a State plan;
shall be treated as medical assistance provided by such plan for
purposes of section 1396b of this title.
(Aug. 14, 1935, ch. 531, title XIX, 1920, as added Oct. 21, 1986,
Pub. L. 99-509, title IX, 9407(b), 100 Stat. 2058, and amended July 1,
1988, Pub. L. 100-360, title IV, 411(k)(16)(A), (B), 102 Stat. 799;
Oct. 13, 1988, Pub. L. 100-485, title VI, 608(d)(26)(L), 102 Stat.
2422; Nov. 5, 1990, Pub. L. 101-508, title IV, 4605(a), (b), 104 Stat.
1388-169.)
The Indian Health Care Improvement Act, referred to in subsec.
(b)(2)(D)(i)(III), is Pub. L. 94-437, Sept. 30, 1976, 90 Stat. 1400,
as amended. Title V of the Indian Health Care Improvement Act is
classified generally to subchapter IV ( 1651 et seq.) of chapter 18 of
Title 25, Indians. For complete classification of this Act to the Code,
see Short Title note set out under section 1601 of Title 25 and Tables.
Section 4(a) of the Agriculture and Consumer Protection Act of 1973,
referred to in subsec. (b)(2)(D)(ii)(II), is section 4(a) of Pub. L.
93-86, Aug. 10, 1973, 87 Stat. 249, as amended, which is set out as a
note under section 612c of Title 7, Agriculture.
The Indian Self-Determination Act (Public Law 93-638), referred to in
subsec. (b)(2)(D)(iv), is title I of Pub. L. 93-638, Jan. 4, 1975, 88
Stat. 2206, as amended, which is classified principally to subchapter
II ( 450f et seq.) of chapter 14 of Title 25, Indians. For complete
classification of this Act to the Code, see Short Title note set out
under section 450 of Title 25 and Tables.
A prior section 1920 of act Aug. 14, 1935, was renumbered section
1928, and is classified to section 1396s of this title.
1990 -- Subsec. (b)(1)(B). Pub. L. 101-508, 4605(a)(1), inserted
''or'' at end of cl. (i), redesignated cl. (iii) as (ii) and amended
it generally, and struck out former cl. (ii). Prior to amendment, cls.
(ii) and (iii) read as follows:
''(ii) the day that is 45 days after the date on which the provider
makes the determination referred to in subparagraph (A), or
''(iii) in the case of a woman who does not file an application for
medical assistance within 14 calendar days after the date on which the
provider makes the determination referred to in subparagraph (A), the
fourteenth calendar day after such determination is made; and''.
Subsec. (c)(2)(B). Pub. L. 101-508, 4605(a)(2), substituted ''by not
later than the last day of the month following the month during which''
for ''within 14 calendar days after the date on which''.
Subsec. (c)(3). Pub. L. 101-508, 4605(b), inserted before period at
end '', which application may be the application used for the receipt of
medical assistance by individuals described in section 1396a(l)(1)(A) of
this title''.
Pub. L. 101-508, 4605(a)(2), substituted ''by not later than the
last day of the month following the month during which'' for ''within 14
calendar days after the date on which''.
1988 -- Subsec. (b)(2)(D)(i). Pub. L. 100-360, 411(k)(16)(B)(i),
substituted ''section 254b, 254c, or 256 of this title,'' for ''section
254b of this title or section 254c of this title, or'' in subcl. (I),
substituted ''chapter, or'' for ''chapter;'' in subcl. (II), and added
subcl. (III).
Subsec. (b)(2)(D)(ii)(II). Pub. L. 100-360, 411(k)(16)(B)(ii), as
amended by Pub. L. 100-485, 608(d)(26)(L)(i), struck out ''or'' after
''1973;''.
Subsec. (b)(2)(D)(iii). Pub. L. 100-360, 411(k)(16)(B)(iii), as
added by Pub. L. 100-485, 608(d)(26)(L)(iii), substituted ''program;
or'' for ''program.''
Subsec. (b)(2)(D)(iv). Pub. L. 100-360, 411(k)(16)(B)(iv), formerly
411(k)(16)(B)(iii), as redesignated by Pub. L. 100-485,
608(d)(26)(L)(ii), added cl. (iv).
Subsec. (d)(1)(B). Pub. L. 100-360, 411(k)(16)(A), substituted ''by
a provider that is eligible for payments under the State plan'' for ''by
a qualified provider''.
Section 4605(c) of Pub. L. 101-508 provided that:
''(1) The amendments made by subsection (a) (amending this section)
apply to payments under title XIX of the Social Security Act (this
subchapter) for calendar quarters beginning on or after July 1, 1991,
without regard to whether or not final regulations to carry out such
amendments have been promulgated by such date.
''(2) The amendment made by subsection (b) (amending this section)
shall be effective as if included in the enactment of section 9407(b) of
the Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99-509, enacting
this section).''
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Section 411(k)(16)(C) of Pub. L. 100-360 provided that: ''The
amendments made by this paragraph (amending this section) shall be
effective as if they were included in section 9407(b) of the Omnibus
Budget Reconciliation Act of 1986 (Pub. L. 99-509).''
Section applicable to ambulatory prenatal care furnished in calendar
quarters beginning on or after Apr. 1, 1987, without regard to whether
or not final regulations to carry out such section have been
promulgated, see section 9407(d) of Pub. L. 99-509, set out as an
Effective Date of 1986 Amendment note under section 1396a of this title.
42 USC 1396r-2. Information concerning sanctions taken by State
licensing authorities against health care practitioners and providers
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Information reporting requirement
The requirement referred to in section 1396a(a)(49) of this title is
that the State must provide for the following:
(1) Information reporting system
The State must have in effect a system of reporting the following
information with respect to formal proceedings (as defined by the
Secretary in regulations) concluded against a health care practitioner
or entity by any authority of the State (or of a political subdivision
thereof) responsible for the licensing of health care practitioners (or
any peer review organization or private accreditation entity reviewing
the services provided by health care practitioners) or entities:
(A) Any adverse action taken by such licensing authority as a result
of the proceeding, including any revocation or suspension of a license
(and the length of any such suspension), reprimand, censure, or
probation.
