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United States Code (Last Updated: May 24, 2014) |
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Title 42. THE PUBLIC HEALTH AND WELFARE |
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Chapter 7. SOCIAL SECURITY |
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SubChapter XVIII. HEALTH INSURANCE FOR AGED AND DISABLED |
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Part B. Supplementary Medical Insurance Benefits for Aged and Disabled |
§ 1395l. Payment of benefits
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(a) Amounts Except as provided in section 1395mm of this title, and subject to the succeeding provisions of this section, there shall be paid from the Federal Supplementary Medical Insurance Trust Fund, in the case of each individual who is covered under the insurance program established by this part and incurs expenses for services with respect to which benefits are payable under this part, amounts equal to— (1) in the case of services described in section 1395k(a)(1) of this title—80 percent of the reasonable charges for the services; except that (A) an organization which provides medical and other health services (or arranges for their availability) on a prepayment basis (and either is sponsored by a union or employer, or does not provide, or arrange for the provision of, any inpatient hospital services) may elect to be paid 80 percent of the reasonable cost of services for which payment may be made under this part on behalf of individuals enrolled in such organization in lieu of 80 percent of the reasonable charges for such services if the organization undertakes to charge such individuals no more than 20 percent of such reasonable cost plus any amounts payable by them as a result of subsection (b) of this section, (B) with respect to items and services described in section 1395x(s)(10)(A) of this title, the amounts paid shall be 100 percent of the reasonable charges for such items and services, (C) with respect to expenses incurred for those physicians’ services for which payment may be made under this part that are described in section 1395y(a)(4) of this title, the amounts paid shall be subject to such limitations as may be prescribed by regulations, (D) with respect to clinical diagnostic laboratory tests for which payment is made under this part (i)(I) on the basis of a fee schedule under subsection (h)(1) of this section (for tests furnished before January 1, 2017 ) or section 1395m(d)(1) of this title, the amount paid shall be equal to 80 percent (or 100 percent, in the case of such tests for which payment is made on an assignment-related basis) of the lesser of the amount determined under such fee schedule, the limitation amount for that test determined under subsection (h)(4)(B) of this section, or the amount of the charges billed for the tests, or (II) under section 1395m–1 of this title (for tests furnished on or afterJanuary 1, 2017 ), the amount paid shall be equal to 80 percent (or 100 percent, in the case of such tests for which payment is made on an assignment-related basis) of the lesser of the amount determined under such section or the amount of the charges billed for the tests, or (ii) for tests furnished beforeJanuary 1, 2017 , on the basis of a negotiated rate established under subsection (h)(6) of this section, the amount paid shall be equal to 100 percent of such negotiated rate,, (2) and (4) of subsection (m) shall apply to the determination of additional payments under this subsection in the same manner as such provisions apply to the determination of additional payments under subsection (m).
References In Text
Section 626(d) of Medicare Prescription Drug, Improvement, and Modernization Act of 2003, referred to in subsec. (i)(2)(D)(i), is section 626(d) of Pub. L. 108–173, which is set out as a note under this section.
Section 9320(k) of the Omnibus Budget Reconciliation Act of 1986, as amended by section 6132 of the Omnibus Budget Reconciliation Act of 1989, referred to in subsec. (l)(1)(C), is section 9320(k) of Pub. L. 99–509, as amended, which is set out as a note under section 1395k of this title.
The amendments made by section 9320 of the Omnibus Budget Reconciliation Act of 1986, referred to in subsec. (l)(3)(B), are amendments made by section 9320 of Pub. L. 99–509, which amended sections 1395k, 1395l, 1395u, 1395x, 1395y, 1395aa, 1395bb, 1395cc, 1395ww, 1396a, and 1396n of this title and provisions set out as a note under section 1395ww of this title.
Section 4521 of The Balanced Budget Act of 1997, referred to in subsec. (t)(7)(F), is section 4521 of Pub. L. 105–33,
Codification
Pub. L. 111–148, § 10221(a), enacted into law S. 1790, One Hundred Eleventh Congress, as reported by the Committee on Indian Affairs of the Senate in Dec. 2009, “[e]xcept as provided in” section 10221(b) of Pub. L. 111–148. Section 201(b) of S. 1790 would have amended this section but was stricken out by section 10221(b)(4) of Pub. L. 111–148.
