US Code : Title 42, Chapter 7
SUBCHAPTER XVIII -
HEALTH INSURANCE FOR AGED AND DISABLED

§ 1395. Prohibition against any Federal interference.
§ 1395a. Free choice by patient guaranteed.
- (a) Basic freedom of choice.
- (b) Use of private contracts by medicare beneficiaries.
§ 1395b. Option to individuals to obtain other health insurance protection.
§ 1395b-1. Incentives for economy while maintaining or improving quality in provision of health services.
- (a) Grants and contracts to develop and engage in experiments and demonstration projects.
- (b) Waiver of certain payment or reimbursement requirements; advice and recommendations of specialists preceding experiments and demonstration projects.
§ 1395b-2. Notice of medicare benefits; medicare and medigap information.
- (a) Notice of medicare benefits.
- (b) Medicare and medigap information.
- (c) Contents of notice.
§ 1395b-3. Health insurance advisory service for medicare beneficiaries.
- (a) In general.
- (b) Outreach elements.
- (c) Assistance provided.
- (d) Educational material.
- (e) Notice to beneficiaries.
- (f) Report.
§ 1395b-4. Health insurance information, counseling, and assistance grants.
- (a) Grants.
- (b) Grant applications.
- (c) Special grants.
- (d) Criteria for issuing grants.
- (e) Annual State report.
- (f) Report to Congress.
- (g) Authorization of appropriations for grants.
§ 1395b-5. Beneficiary incentive programs.
- (a) Repealed.
- (b) Program to collect information on fraud and abuse.
- (c) Program to collect information on program efficiency.
§ 1395b-6. Medicare Payment Advisory Commission.
- (a) Establishment.
- (b) Duties.
- (c) Membership.
- (d) Director and staff; experts and consultants.
- (e) Powers.
- (f) Authorization of appropriations.
§ 1395b-7. Explanation of medicare benefits.
- (a) In general.
- (b) Request for itemized statement for medicare items and services.

PART A - HOSPITAL INSURANCE BENEFITS FOR AGED AND DISABLED

§ 1395c. Description of program.
§ 1395d. Scope of benefits.
- (a) Entitlement to payment for inpatient hospital services, post-hospital extended care services, home health services, and hospice care.
- (b) Services not covered.
- (c) Inpatients of psychiatric hospitals.
- (d) Hospice care; election; waiver of rights; revocation; change of election.
- (e) Services taken into account.
- (f) Coverage of extended care services without regard to three-day prior hospitalization requirement.
- (g) ''Spell of illness'' defined.
§ 1395e. Deductibles and coinsurance.
- (a) Inpatient hospital services; outpatient hospital diagnostic services; blood; post-hospital extended care services.
- (b) Inpatient hospital deductible; application.
§ 1395f. Conditions of and limitations on payment for services.
- (a) Requirement of requests and certifications.
- (b) Amount paid to provider of services.
- (c) No payments to Federal providers of services.
- (d) Payments for emergency hospital services.
- (e) Payment for inpatient hospital services prior to notification of noneligibility.
- (f) Payment for certain inpatient hospital services furnished outside United States.
- (g) Payments to physicians for services rendered in teaching hospitals.
- (h) Payment for specified hospital services provided in Department of Veterans Affairs hospitals; amount of payment.
- (i) Payment for hospice care.
- (j) Elimination of lesser-of-cost-or-charges provision.
- (k) Payments to home health agencies for durable medical equipment.
- (l) Payment for inpatient critical access hospital services.
§ 1395g. Payments to providers of services.
- (a) Determination of amount.
- (b) Conditions.
- (c) Payments under assignment or power of attorney.
- (d) Accrual of interest on balance of excess or deficit not paid.
- (e) Periodic interim payments.
§ 1395h. Use of public or private agencies or organizations to facilitate payment to providers of services.
- (a) Authorization for agreement by Secretary for implementation; scope of agreement.
- (b) Prerequisites for agreement or renewal of agreement by Secretary.