(B) Any dismissal or closure of the proceedings by reason of the
practitioner or entity surrendering the license or leaving the State or
jurisdiction.
(C) Any other loss of the license of the practitioner or entity,
whether by operation of law, voluntary surrender, or otherwise.
(D) Any negative action or finding by such authority, organization,
or entity regarding the practitioner or entity.
(2) Access to documents
The State must provide the Secretary (or an entity designated by the
Secretary) with access to such documents of the authority described in
paragraph (1) as may be necessary for the Secretary to determine the
facts and circumstances concerning the actions and determinations
described in such paragraph for the purpose of carrying out this
chapter.
(b) Form of information
The information described in subsection (a)(1) of this section shall
be provided to the Secretary (or to an appropriate private or public
agency, under suitable arrangements made by the Secretary with respect
to receipt, storage, protection of confidentiality, and dissemination of
information) in such a form and manner as the Secretary determines to be
appropriate in order to provide for activities of the Secretary under
this chapter and in order to provide, directly or through suitable
arrangements made by the Secretary, information --
(1) to agencies administering Federal health care programs, including
private entities administering such programs under contract,
(2) to licensing authorities described in subsection (a)(1) of this
section,
(3) to State agencies administering or supervising the administration
of State health care programs (as defined in section 1320a-7(h) of this
title),
(4) to utilization and quality control peer review organizations
described in part B of subchapter XI of this chapter and to appropriate
entities with contracts under section 1320c-3(a)(4)(C) of this title
with respect to eligible organizations reviewed under the contracts,
(5) to State medicaid fraud control units (as defined in section
1396b(q) of this title),
(6) to hospitals and other health care entities (as defined in
section 431 of the Health Care Quality Improvement Act of 1986 (42
U.S.C. 11151)), with respect to physicians or other licensed health care
practitioners that have entered (or may be entering) into an employment
or affiliation relationship with, or have applied for clinical
privileges or appointments to the medical staff of, such hospitals or
other health care entities (and such information shall be deemed to be
disclosed pursuant to section 427 (42 U.S.C. 11137) of, and be subject
to the provisions of, that Act (42 U.S.C. 11101 et seq.)),
(7) to the Attorney General and such other law enforcement officials
as the Secretary deems appropriate, and
(8) upon request, to the Comptroller General,
in order for such authorities to determine the fitness of individuals
to provide health care services, to protect the health and safety of
individuals receiving health care through such programs, and to protect
the fiscal integrity of such programs.
(c) Confidentiality of information provided
The Secretary shall provide for suitable safeguards for the
confidentiality of the information furnished under subsection (a) of
this section. Nothing in this subsection shall prevent the disclosure
of such information by a party which is otherwise authorized, under
applicable State law, to make such disclosure.
(d) Appropriate coordination
The Secretary shall provide for the maximum appropriate coordination
in the implementation of subsection (a) of this section and section 422
of the Health Care Quality Improvement Act of 1986 (42 U.S.C. 11132).
(Aug. 14, 1935, ch. 531, title XIX, 1921, as added Aug. 18, 1987,
Pub. L. 100-93, 5(b), 101 Stat. 690, and amended Nov. 5, 1990, Pub. L.
101-508, title IV, 4752(f)(1), 104 Stat. 1388-208.)
Part B of subchapter XI of this chapter, referred to in subsec.
(b)(4), is classified to section 1320c et seq. of this title.
That Act, referred to in subsec. (b)(6), is title IV of Pub. L.
99-660, Nov. 14, 1986, 100 Stat. 3784, as amended, known as the Health
Care Quality Improvement Act of 1986, which is classified generally to
chapter 117 ( 11101 et seq.) of this title. For complete classification
of this Act to the Code, see Short Title note set out under section
11101 of this title and Tables.
A prior section 1921 of act Aug. 14, 1935, was renumbered section
1928, and is classified to section 1396s of this title.
1990 -- Subsec. (a)(1). Pub. L. 101-508, 4752(f)(1)(A), inserted
''(or any peer review organization or private accreditation entity
reviewing the services provided by health care practitioners)'' after
''health care practitioners'' in introductory provisions.
Subsec. (a)(1)(D). Pub. L. 101-508, 4752(f)(1)(B), added subpar.
(D).
Section 4752(f)(2) of Pub. L. 101-508 provided that: ''The
amendments made by paragraph (1) (amending this section) shall apply to
State information reporting systems as of January 1, 1992, without
regard to whether or not the Secretary of Health and Human Services has
promulgated any regulations to carry out such amendments by such date.''
Section applicable, with certain exceptions, to payments under
subchapter XIX of this chapter for calendar quarters beginning more than
thirty days after Aug. 18, 1987, without regard to whether or not final
regulations to carry out this section have been published by that date,
see section 15(c)(1), (2) of Pub. L. 100-93 set out as an Effective
Date of 1987 Amendment note under section 1320a-7 of this title.
42 USC 1396r-3. Correction and reduction plans for intermediate care
facilities for mentally retarded
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Written plans to remedy substantial deficiencies; time for
submission
If the Secretary finds that an intermediate care facility for the
mentally retarded has substantial deficiencies which do not pose an
immediate threat to the health and safety of residents (including
failure to provide active treatment), the State may elect, subject to
the limitations in this section, to --
(1) submit, within the number of days specified by the Secretary in
regulations which apply to submission of compliance plans with respect
to deficiencies of such type, a written plan of correction which details
the extent of the facility's current compliance with the standards
promulgated by the Secretary, including all deficiencies identified
during a validation survey, and which provides for a timetable for
completion of necessary steps to correct all staffing deficiencies
within 6 months, and a timetable for rectifying all physical plant
deficiencies within 6 months; or
(2) submit, within a time period consisting of the number of days
specified for submissions under paragraph (1) plus 35 days, a written
plan for permanently reducing the number of certified beds, within a
maximum of 36 months, in order to permit any noncomplying buildings (or
distinct parts thereof) to be vacated and any staffing deficiencies to
be corrected (hereinafter in this section referred to as a ''reduction
plan'').