Amendments
2014—Subsec. (a)(1)(D)(i). Pub. L. 113–93, § 216(b)(1)(A)(i)–(iii), designated existing provisions as subcl. (I), substituted “subsection (h)(1) of this section (for tests furnished before
Subsec. (a)(1)(D)(ii). Pub. L. 113–93, § 216(b)(1)(A)(iv), substituted “for tests furnished before
Subsec. (a)(2)(D)(i). Pub. L. 113–93, § 216(b)(1)(B)(i)–(iii), designated existing provisions as subcl. (I), substituted “subsection (h)(1) of this section (for tests furnished before
Subsec. (a)(2)(D)(ii). Pub. L. 113–93, § 216(b)(1)(B)(iv), substituted “for tests furnished before
Subsec. (b)(3)(B). Pub. L. 113–93, § 216(b)(1)(C), substituted “for tests furnished before
Subsec. (g)(5)(A). Pub. L. 113–93, § 103(1), substituted “
Subsec. (g)(6)(A). Pub. L. 113–93, § 103(2), substituted “
Subsec. (h)(2)(A)(i). Pub. L. 113–93, § 216(b)(1)(D), substituted “and, for tests furnished before
Subsec. (h)(3). Pub. L. 113–93, § 216(b)(1)(E), in introductory provisions, substituted “fee schedules (for tests furnished before
Subsec. (h)(6). Pub. L. 113–93, § 216(b)(1)(F), substituted “For tests furnished before
Subsec. (h)(7). Pub. L. 113–93, § 216(b)(1)(G), substituted “and (4) and section 1395m–1 of this title” for “and (4)” and “under this part” for “under this subsection”.
Subsec. (t)(16)(E). Pub. L. 113–93, § 218(b)(2), added subpar. (E).
Subsec. (t)(20). Pub. L. 113–93, § 218(a)(2)(A), added par. (20).
2013—Subsec. (g)(5)(A). Pub. L. 113–67, § 1103(1), substituted “
Pub. L. 112–240, § 603(a)(1), substituted “
Subsec. (g)(5)(D). Pub. L. 112–240, § 603(c), added subpar. (D).
Subsec. (g)(6). Pub. L. 112–240, § 603(b), designated existing provisions as subpar. (A) and added subpar. (B).
Subsec. (g)(6)(A). Pub. L. 113–67, § 1103(2), substituted “
Pub. L. 112–240, § 603(a)(2), substituted “
Subsec. (t)(16)(D). Pub. L. 112–240, § 634, added subpar. (D).
2012—Subsec. (g)(1), (3). Pub. L. 112–96, § 3005(b)(1), substituted “but (except as provided in paragraph (6)) not described in subsection (a)(8)(B)” for “but not described in subsection (a)(8)(B) of this section”.
Subsec. (g)(5). Pub. L. 112–96, § 3005(a), designated existing provisions as subpar. (A), substituted “
Subsec. (g)(6). Pub. L. 112–96, § 3005(b)(2), added par. (6).
Subsec. (h)(2)(A)(i). Pub. L. 112–96, § 3202(1), substituted “clause (v), subparagraph (B), and paragraph (4)” for “paragraph (4)”.
Subsec. (h)(2)(A)(iv). Pub. L. 112–96, § 3202(2), realigned margins.
Subsec. (h)(2)(A)(v). Pub. L. 112–96, § 3202(3), added cl. (v).
Subsec. (t)(7)(D)(i)(II). Pub. L. 112–96, § 3002(a)(1), substituted “
Subsec. (t)(7)(D)(i)(III). Pub. L. 112–96, § 3002(a)(2), substituted “
2011—Subsec. (g)(5). Pub. L. 112–78, § 304, substituted “
Subsec. (t)(7)(D)(i)(II). Pub. L. 112–78, § 308(1), substituted “
Subsec. (t)(7)(D)(i)(III). Pub. L. 112–78, § 308(2), substituted “2009, and before
2010—Subsec. (a). Pub. L. 111–148, § 10501(i)(3)(C)(ii), inserted concluding provisions.