- (c) Terms and conditions of agreements; prompt payment of claims.
- (d) Nomination of agency or organization; withdrawal.
- (e) Assignment or reassignment of provider of services; designation of agency or organization to perform provider services and home health agency functions.
- (f) Development of standards, criteria, and procedures by Secretary for evaluation of agency or organization performance.
- (g) Termination of agreement; procedures applicable.
- (h) Bonding requirement under agreement for officers and employees of agency or organization.
- (i) Liability of certifying and disbursing officers designated under agreement for negligent, etc., payments.
- (j) Denial of claim; notification and reconsideration.
- (k) Annual reporting requirement on erroneous payment recovery.
- (l) No authority for activities carried out under Medicare Integrity Program.
§ 1395i. Federal Hospital Insurance Trust Fund.
- (a) Creation; deposits; transfers from Treasury.
- (b) Board of Trustees; composition; meetings; duties.
- (c) Investment of Trust Fund by Managing Trustee.
- (d) Authority of Managing Trustee to sell obligations.
- (e) Interest on and proceeds from sale or redemption of obligations.
- (f) Payment of estimated taxes.
- (g) Transfers from other Funds.
- (h) Payments from Trust Fund amounts certified by Secretary.
- (i) Payment of travel expenses for travel within United States; reconsideration interviews and proceedings before administrative law judges.
- (j) Loans from other Funds; interest; repayment; report to Congress.
- (k) Health Care Fraud and Abuse Control Account.
§ 1395i-1. Authorization of appropriations.
§ 1395i-1a. Repealed.
§ 1395i-2. Hospital insurance benefits for uninsured elderly individuals not otherwise eligible.
- (a) Individuals eligible to enroll.
- (b) Time, manner, and form of enrollment.
- (c) Period of enrollment; scope of coverage.
- (d) Monthly premiums.
- (e) Contract or other arrangement for payment of monthly premiums.
- (f) Deposit of amounts into Treasury.
- (g) Buy-in under this part for qualified medicare beneficiaries.
§ 1395i-2a. Hospital insurance benefits for disabled individuals who have exhausted other entitlement.
- (a) Eligibility.
- (b) Enrollment.
- (c) Coverage period.
- (d) Payment of premiums.
§ 1395i-3. Requirements for, and assuring quality of care in, skilled nursing facilities.
- (a) ''Skilled nursing facility'' defined.
- (b) Requirements relating to provision of services.
- (c) Requirements relating to residents' rights.
- (d) Requirements relating to administration and other matters.
- (e) State requirements relating to skilled nursing facility requirements.
- (f) Responsibilities of Secretary relating to skilled nursing facility requirements.
- (g) Survey and certification process.
- (h) Enforcement process.
- (i) Construction.
§ 1395i-4. Medicare rural hospital flexibility program.
- (a) Establishment.
- (b) Application.
- (c) Medicare rural hospital flexibility program described.
- (d) ''Rural health network'' defined.
- (e) Certification by Secretary.
- (f) Permitting maintenance of swing beds.
- (g) Grants.
- (h) Grandfathering of certain facilities.
- (i) Waiver of conflicting part A provisions.
- (j) Authorization of appropriations.
§ 1395i-5. Conditions for coverage of religious nonmedical health care institutional services.
- (a) In general.
- (b) Election.
- (c) Monitoring and safeguard against excessive expenditures.
- (d) Sunset.
- (e) Annual report.

PART B - SUPPLEMENTARY MEDICAL INSURANCE BENEFITS FOR AGED AND DISABLED

§ 1395j. Establishment of supplementary medical insurance program for aged and disabled.
§ 1395k. Scope of benefits; definitions.
§ 1395l. Payment of benefits.
- (a) Amounts.
- (b) Deductible provision.
- (c) Mental disorders.
- (d) Nonduplication of payments.
- (e) Information for determination of amounts due.
- (f) Maximum rate of payment per visit for independent rural health clinics.
- (g) Physical therapy services.