(b) Conditions for approval of reduction plans
As conditions of approval of any reduction plan submitted pursuant to
subsection (a)(2) of this section, the State must --
(1) provide for a hearing to be held at the affected facility at
least 35 days prior to submission of the reduction plan, with reasonable
notice thereof to the staff and residents of the facility, responsible
members of the residents' families, and the general public;
(2) demonstrate that the State has successfully provided home and
community services similar to the services proposed to be provided under
the reduction plan for similar individuals eligible for medical
assistance; and
(3) provide assurances that the requirements of subsection (c) of
this section shall be met with respect to the reduction plan.
(c) Contents of reduction plan
The reduction plan must --
(1) identify the number and service needs of existing facility
residents to be provided home or community services and the timetable
for providing such services, in 6 month intervals, within the 36-month
period;
(2) describe the methods to be used to select such residents for home
and community services and to develop the alternative home and community
services to meet their needs effectively;
(3) describe the necessary safeguards that will be applied to protect
the health and welfare of the former residents of the facility who are
to receive home or community services, including adequate standards for
consumer and provider participation and assurances that applicable State
licensure and applicable State and Federal certification requirements
will be met in providing such home or community services;
(4) provide that residents of the affected facility who are eligible
for medical assistance while in the facility shall, at their option, be
placed in another setting (or another part of the affected facility) so
as to retain their eligibility for medical assistance;
(5) specify the actions which will be taken to protect the health and
safety of, and to provide active treatment for, the residents who remain
in the affected facility while the reduction plan is in effect;
(6) provide that the ratio of qualified staff to residents at the
affected facility (or the part thereof) which is subject to the
reduction plan will be the higher of --
(A) the ratio which the Secretary determines is necessary in order to
assure the health and safety of the residents of such facility (or part
thereof); or
(B) the ratio which was in effect at the time that the finding of
substantial deficiencies (referred to in subsection (a) of this section)
was made; and
(7) provide for the protection of the interests of employees affected
by actions under the reduction plan, including --
(A) arrangements to preserve employee rights and benefits;
(B) training and retraining of such employees where necessary;
(C) redeployment of such employees to community settings under the
reduction plan; and
(D) making maximum efforts to guarantee the employment of such
employees (but this requirement shall not be construed to guarantee the
employment of any employee).
(d) Notice and comment; approval of more than 15 reduction plans in
any fiscal year; corrections costing $2,000,000 or more
(1) The Secretary must provide for a period of not less than 30 days
after the submission of a reduction plan by a State, during which
comments on such reduction plan may be submitted to the Secretary,
before the Secretary approves or disapproves such reduction plan.
(2) If the Secretary approves more than 15 reduction plans under this
section in any fiscal year, any reduction plans approved in addition to
the first 15 such plans approved, must be for a facility (or part
thereof) for which the costs of correcting the substantial deficiencies
(referred to in subsection (a) of this section) are $2,000,000 or
greater (as demonstrated by the State to the satisfaction of the
Secretary).
(e) Termination of provider agreements; disallowance of percentage
amounts for purposes of Federal financial participation
(1) If the Secretary, at the conclusion of the 6-month plan of
correction described in subsection (a)(1) of this section, determines
that the State has substantially failed to correct the deficiencies
described in subsection (a) of this section, the Secretary may terminate
the facility's provider agreement in accordance with the provisions of
section 1396i(b) of this title.
(2) In the case of a reduction plan described in subsection (a)(2) of
this section, if the Secretary determines, at the conclusion of the
initial 6-month period or any 6-month interval thereafter, that the
State has substantially failed to meet the requirements of subsection
(c) of this section, the Secretary shall --
(A) terminate the facility's provider agreement in accordance with
the provisions of section 1396i(b) of this title; or
(B) if the State has failed to meet such requirements despite good
faith efforts, disallow, for purposes of Federal financial
participation, an amount equal to 5 percent of the cost of care for all
eligible individuals in the facility for each month for which the State
fails to meet such requirements.
(f) Applicability of section limited to plans approved by January 1,
1990
The provisions of this section shall apply only to plans of
correction and reduction plans approved by the Secretary by January 1,
1990.
(Aug. 14, 1935, ch. 531, title XIX, 1922, formerly 1919, as added
Apr. 7, 1986, Pub. L. 99-272, title IX, 9516(a), 100 Stat. 213;
renumbered 1922 and amended Dec. 22, 1987, Pub. L. 100-203, title IV,
4211(a)(2), 4212(e)(5), 101 Stat. 1330-182; amended July 1, 1988, Pub.
L. 100-360, title IV, 411(l)(6)(E), 102 Stat. 804; Nov. 10, 1988,
Pub. L. 100-647, title VIII, 8433(a), 102 Stat. 3804.)
A prior section 1922 of act Aug. 14, 1935, was renumbered section
1928, and is classified to section 1396s of this title.
1988 -- Subsec. (a). Pub. L. 100-647, 8433(a)(1), inserted
''(including failure to provide active treatment)'' after ''residents''
in introductory provisions.
Subsec. (c)(5). Pub. L. 100-647, 8433(a)(2), inserted '', and to
provide active treatment for,'' after ''safety of''.
Subsec. (e)(1), (2)(A). Pub. L. 100-360, 411(l)(6)(E), substituted
''1396i(b)'' for ''1396i(c)''.
Subsec. (f). Pub. L. 100-647, 8433(a)(3), substituted ''by January
1, 1990'' for ''within 3 years after the effective date of final
regulations implementing this section''.
Section 8433(b) of Pub. L. 100-647 provided that: ''The amendments
made by subsection (a) (amending this section) shall become effective on
the date of the enactment of this Act (Nov. 10, 1988), and shall apply
to any proceeding where there has not yet been a final determination by
the Secretary (as defined for purposes of judicial review) as of the
date of the enactment of this Act.''