- (h) Fee schedules for clinical diagnostic laboratory tests; percentage of prevailing charge level; nominal fee for samples; adjustments; recipients of payments; negotiated payment rate.
- (i) Outpatient surgery.
- (j) Accrual of interest on balance of excess or deficit not paid.
- (k) Hepatitis B vaccine.
- (l) Fee schedule for services of certified registered nurse anesthetists.
- (m) Incentive payments for physicians' services furnished in underserved areas.
- (n) Payments to hospital outpatient departments for radiology; amount; definitions.
- (o) Limitation on benefit for payment for therapeutic shoes for individuals with severe diabetic foot disease.
- (p) Repealed.
- (q) Requests for payment to include information on referring physician.
- (r) Cap on prevailing charge; billing on assignment-related basis.
- (s) Other prepaid organizations.
- (t) Prospective payment system for hospital outpatient department services.
§ 1395m. Special payment rules for particular items and services.
- (a) Payment for durable medical equipment.
- (b) Fee schedules for radiologist services.
- (c) Payments and standards for screening mammography.
- (d) Frequency limits and payment for colorectal cancer screening tests.
- (e) Repealed.
- (f) Reduction in payments for physician pathology services during 1991.
- (g) Payment for outpatient critical access hospital services.
- (h) Payment for prosthetic devices and orthotics and prosthetics.
- (i) Payment for surgical dressings.
- (j) Requirements for suppliers of medical equipment and supplies.
- (k) Payment for outpatient therapy services and comprehensive outpatient rehabilitation services.
- (l) Establishment of fee schedule for ambulance services.
§ 1395n. Procedure for payment of claims of providers of services.
- (a) Conditions for payment for services described in section 1395k(a)(2) of this title.
- (b) Conditions for payment for services described in section 1395x(s) of this title.
- (c) Collection of charges from individuals for services specified in section 1395x(s) of this title.
- (d) Payment to Federal provider of services or other Federal agencies prohibited.
- (e) Payment to fund designated by medical staff or faculty of medical school.
§ 1395o. Eligible individuals.
§ 1395p. Enrollment periods.
- (a) Generally; regulations.
- (b) Repealed.
- (c) Initial general enrollment period; eligible individuals before March 1, 1966.
- (d) Eligible individuals on or after March 1, 1966
- (e) General enrollment period.
- (f) Individuals deemed enrolled in medical insurance program.
- (g) Commencement of enrollment period.
- (h) Waiver of enrollment period requirements where individual's rights were prejudiced by administrative error or inaction.
- (i) Special enrollment periods.
§ 1395q. Coverage period.
- (a) Commencement.
- (b) Continuation.
- (c) Termination.
- (d) Payment of expenses incurred during coverage period.
- (e) Commencement of coverage for special enrollment periods.
§ 1395r. Amount of premiums for individuals enrolled under this part.
- (a) Determination of monthly actuarial rates and premiums.
- (b) Increase in monthly premium.
- (c) Premiums rounded to nearest multiple of ten cents.
- (d) ''Continuous period of eligibility'' defined.
- (e) State payment of part B late enrollment premium increases.
- (f) Limitation on increase in monthly premium.
§ 1395s. Payment of premiums.
- (a) Deductions from section 402 or 423 monthly benefits.
- (b) Deductions from railroad retirement annuities or pensions.
- (c) Portion of monthly premium in excess of deducted amount.
- (d) Deductions from civil service retirement annuities.
- (e) Manner and time of payment prescribed by Secretary.
- (f) Deposit of amounts in Treasury.
- (g) Premium payability period.
- (h) Exempted monthly benefits.
§ 1395t. Federal Supplementary Medical Insurance Trust Fund.
- (a) Creation; deposits; fund transfers.
- (b) Board of Trustees; composition; meetings; duties.
- (c) Investment of Trust Fund by Managing Trustee.
- (d) Authority of Managing Trustee to sell obligations.
- (e) Interest on or proceeds from sale or redemption of obligations.
- (f) Transfers to other Funds.
- (g) Payments from Trust Fund of amounts provided for by this part or with respect to administrative expenses.
- (h) Payments from Trust Fund of costs incurred by Director of Office of Personnel Management.
- (i) Payments from Trust Fund of costs incurred by Railroad Retirement Board.
1395t-1, 1395t-2. Repealed.
§ 1395u. Use of carriers for administration of benefits.
- (a) Authority of Secretary to enter into contracts with carriers.
- (b) Applicability of competitive bidding provisions; findings as to financial responsibility, etc., of carrier; contractual duties imposed by contract.
- (c) Advances of funds to carrier; prompt payment of claims.
- (d) Surety bonds.
- (e) Liability of certifying or disbursing officers or carriers.
- (f) ''Carrier'' defined.
- (g) Authority of Railroad Retirement Board to enter into contracts with carriers.
- (h) Participating physician or supplier; agreement with Secretary; publication of directories; availability; inclusion of program in explanation of benefits; payment of claims on assignment-related basis.
- (i) Definitions.
- (j) Monitoring of charges of nonparticipating physicians; sanctions; restitution.
- (k) Sanctions for billing for services of assistant at cataract operations.
- (l) Prohibition of unassigned billing of services determined to be medically unnecessary by carrier.
- (m) Disclosure of information of unassigned claims for certain physicians' services.
- (n) Elimination of markup for certain purchased services.
- (o) Reimbursement for drugs and biologicals.
- (p) Requiring submission of diagnostic information.
- (q) Anesthesia services; counting actual time units.
- (r) Establishment of physician identification system.
- (s) Application of fee schedule.
- (t) Facility provider number required on claims submitted by physicians.
§ 1395v. Agreements with States.
- (a) Duty of Secretary; enrollment of eligible individuals.
- (b) Coverage of groups to which applicable.
- (c) Eligible individuals.
- (d) Monthly premiums; coverage periods.
- (e) Subsection (d)(3) terminations deemed resulting in section 1395p enrollment.
- (f) ''Carrier'' as including State agency; provisions facilitating deductions, coinsurance, etc., and leading to economy and efficiency of operation.
- (g) Subsection (b) exclusions from coverage groups.
- (h) Modifications respecting subsection (b) coverage groups.
- (i) Enrollment of qualified medicare beneficiaries.
§ 1395w. Appropriations to cover Government contributions and contingency reserve.
§ 1395w-1. Repealed.
§ 1395w-2. Intermediate sanctions for providers or suppliers of clinical diagnostic laboratory tests.
§ 1395w-3. Demonstration projects for competitive acquisition of items and services.
- (a) Establishment of demonstration project bidding areas.
- (b) Awarding of contracts in areas.
- (c) Expansion of projects.
- (d) Services described.
- (e) Termination.
§ 1395w-4. Payment for physicians' services.
- (a) Payment based on fee schedule.
- (b) Establishment of fee schedules.
- (c) Determination of relative values for physicians' services.
- (d) Conversion factors.
- (e) Geographic adjustment factors.
- (f) Sustainable growth rate.
- (g) Limitation on beneficiary liability.
- (h) Sending information to physicians.
- (i) Miscellaneous provisions.
- (j) Definitions.

PART C - MEDICARE+CHOICE PROGRAM

§ 1395w-21. Eligibility, election, and enrollment.
- (a) Choice of medicare benefits through Medicare+Choice plans.
- (b) Special rules.
- (c) Process for exercising choice.
- (d) Providing information to promote informed choice.
- (e) Coverage election periods.
- (f) Effectiveness of elections and changes of elections.
- (g) Guaranteed issue and renewal.
- (h) Approval of marketing material and application forms.
- (i) Effect of election of Medicare+Choice plan option.
§ 1395w-22. Benefits and beneficiary protections.
- (a) Basic benefits.
- (b) Antidiscrimination.
- (c) Disclosure requirements.
- (d) Access to services.
- (e) Quality assurance program.
- (f) Grievance mechanism.
- (g) Coverage determinations, reconsiderations, and appeals.
- (h) Confidentiality and accuracy of enrollee records.