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.
Section 9516(b) of Pub. L. 99-272 provided that:
''(1) The amendment made by this section (enacting this section)
shall become effective on the date of the enactment of this Act (Apr.
7, 1986).
''(2) The Secretary of Health and Human Services shall issue a notice
of proposed rulemaking with respect to section 1919 of the Social
Security Act (this section) within 60 days after the date of the
enactment of this Act, and shall allow a period of 30 days for comment
thereon prior to promulgating final regulations implementing such
section.''
Section 4217 of Pub. L. 100-203 provided that:
''(a) In General. -- Not later than 30 days after the date of
enactment of this Act (Dec. 22, 1987), the Secretary of Health and Human
Services shall promulgate final regulations to implement the amendments
made by section 9516 of the Consolidated Omnibus Budget Reconciliation
Act of 1985 (enacting this section).
''(b) The regulations promulgated under paragraph (1) shall be
effective as if promulgated on the date of enactment of the Consolidated
Omnibus Budget Reconciliation Act of 1985 (Apr. 7, 1986).''
Section 9516(c) of Pub. L. 99-272, as amended by Pub. L. 100-203,
title IV, 4211(l), Dec. 22, 1987, 101 Stat. 1330-207, provided that:
''The Secretary of Health and Human Services shall submit a report to
the Congress on the implementation and results of section 1922 of the
Social Security Act (this section). Such report shall be submitted not
later than 30 months after the effective date of final regulations
promulgated to implement such section.''
42 USC 1396r-4. Adjustment in payment for inpatient hospital services
furnished by disproportionate share hospitals
TITLE 42 -- THE PUBLIC HEALTH AND WELFARE
(a) Implementation of requirement
(1) A State plan under this subchapter shall not be considered to
meet the requirement of section 1396a(a)(13)(A) of this title (insofar
as it requires payments to hospitals to take into account the situation
of hospitals which serve a disproportionate number of low income
patients with special needs), as of July 1, 1988, unless the State has
submitted to the Secretary, by not later than such date, an amendment to
such plan that --
(A) specifically defines the hospitals so described (and includes in
such definition any disproportionate share hospital described in
subsection (b)(1) of this section which meets the requirement of
subsection (d) of this section), and
(B) provides, effective for inpatient hospital services provided not
later than July 1, 1988, for an appropriate increase in the rate or
amount of payment for such services provided by such hospitals,
consistent with subsection (c) of this section.
(2)(A) In order to be considered to have met such requirement of
section 1396a(a)(13)(A) of this title as of July 1, 1989, the State must
submit to the Secretary by not later than April 1, 1989, the State plan
amendment described in paragraph (1), consistent with subsection (c) of
this section, effective for inpatient hospital services provided on or
after July 1, 1989.
(B) In order to be considered to have met such requirement of section
1396a(a)(13)(A) of this title as of July 1, 1990, the State must submit
to the Secretary by not later than April 1, 1990, the State plan
amendment described in paragraph (1), consistent with subsections (c)
and (f) of this section, effective for inpatient hospital services
provided on or after July 1, 1990.
(C) If a State plan under this subchapter provides for payments for
inpatient hospital services on a prospective basis (whether per diem,
per case, or otherwise), in order for the plan to be considered to have
met such requirement of section 1396a(a)(13)(A) of this title as of July
1, 1989, the State must submit to the Secretary by not later than April
1, 1989, a State plan amendment that provides, in the case of hospitals
defined by the State as disproportionate share hospitals under paragraph
(1)(A), for an outlier adjustment in payment amounts for medically
necessary inpatient hospital services provided on or after July 1, 1989,
involving exceptionally high costs or exceptionally long lengths of stay
for individuals under one year of age.
(3) The Secretary shall, not later than 90 days after the date a
State submits an amendment under this subsection, review each such
amendment for compliance with such requirement and by such date shall
approve or disapprove each such amendment. If the Secretary disapproves
such an amendment, the State shall immediately submit a revised
amendment which meets such requirement.
(4) The requirement of this subsection may not be waived under
section 1396n(b)(4) of this title.
(b) Hospitals deemed disproportionate share
(1) For purposes of subsection (a)(1) of this section, a hospital
which meets the requirement of subsection (d) of this section is deemed
to be a disproportionate share hospital if --
(A) the hospital's medicaid inpatient utilization rate (as defined in
paragraph (2)) is at least one standard deviation above the mean
medicaid inpatient utilization rate for hospitals receiving medicaid
payments in the State; or
(B) the hospital's low-income utilization rate (as defined in
paragraph (3)) exceeds 25 percent.
(2) For purposes of paragraph (1)(A), the term ''medicaid inpatient
utilization rate'' means, for a hospital, a fraction (expressed as a
percentage), the numerator of which is the hospital's number of
inpatient days attributable to patients who (for such days) were
eligible for medical assistance under a State plan approved under this
subchapter in a period, and the denominator of which is the total number
of the hospital's inpatient days in that period. In this paragraph, the
term ''inpatient day'' includes each day in which an individual
(including a newborn) is an inpatient in the hospital, whether or not
the individual is in a specialized ward and whether or not the
individual remains in the hospital for lack of suitable placement
elsewhere.
(3) For purposes of paragraph (1)(B), the term ''low-income
utilization rate'' means, for a hospital, the sum of --
(A) the fraction (expressed as a percentage) --
(i) the numerator of which is the sum (for a period) of (I) the total
revenues paid the hospital for patient services under a State plan under
this subchapter and (II) the amount of the cash subsidies for patient
services received directly from State and local governments, and
(ii) the denominator of which is the total amount of revenues of the
hospital for patient services (including the amount of such cash
subsidies) in the period; and
(B) a fraction (expressed as a percentage) --
(i) the numerator of which is the total amount of the hospital's
charges for inpatient hospital services which are attributable to
charity care in a period, less the portion of any cash subsidies
described in clause (i)(II) of subparagraph (A) in the period reasonably
attributable to inpatient hospital services, and
(ii) the denominator of which is the total amount of the hospital's
charges for inpatient hospital services in the hospital in the period.