- (i) Information on advance directives.
- (j) Rules regarding provider participation.
- (k) Treatment of services furnished by certain providers.
§ 1395w-23. Payments to Medicare+Choice organizations.
- (a) Payments to organizations.
- (b) Annual announcement of payment rates.
- (c) Calculation of annual Medicare+Choice capitation rates.
- (d) ''Medicare+Choice payment area'' defined.
- (e) Special rules for individuals electing MSA plans.
- (f) Payments from Trust Fund.
- (g) Special rule for certain inpatient hospital stays.
- (h) Special rule for hospice care.
§ 1395w-24. Premiums.
- (a) Submission of proposed premiums and related information.
- (b) Monthly premium charged.
- (c) Uniform premium.
- (d) Terms and conditions of imposing premiums.
- (e) Limitation on enrollee liability.
- (f) Requirement for additional benefits.
- (g) Prohibition of State imposition of premium taxes.
§ 1395w-25. Organizational and financial requirements for Medicare+Choice organizations; provider-sponsored organizations.
- (a) Organized and licensed under State law.
- (b) Assumption of full financial risk.
- (c) Certification of provision against risk of insolvency for unlicensed PSOs.
- (d) ''Provider-sponsored organization'' defined.
§ 1395w-26. Establishment of standards.
- (a) Establishment of solvency standards for provider-sponsored organizations.
- (b) Establishment of other standards.
§ 1395w-27. Contracts with Medicare+Choice organizations.
- (a) In general.
- (b) Minimum enrollment requirements.
- (c) Contract period and effectiveness.
- (d) Protections against fraud and beneficiary protections.
- (e) Additional contract terms.
- (f) Prompt payment by Medicare+Choice organization.
- (g) Intermediate sanctions.
- (h) Procedures for termination.
§ 1395w-28. Definitions; miscellaneous provisions.
- (a) Definitions relating to Medicare+Choice organizations.
- (b) Definitions relating to Medicare+Choice plans.
- (c) Other references to other terms.
- (d) Coordinated acute and long-term care benefits under Medicare+Choice plan.
- (e) Restriction on enrollment for certain Medicare+Choice plans.

PART D - MISCELLANEOUS PROVISIONS

§ 1395x. Definitions.
- (a) Spell of illness.
- (b) Inpatient hospital services.
- (c) Inpatient psychiatric hospital services.
- (d) Repealed.
- (e) Hospital.
- (f) Psychiatric hospital.
- (g) Outpatient occupational therapy services.
- (h) Extended care services.
- (i) Post-hospital extended care services.
- (j) Skilled nursing facility.
- (k) Utilization review.
- (l) Agreements for transfer between skilled nursing facilities and hospitals.
- (m) Home health services.
- (n) Durable medical equipment.
- (o) Home health agency.
- (p) Outpatient physical therapy services.
- (q) Physicians' services.
- (r) Physician.
- (s) Medical and other health services.
- (t) Drugs and biologicals.
- (u) Provider of services.
- (v) Reasonable costs.
- (w) Arrangements for certain services; payments pursuant to arrangements for utilization review activities.
- (x) State and United States.
- (y) Extended care in religious nonmedical health care institutions.
- (z) Institutional planning.
- (aa) Rural health clinic services and Federally qualified health center services.
- (bb) Services of a certified registered nurse anesthetist.
- (cc) Comprehensive outpatient rehabilitation facility services.
- (dd) Hospice care; hospice program; definitions; certification; waiver by Secretary.
- (ee) Discharge planning process.
- (ff) Partial hospitalization services.
- (gg) Certified nurse-midwife services.
- (hh) Clinical social worker; clinical social worker services.
- (ii) Qualified psychologist services.
- (jj) Screening mammography.
- (kk) Covered osteoporosis drug.
- (ll) Speech-language pathology services; audiology services.
- (mm) Critical access hospital; critical access hospital services.
- (nn) Screening pap smear; screening pelvic exam.
- (oo) Prostate cancer screening tests.
- (pp) Colorectal cancer screening tests.
- (qq) Diabetes outpatient self-management training services.
- (rr) Bone mass measurement.
- (ss) Religious nonmedical health care institution.
- (tt) Post-institutional home health services; home health spell of illness.
§ 1395y. Exclusions from coverage and medicare as secondary payer.
- (a) Items or services specifically excluded.
- (b) Medicare as secondary payer.
- (c) Drug products.
- (d) Repealed.
- (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.
- (f) Utilization guidelines for provision of home health services.
- (g) Contracts with utilization and quality control peer review organizations.
- (h) Repealed.
- (i) Awards and contracts for original research and experimentation of new and existing medical procedures; conditions.
§ 1395z. Consultation with State agencies and other organizations to develop conditions of participation for providers of services.
§ 1395aa. Agreements with States.
- (a) Use of State agencies to determine compliance by providers of services with conditions of participation.
- (b) Payment in advance or by way of reimbursement to State for performance of functions of subsection (a).
- (c) Use of State or local agencies to survey hospitals.
- (d) Fulfillment of requirements by States.
- (e) Prohibition of user fees for survey and certification.
§ 1395bb. Effect of accreditation.
- (a) In general.
- (b) Accreditation by American Osteopathic Association or other national accreditation body.
- (c) Disclosure of accreditation survey.
- (d) Deficiencies.
- (e) State or local accreditation.
§ 1395cc. Agreements with providers of services.
- (a) Filing of agreements; eligibility for payment; charges with respect to items and services.
- (b) Termination or nonrenewal of agreements.
- (c) Refiling after termination or nonrenewal; agreements with skilled nursing facilities.
- (d) Decision to withhold payment for failure to review long-stay cases.
- (e) ''Provider of services'' defined.
- (f) Maintenance of written policies and procedures.
- (g) Penalties for improper billing.
- (h) Dissatisfaction with determination of Secretary; appeal by institutions or agencies; single notice and hearing.
- (i) Intermediate sanctions for psychiatric hospitals.
§ 1395dd. Examination and treatment for emergency medical conditions and women in labor.
- (a) Medical screening requirement.
- (b) Necessary stabilizing treatment for emergency medical conditions and labor.
- (c) Restricting transfers until individual stabilized.
- (d) Enforcement.
- (e) Definitions.
- (f) Preemption.
- (g) Nondiscrimination.
- (h) No delay in examination or treatment.
- (i) Whistleblower protections.
§ 1395ee. Practicing Physicians Advisory Council.
- (a) Appointment.
- (b) Meetings.
- (c) Reimbursement of expenses.
§ 1395ff. Determinations of Secretary.
- (a) Entitlement to and amount of benefits.
- (b) Appeal by individuals; provider representation of beneficiaries.
§ 1395gg. Overpayment on behalf of individuals and settlement of claims for benefits on behalf of deceased individuals.
- (a) Payments to providers of services or other person regarded as payment to individuals.
- (b) Incorrect payments on behalf of individuals; payment adjustment.
- (c) Exception to subsection (b) payment adjustment.
- (d) Liability of certifying or disbursing officer for failure to recoup.
- (e) Settlement of claims for benefits under this subchapter on behalf of deceased individuals.
- (f) Settlement of claims for section 1395k benefits on behalf of deceased individuals.
- (g) Refund of premiums for deceased individuals.
§ 1395hh. Regulations.
- (a) Authority to prescribe regulations; ineffectiveness of substantive rules not promulgated by regulation.
- (b) Notice of proposed regulations; public comment.
- (c) Publication of certain rules; public inspection; changes in data collection and retrieval.
§ 1395ii. Application of certain provisions of subchapter II.
§ 1395jj. Designation of organization or publication by name.
§ 1395kk. Administration of insurance programs.
- (a) Functions of Secretary; performance directly or by contract.
- (b) Contracts to secure special data, actuarial information, etc.
- (c) Oaths and affirmations.
§ 1395ll. Studies and recommendations.
- (a) Health care of the aged and disabled.