The numerator under subparagraph (B)(i) shall not include contractual
allowances and discounts (other than for indigent patients not eligible
for medical assistance under a State plan approved under this
subchapter).
(4) The Secretary may not restrict a State's authority to designate
hospitals as disproportionate share hospitals under this section. The
previous sentence shall not be construed to affect the authority of the
Secretary to reduce payments pursuant to section 1396b(w)(1)(A)(iii) of
this title if the Secretary determines that, as a result of such
designations, there is in effect a hold harmless provision described in
section 1396b(w)(4) of this title.
(c) Payment adjustment
Subject to subsection (f) of this section, in order to be consistent
with this subsection, a payment adjustment for a disproportionate share
hospital must either --
(1) be in an amount equal to at least the product of (A) the amount
paid under the State plan to the hospital for operating costs for
inpatient hospital services (of the kind described in section
1395ww(a)(4) of this title), and (B) the hospital's disproportionate
share adjustment percentage (established under section
1395ww(d)(5)(F)(iv) of this title);
(2) provide for a minimum specified additional payment amount (or
increased percentage payment) and (without regard to whether the
hospital is described in subparagraph (A) or (B) of subsection (b)(1) of
this section) for an increase in such a payment amount (or percentage
payment) in proportion to the percentage by which the hospital's
medicaid utilization rate (as defined in subsection (b)(2) of this
section) exceeds one standard deviation above the mean medicaid
inpatient utilization rate for hospitals receiving medicaid payments in
the State or the hospital's low-income utilization rate (as defined in
paragraph /1/ (b)(3) of this section); or
(3) provide for a minimum specified additional payment amount (or
increased percentage payment) that varies according to type of hospital
under a methodology that --
(A) applies equally to all hospitals of each type; and
(B) results in an adjustment for each type of hospital that is
reasonably related to the costs, volume, or proportion of services
provided to patients eligible for medical assistance under a State plan
approved under this subchapter or to low-income patients. /2/
except that, for purposes of paragraphs (1)(B) and (2)(A) of
subsection (a) of this section, the payment adjustment for a
disproportionate share hospital is consistent with this subsection if
the appropriate increase in the rate or amount of payment is equal to at
least one-third of the increase otherwise applicable under this
subsection (in the case of such paragraph (1)(B)) and at least
two-thirds of such increase (in the case of paragraph (2)(A)). In the
case of a hospital described in subsection (d)(2)(A)(i) of this section
(relating to children's hospitals), in computing the hospital's
disproportionate share adjustment percentage for purposes of paragraph
(1)(B) of this subsection, the disproportionate patient percentage
(defined in section 1395ww(d)(5)(F)(vi) of this title) shall be computed
by substituting for the fraction described in subclause (I) of such
section the fraction described in subclause (II) of that section. If a
State elects in a State plan amendment under subsection (a) of this
section to provide the payment adjustment described in paragraph (2),
the State must include in the amendment a detailed description of the
specific methodology to be used in determining the specified additional
payment amount (or increased percentage payment) to be made to each
hospital qualifying for such a payment adjustment and must publish at
least annually the name of each hospital qualifying for such a payment
adjustment and the amount of such payment adjustment made for each such
hospital.
(d) Requirement to qualify as disproportionate share hospital
(1) Except as provided in paragraph (2), no hospital may be defined
or deemed as a disproportionate share hospital under a State plan under
this subchapter or under subsection (b) of this section unless the
hospital has at least 2 obstetricians who have staff privileges at the
hospital and who have agreed to provide obstetric services to
individuals who are entitled to medical assistance for such services
under such State plan.
(2)(A) Paragraph (1) shall not apply to a hospital --
(i) the inpatients of which are predominantly individuals under 18
years of age; or
(ii) which does not offer nonemergency obstetric services to the
general population as of December 22, 1987.
(B) In the case of a hospital located in a rural area (as defined for
purposes of section 1395ww of this title), in paragraph (1) the term
''obstetrician'' includes any physician with staff privileges at the
hospital to perform nonemergency obstetric procedures.
(e) Special rule
(1) A State plan shall be considered to meet the requirement of
section 1396a(a)(13)(A) of this title (insofar as it requires payments
to hospitals to take into account the situation of hospitals which serve
a disproportionate number of low income patients with special needs)
without regard to the requirement of subsection (a) of this section if
(A)(i) the plan provided for payment adjustments based on a pooling
arrangement involving a majority of the hospitals participating under
the plan for disproportionate share hospitals as of January 1, 1984, or
(ii) the plan as of January 1, 1987, provided for payment adjustments
based on a statewide pooling arrangement involving all acute care
hospitals and the arrangement provides for reimbursement of the total
amount of uncompensated care provided by each participating hospital,
and (B) the aggregate amount of the payment adjustments under the plan
for such hospitals is not less than the aggregate amount of such
adjustments otherwise required to be made under such subsection.
(2) In the case of a State that used a health insuring organization
before January 1, 1986, to administer a portion of its plan on a
statewide basis, beginning on July 1, 1988 --
(A) the requirements of subsections (b) and (c) of this section shall
not apply if the aggregate amount of the payment adjustments under the
plan for disproportionate share hospitals (as defined under the State
plan) is not less than the aggregate amount of payment adjustments
otherwise required to be made if such subsections applied, and
(B) subsection (d)(2)(B) of this section shall apply to hospitals
located in urban areas, as well as in rural areas.