- (b) Operation and administration of insurance programs.
§ 1395mm. Payments to health maintenance organizations and competitive medical plans.
- (a) Rates and adjustments.
- (b) Definitions; requirements.
- (c) Enrollment in plan; duties of organization to enrollees.
- (d) Right to enroll with contracting organization in geographic area.
- (e) Limitation on charges; election of coverage; ''adjusted community rate'' defined; workmen's compensation and insurance benefits.
- (f) Membership requirements.
- (g) Risk-sharing contract.
- (h) Reasonable cost reimbursement contract; requirements.
- (i) Duration, termination, effective date, and terms of contract; powers and duties of Secretary.
- (j) Payment in full and limitation on actual charges; physicians, providers of services, or renal dialysis facilities not under contract with organization.
- (k) Risk-sharing contracts.
§ 1395nn. Limitation on certain physician referrals.
- (a) Prohibition of certain referrals.
- (b) General exceptions to both ownership and compensation arrangement prohibitions.
- (c) General exception related only to ownership or investment prohibition for ownership in publicly-traded securities and mutual funds.
- (d) Additional exceptions related only to ownership or investment prohibition.
- (e) Exceptions relating to other compensation arrangements.
- (f) Reporting requirements.
- (g) Sanctions.
- (h) Definitions and special rules.
§ 1395oo. Provider Reimbursement Review Board.
- (a) Establishment.
- (b) Appeals by groups.
- (c) Right to counsel; rules of evidence.
- (d) Decisions of Board.
- (e) Rules and regulations.
- (f) Finality of decision; judicial review; determinations of Board authority; jurisdiction; venue; interest on amount in controversy.
- (g) Certain findings not reviewable.
- (h) Composition and compensation.
- (i) Technical and clerical assistance.
- (j) ''Provider of services'' defined.
§ 1395pp. Limitation on liability where claims are disallowed.
- (a) Conditions prerequisite to payment for items and services notwithstanding determination of disallowance.
- (b) Knowledge of person or provider that payment could not be made; indemnification of individual.
- (c) Knowledge of both provider and individual to whom items or services were furnished that payment could not be made.
- (d) Exercise of rights.
- (e) Payment where beneficiary not at fault.
- (f) Presumption with respect to coverage denial; rebuttal; requirements; ''fiscal intermediary'' defined.
- (g) Coverage denial defined.
- (h) Supplier responsibility for items furnished on assignment basis.
§ 1395qq. Indian health service facilities.
- (a) Eligibility for payments; conditions and requirements.
- (b) Eligibility based on submission of plan to achieve compliance with conditions and requirements; twelve-month period.
- (c) Payments into special fund for improvements to achieve compliance with conditions and requirements; certification of compliance by Secretary.
- (d) Report by Secretary; status of facilities in complying with conditions and requirements.
§ 1395rr. End stage renal disease program.
- (a) Type, duration, and scope of benefits.
- (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.
- (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.
- (d) Donors of kidney for transplant surgery.
- (e) Reimbursement of providers, facilities, and nonprofit entities for costs of artificial kidney and automated dialysis peritoneal machines for home dialysis.
- (f) Experiments, studies, and pilot projects.
- (g) Conditional approval of dialysis facilities; restriction-of-payments notice to public and facility; notice and hearing; judicial review.
§ 1395ss. Certification of medicare supplemental health insurance policies.
- (a) Submission of policy by insurer.
- (b) Standards and requirements; periodic review by Secretary.
- (c) Requisite findings.
- (d) Criminal penalties; civil penalties for certain violations.
- (e) Dissemination of information.
- (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.
- (g) Definitions.
- (h) Rules and regulations.
- (i) Commencement of certification program.
- (j) State regulation of policies issued in other States.
- (k) Amended NAIC Model Regulation or Federal model standards applicable; effective date; medicare supplemental policy and State regulatory program meeting applicable standards.
- (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.
- (m) Revision of amended NAIC Model Regulation and amended Federal model standards; effective dates; medicare supplemental policy and State regulatory program meeting applicable standards.