(f) Denial of Federal financial participation for payments in excess
of certain limits
(1) In general
(A) Application of State-specific limits
Except as provided in subparagraph (D), payment under section
1396b(a) of this title shall not be made with respect to any payment
adjustment made under this section for hospitals in a State (as defined
in paragraph (4)(B)) for quarters --
(i) in fiscal year 1992 (beginning on or after January 1, 1992),
unless --
(I) the payment adjustments are made --
(a) in accordance with the State plan in effect or amendments
submitted to the Secretary by September 30, 1991,
(b) in accordance with the State plan in effect or amendments
submitted to the Secretary by November 26, 1991, or modification
thereof, if the amendment designates only disproportionate share
hospitals with a medicaid or low-income utilization percentage at or
above the Statewide /3/ arithmetic mean, or
(c) in accordance with a payment methodology which was established
and in effect as of September 30, 1991, or in accordance with
legislation or regulations enacted or adopted as of such date; or
(II) the payment adjustments are the minimum adjustments required in
order to meet the requirements of subsection (c)(1) of this section; or
(ii) in a subsequent fiscal year, to the extent that the total of
such payment adjustments exceeds the State disproportionate share
hospital (in this subsection referred to as ''DSH'') allotment for the
year (as specified in paragraph (2)).
(B) National DSH payment limit
The national DSH payment limit for a fiscal year is equal to 12
percent of the total amount of expenditures under State plans under this
subchapter for medical assistance during the fiscal year.
(C) Publication of State DSH allotments and national DSH payment
limit
Before the beginning of each fiscal year (beginning with fiscal year
1993), the Secretary shall, consistent with section 1396b(d) of this
title, estimate and publish --
(i) the national DSH payment limit for the fiscal year, and
(ii) the State DSH allotment for each State for the year.
(D) Conditional exception for certain States
Subject to subparagraph (E), beginning with payments for quarters
beginning on or after January 1, 1996, and at the option of a State,
subparagraph (A) shall not apply in the case of a State which defines a
hospital as a disproportionate share hospital under subsection (a)(1) of
this section only if the hospital meets any of the following
requirements:
(i) The hospital's medicaid inpatient utilization rate (as defined in
subsection (b)(2) of this section) is at or above the mean medicaid
inpatient utilization rate for all hospitals in the State.
(ii) The hospital's low-income utilization rate (as defined in
subsection (b)(3) of this section) is at or above the mean low-income
utilization rate for all hospitals in the State.
(iii) The number of inpatient days of the hospital attributable to
patients who (for such days) were eligible for medical assistance under
the State plan is equal to at least 1 percent of the total number of
such days for all hospitals in the State.
(iv) The hospital meets such alternative requirements as the
Secretary may establish by regulation, taking into account the special
circumstances of children's hospitals, hospitals located in rural areas,
and sole community hospitals.
(E) Condition for option
The option specified in subparagraph (D) shall not apply for payments
for a quarter beginning before the date of enactment of legislation
establishing a limit on payment adjustments under this section which
would apply in the case of a state /4/ exercising such option.
(2) Determination of State DSH allotments
(A) In general
Subject to subparagraph (B), the State DSH allotment for a fiscal
year is equal to the State DSH allotment for the previous fiscal year
(or, for fiscal year 1993, the State base allotment as defined in
paragraph (4)(C)), increased by --
(i) the State growth factor (as defined in paragraph (4)(E)) for the
fiscal year, and
(ii) the State supplemental amount for the fiscal year (as determined
under paragraph (3)).
(B) Exceptions
(i) Limit to 12 percent or base allotment
A State DSH allotment under subparagraph (A) for a fiscal year shall
not exceed 12 percent of the total amount of expenditures under the
State plan for medical assistance during the fiscal year, except that,
in the case of a high DSH State (as defined in paragraph (4)(A)), the
State DSH allotment shall equal the State based allotment.
(ii) Exception for minimum required adjustment
No State DSH allotment shall be less than the minimum amount of
payment adjustments the State is required to make in the fiscal year to
meet the requirements of subsection (c)(1) of this section.
(3) State supplemental amounts
The Secretary shall determine a supplemental amount for each State
that is not a high DSH State for a fiscal year as follows:
(A) Determination of redistribution pool
The Secretary shall subtract from the national DSH payment limit
(specified in paragraph (1)(B)) for the fiscal year the following:
(i) the total of the State base allotments for high DSH States;
(ii) the total of State DSH allotments for the previous fiscal year
(or, in the case of fiscal year 1993, the total of State base
allotments) for all States other than high DSH States;
(iii) the total of the State growth amounts for all States other than
high DSH States for the fiscal year; and
(iv) the total additions to State DSH allotments the Secretary
estimates will be attributable to paragraph (2)(B)(ii).
(B) Distribution of pool based on total medicaid expenditures for
medical assistance
The supplemental amount for a State for a fiscal year is equal to the
lesser of --
(i) the product of the amount determined under subparagraph (A) and
the ratio of --
(I) the total amount of expenditures made under the State plan under
this subchapter for medical assistance during the fiscal year, to
(II) the total amount of expenditures made under the State plans
under this subchapter for medical assistance during the fiscal year for
all States which are not high DSH States in the fiscal year, or
(ii) the amount that would raise the State DSH allotment to the
maximum permitted under paragraph (2)(B).
(4) Definitions
In this subsection:
(A) High DSH State
The term ''high DSH State'' means, for a fiscal year, a State for
which the State base allotment exceeds 12 percent of the total amount of
expenditures made under the State plan under this subchapter for medical
assistance during the fiscal year.
(B) State
The term ''State'' means only the 50 States and the District of
Columbia but does not include any State whose entire program under this
subchapter is operated under a waiver granted under section 1315 of this
title.
(C) State base allotment
The term ''State base allotment'' means, with respect to a State, the
greater of --
(i) the total amount of payment adjustments made under subsection (c)
of this section under the State plan during fiscal year 1992 (excluding
any such payment adjustments for which a reduction may be made under
paragraph (1)(A)(i)), or
(ii) $1,000,000.
The amount under clause (i) shall be determined by the Secretary and
shall include only payment adjustments described in paragraph
(1)(A)(i)(I).
(D) State growth amount
The term ''State growth amount'' means, with respect to a State for a
fiscal year, the lesser of --
(i) the product of the State growth factor and the State DSH payment
limit for the previous fiscal year, or
(ii) the amount by which 12 percent of the total amount of
expenditures made under the State plan under this subchapter for medical
assistance during the fiscal year exceeds the State DSH allotment for
the previous fiscal year.