- (n) Transition compliance with revision of NAIC Model Regulation and Federal model standards.
- (o) Requirements of group benefits; core group benefits; uniform outline of coverage.
- (p) Standards for group benefits.
- (q) Guaranteed renewal of policies; termination; suspension.
- (r) Required ratio of aggregate benefits to aggregate premiums.
- (s) Coverage for pre-existing conditions.
- (t) Medicare select policies.
- (u) Additional rules relating to individuals enrolled in MSA plans and in private fee-for-service plans.
§ 1395tt. Hospital providers of extended care services.
- (a) Hospital facility agreements; reasonable costs of services.
- (b) Eligible facilities.
- (c) Terms and conditions of facility agreements.
- (d) Post-hospital extended care services.
- (e) Reimbursement for routine hospital services.
- (f) Conditions applicable to skilled nursing facilities.
- (g) Agreements on demonstration basis.
§ 1395uu. Payments to promote closing or conversion of underutilized hospital facilities.
- (a) Transitional allowances; procedures applicable.
- (b) Allowable costs as transitional allowances; findings and determinations.
- (c) Factors determinative of transitional allowance.
- (d) Hearing to review determination.
§ 1395vv. Withholding payments from certain medicaid providers.
- (a) Adjustments by Secretary.
- (b) Implementing regulations; notice, opportunity to be heard, etc.
- (c) Payment to States of amounts recovered.
§ 1395ww. Payments to hospitals for inpatient hospital services.
- (a) Determination of costs for inpatient hospital services; limitations; exemptions; ''operating costs of inpatient hospital services'' defined.
- (b) Computation of payment; definitions; exemptions; adjustments.
- (c) Payment in accordance with State hospital reimbursement control system; amount of payment; discontinuance of payments.
- (d) Inpatient hospital service payments on basis of prospective rates; Medicare Geographical Classification Review Board.
- (e) Proportional adjustments in applicable percentage increases.
- (f) Reporting of costs of hospitals receiving payments on basis of prospective rates.
- (g) Prospective payment for capital-related costs; return on equity capital for hospitals.
- (h) Payments for direct graduate medical education costs.
- (i) Avoiding duplicative payments to hospitals participating in rural demonstration programs.
- (j) Prospective payment for inpatient rehabilitation services.
- (k) Payment to nonhospital providers.
§ 1395xx. Payment of provider-based physicians and payment under certain percentage arrangements.
- (a) Criteria; amount of payments.
- (b) Prohibition of recognition of payments under certain percentage agreements.
§ 1395yy. Payment to skilled nursing facilities for routine service costs.
- (a) Per diem limitations.
- (b) Excess overhead allocations for hospital-based facilities.
- (c) Adjustments in limitations; publication of data.
- (d) Access to skilled nursing facilities.
- (e) Prospective payment.
1395zz, 1395aaa. Repealed or Transferred.
§ 1395bbb. Conditions of participation for home health agencies; home health quality.
- (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.
- (b) Duty of Secretary.
- (c) Surveys of home health agencies.
- (d) Assessment process; reports to Congress.
- (e) Enforcement.
- (f) Intermediate sanctions.
- (g) Payment on basis of location of service.
§ 1395ccc. Offset of payments to individuals to collect past-due obligations arising from breach of scholarship and loan contract.
- (a) In general.
- (b) Past-due obligation.
- (c) Collection under this section shall not be exclusive.
- (d) Collection from providers and health maintenance organizations.
- (e) Transfer from trust funds.
§ 1395ddd. Medicare Integrity Program.
- (a) Establishment of Program.
- (b) Activities described.
- (c) Eligibility of entities.
- (d) Process for entering into contracts.
- (e) Limitation on contractor liability.
§ 1395eee. Payments to, and coverage of benefits under, programs of all-inclusive care for elderly
(PACE).
- (a) Receipt of benefits through enrollment in PACE
§ 1395fff. Prospective payments for Home Health Services
§ 1395ggg. Medicare subvention project for military retirees