(E) State growth factor
The term ''State growth factor'' means, for a State for a fiscal
year, the percentage by which the expenditures described in section
1396b(a) of this title in the State in the fiscal year exceed such
expenditures in the previous fiscal year.
(Aug. 14, 1935, ch. 531, title XIX, 1923, formerly Pub. L. 100-203,
title IV, 4112, Dec. 22, 1987, 101 Stat. 1330-148; redesignated 1923
of act Aug. 14, 1935, and amended July 1, 1988, Pub. L. 100-360, title
III, 302(b)(2), title IV, 411(k)(6)(A)-(B)(ix), 102 Stat. 752,
792-794; Oct. 13, 1988, Pub. L. 100-485, title VI, 608(d)(15)(C),
(26)(A)-(F), 102 Stat. 2417, 2421, 2422; Dec. 19, 1989, Pub. L.
101-239, title VI, 6411(c)(1), 103 Stat. 2270; Nov. 5, 1990, Pub. L.
101-508, title IV, 4702(a), 4703(a)-(c), 104 Stat. 1388-171; Dec. 12,
1991, Pub. L. 102-234, 3(b)(1), (2)(A), (c), 105 Stat. 1799, 1802,
1803.)
Prior to redesignation by Pub. L. 100-360, section 4112 of Pub. L.
100-203, cited in the credits to this section, was classified as a note
under section 1396a of this title.
A prior section 1923 of act Aug. 14, 1935, was renumbered section
1928, and is classified to section 1396s of this title.
1991 -- Subsec. (a)(2)(B). Pub. L. 102-234, 3(b)(2)(A)(i),
substituted ''subsections (c) and (f)'' for ''subsection (c)''.
Subsec. (b)(4). Pub. L. 102-234, 3(c), added par. (4).
Subsec. (c). Pub. L. 102-234, 3(b)(2)(A)(ii), substituted ''Subject
to subsection (f) of this section, in order'' for ''In order''.
Subsec. (f). Pub. L. 102-234, 3(b)(1), added subsec. (f).
1990 -- Subsec. (b)(2). Pub. L. 101-508, 4702(a), inserted at end
''In this paragraph, the term 'inpatient day' includes each day in which
an individual (including a newborn) is an inpatient in the hospital,
whether or not the individual is in a specialized ward and whether or
not the individual remains in the hospital for lack of suitable
placement elsewhere.''
Subsec. (c)(2). Pub. L. 101-508, 4703(c), inserted before semicolon
at end ''or the hospital's low-income utilization rate (as defined in
paragraph (b)(3) of this section)''.
Subsec. (c)(3). Pub. L. 101-508, 4703(a), added par. (3).
Subsec. (e)(2). Pub. L. 101-508, 4703(b), struck out ''during the
3-year period'' before ''beginning on''.
1989 -- Subsec. (e)(1). Pub. L. 101-239 designated portion of
existing provisions as cls. (A) and (B), and in cl. (A) designated
existing provisions as subcl. (i) and added subcl. (ii).
1988 -- Pub. L. 100-360, 411(k)(6)(A)-(B)(ix), as amended by Pub.
L. 100-485, 608(d)(26)(F), amended Pub. L. 100-203, 4112, so as to
redesignate section 4112 of Pub. L. 100-203 as this section.
Subsec. (a). Pub. L. 100-360, 411(k)(6)(B)(iv), struck out ''of
Health and Human Services'' after ''to the Secretary'' wherever
appearing in pars. (1) and (2).
Subsec. (a)(1). Pub. L. 100-360, 411(k)(6)(B)(ii), (iii),
substituted ''A State plan under this subchapter'' for ''A State's plan
under title XIX of the Social Security Act'', and made technical
amendment to reference to section 1396a(a)(13)(A) of this title
involving underlying provisions of original act.
Subsec. (a)(2)(A). Pub. L. 100-360, 411(k)(6)(A)(i), substituted
''April 1, 1989'' for ''such date'' and inserted before period at end
'', effective for inpatient hospital services provided on or after July
1, 1989''.
Subsec. (a)(2)(B). Pub. L. 100-360, 411(k)(6)(A)(ii), substituted
''April 1, 1990'' for ''such date'' and inserted before period at end
'', effective for inpatient hospital services provided on or after July
1, 1990''.
Subsec. (a)(2)(C). Pub. L. 100-485, 608(d)(15)(C), realigned the
margin of subpar. (C).
Pub. L. 100-360, 302(b)(2), added subpar. (C).
Subsec. (a)(3). Pub. L. 100-360, 411(k)(6)(A)(iii), inserted par.
(3) designation and substituted ''90 days after the date a State submits
an amendment'' for ''June 30 of each year in which the State is required
to submit an amendment''.
Subsec. (a)(4). Pub. L. 100-360, 411(k)(6)(A)(iii)(II), (III),
(B)(v), inserted par. (4) designation and made technical amendment to
reference to section 1396n(b)(4) of this title involving underlying
provisions of original act.
Subsec. (b)(2). Pub. L. 100-360, 411(k)(6)(A)(iv), substituted ''a
State plan'' for ''the State plan''.
Pub. L. 100-360, 411(k)(6)(B)(vi), as amended by Pub. L. 100-485,
608(d)(26)(F), substituted ''under this subchapter'' for ''under
subchapter XIX of this chapter''.
Subsec. (b)(3). Pub. L. 100-360, 411(k)(6)(B)(vi), as amended by
Pub. L. 100-485, 608(d)(26)(F), substituted ''under this subchapter''
for ''under subchapter XIX of this chapter'' in last sentence.
Subsec. (b)(3)(A)(i). Pub. L. 100-360, 411(k)(6)(B)(vi), as amended
by Pub. L. 100-485, 608(d)(26)(F), substituted ''under this
subchapter'' for ''under subchapter XIX of this chapter''.
Subsec. (b)(3)(B)(i). Pub. L. 100-485, 608(d)(26)(D), inserted ''of
subparagraph (A)'' after ''clause (i)(II)''.
Pub. L. 100-360, 411(k)(6)(A)(v), inserted '', less the portion of
any cash subsidies described in clause (i)(II) in the period reasonably
attributable to inpatient hospital services'' after ''charity care in a
period''.
Subsec. (c). Pub. L. 100-485, 608(d)(26)(E), substituted ''this
subsection'' for ''subsection (c)'' in concluding provisions.
Pub. L. 100-360, 411(k)(6)(A)(vi)(I), (II), (V), in concluding
provisions, substituted ''paragraphs (1)(B) and (2)(A) of subsection (a)
of this section'' for ''paragraphs (2)(A) and (2)(B)'', ''such paragraph
(1)(B)'' for ''paragraph (2)(A)'', and ''such paragraph (2)(A)'' for
''paragraph (2)(B)'' and inserted ''at least'' before ''one-third'' and
''two-thirds''.
Pub. L. 100-360, 411(k)(6)(A)(vi)(VI), inserted at end ''In the case
of a hospital described in subsection (d)(2)(A)(i) of this section
(relating to children's hospitals), in computing the hospital's
disproportionate share adjustment percentage for purposes of paragraph
(1)(B) of this subsection, the disproportionate patient percentage
(defined in section 1395ww(d)(5)(F)(vi) of this title) shall be computed
by substituting for the fraction described in subclause (I) of such
section the fraction described in subclause (II) of that section. If a
State elects in a State plan amendment under subsection (a) of this
section to provide the payment adjustment described in paragraph (2),
the State must include in the amendment a detailed description of the
specific methodology to be used in determining the specified additional
payment amount (or increased percentage payment) to be made to each
hospital qualifying for such a payment adjustment and must publish at
least annually the name of each hospital qualifying for such a payment
adjustment and the amount of such payment adjustment made for each such
hospital.''
Subsec. (c)(1). Pub. L. 100-360, 411(k)(6)(A)(vi)(III), inserted
''at least'' after ''equal to''.
Subsec. (c)(2). Pub. L. 100-360, 411(k)(6)(A)(vi)(IV), as amended by
Pub. L. 100-485, 608(d)(26)(A), inserted ''(without regard to whether
the hospital is described in subparagraph (A) or (B) of subsection
(b)(1) of this section)'' after ''payment) and''.
Subsec. (d)(1). Pub. L. 100-360, 411(k)(6)(B)(vi), as amended by
Pub. L. 100-485, 608(d)(26)(F), substituted ''under this subchapter''
for ''under subchapter XIX of this chapter''.
Subsec. (d)(2)(B). Pub. L. 100-360, 411(k)(6)(B)(vii), made
technical amendment to reference to section 1395ww of this title
involving underlying provisions of original Act.
Subsec. (e). Pub. L. 100-360, 411(k)(6)(A)(vii), as amended by Pub.
L. 100-485, 608(d)(26)(B), (C), designated existing provisions as par.
(1), inserted ''based on a pooling arrangement involving a majority of
the hospitals participating under the plan'' after first reference to
''payment adjustments'', added par. (2) and substituted ''statewide''
for ''Statewide'' in par. (2).
Amendments by Pub. L. 102-234 effective Jan. 1, 1992, see section
3(e)(1) of Pub. L. 102-234, set out as a note under section 1396a of
this title.
Section 4702(b) of Pub. L. 101-508 provided that: ''The amendment
made by subsection (a) (amending this section) shall take effect on July
1, 1990.''
Section 4703(d) of Pub. L. 101-508 provided that: ''The amendments
made by this section (amending this section) shall take effect as if
included in the enactment of section 412(a)(2)(4112(a)(2)) of the
Omnibus Budget Reconciliation Act of 1987 (Pub. L. 100-203, enacting
this section).''
Amendment by Pub. L. 100-485 effective as if included in the
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L.
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note
under section 704 of this title.
Amendment by section 302(b)(2) of Pub. L. 100-360 effective July 1,
1988, see section 302(f)(2) of Pub. L. 100-360, set out as a note under
section 1396a of this title.
Except as specifically provided in section 411 of Pub. L. 100-360,
amendment by section 411(k)(6)(A)-(B)(ix) 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.
Section 3(d) of Pub. L. 102-234 provided that:
''(1) In general. -- The Prospective Payment Assessment Commission
shall conduct a study concerning --
''(A) the feasibility and desirability of establishing maximum and
minimum payment adjustments under section 1923(c) of the Social Security
Act (subsec. (c) of this section) for hospitals deemed disproportionate
share hospitals under State medicaid plans, and
''(B) criteria (other than criteria described in clause (i) or (ii)
of section 1923(f)(1)(D) of such Act) that are appropriate for the
designation of disproportionate share hospitals under section 1923 of
such Act.
''(2) Items included in study. -- The Commission shall include in the
study --
''(A) a comparison of the payment adjustments for hospitals made
under such section and the additional payments made under title XVIII of
such Act (subchapter XVIII of this chapter) for hospitals serving a
significantly disproportionate number of low-income patients under the
medicare program; and
''(B) an analysis of the effect the establishment of limits on such
payment adjustments will have on the ability of the hospitals to be
reimbursed for the resource costs incurred by the hospitals in treating
individuals entitled to medical assistance under State medicaid plans
and other low-income patients.
''(3) Report. -- Not later than January 1, 1994, the Commission shall
submit a report on the study conducted under paragraph (1) to the
Committee on Finance of the Senate and the Committee on Energy and
Commerce of the House of Representatives. Such report shall include
such recommendations respecting the designation of disproportionate
share hospitals and the establishment of maximum and minimum payment
adjustments for such hospitals under section 1923 of the Social Security
Act (this section) as may be appropriate.''
/1/ So in original. Probably should be ''subsection''.
/2/ So in original. The period probably should be a semicolon.
/3/ So in original. Probably should not be capitalized.
/4/ So in original. Probably should be capitalized.