Subsec. (a)(1)(K). Pub. L. 111–148, § 3114, inserted “(or 100 percent for services furnished on or after
Subsec. (a)(1)(N). Pub. L. 111–148, § 4103(c)(1)(A), inserted “other than personalized prevention plan services (as defined in section 1395x(hhh)(1) of this title)” after “(as defined in section 1395w–4(j)(3) of this title)”.
Subsec. (a)(1)(T). Pub. L. 111–148, § 4104(b)(1), as amended by Pub. L. 111–148, § 10406, inserted “(or 100 percent if such services are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual)” after “80 percent”.
Subsec. (a)(1)(W). Pub. L. 111–148, § 4104(b)(2), as amended by Pub. L. 111–148, § 10406, inserted “(if such subparagraph were applied, by substituting ‘100 percent’ for ‘80 percent’)” after “subparagraph (D)” in cl. (i) and substituted “100 percent” for “80 percent” in cl. (ii).
Subsec. (a)(1)(X). Pub. L. 111–148, § 4103(c)(1)(B), (C), added subpar. (X).
Subsec. (a)(1)(Y). Pub. L. 111–148, § 4104(b)(3), (4), as amended by Pub. L. 111–148, § 10406, added subpar. (Y).
Subsec. (a)(1)(Z). Pub. L. 111–148, § 10501(i)(3)(B), added subpar. (Z).
Subsec. (a)(2)(F) to (H). Pub. L. 111–148, § 4103(c)(3)(B), which directed amendment of par. (2) by striking “and” at end of subpar. (F), substituting “; and” for comma at end of subpar. (G)(ii), and adding subpar. (H) after subpar. (G)(ii), was executed as directed despite the presence of concluding provisions following subpar. (G)(ii), which were added as part of subpar. (G) by Pub. L. 105–33, § 4603(c)(2)(A)(iv).
Subsec. (a)(3)(B)(i). Pub. L. 111–148, § 10501(i)(3)(C)(i)(I), inserted subcl. (I) designation after “otherwise been provided” and “, or (II) in the case of such services furnished on or after the implementation date of the prospective payment system under section 1395m(o) of this title, under such section (calculated as if ‘100 percent’ were substituted for ‘80 percent’ in such section) for such services if the individual had not been so enrolled” after “been so enrolled”.
Subsec. (b). Pub. L. 111–148, § 4104(c)(2), inserted at end “Paragraph (1) of the first sentence of this subsection shall apply with respect to a colorectal cancer screening test regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as the screening test.”
Subsec. (b)(1). Pub. L. 111–148, § 4104(c)(1), substituted “preventive services described in subparagraph (A) of section 1395x(ddd)(3) of this title that are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual.” for “items and services described in section 1395x(s)(10)(A) of this title”.
Subsec. (b)(10). Pub. L. 111–148, § 4103(c)(4), added par. (10).
Subsec. (g)(5). Pub. L. 111–309, § 104, substituted “and ending on
Pub. L. 111–148, § 3103, which directed substitution of “
Pub. L. 111–144 substituted “
Subsec. (h)(2)(A)(i). Pub. L. 111–148, § 3401(l)(1), inserted “, subject to clause (iv),” after “year) by” and substituted “and 2010” for “through 2013”.
Subsec. (h)(2)(A)(iv). Pub. L. 111–148, § 3401(l)(2), added cl. (iv).
Subsec. (i)(2)(D)(v), (vi). Pub. L. 111–148, § 3401(k), added cl. (v) and redesignated former cl. (v) as (vi).
Subsec. (t)(1)(B)(iv). Pub. L. 111–148, § 4103(c)(3)(A), substituted “, diagnostic mammography, or personalized prevention plan services (as defined in section 1395x(hhh)(1) of this title)” for “and diagnostic mammography”.
Subsec. (t)(2)(D). Pub. L. 111–148, § 10324(b)(1), substituted “subject to paragraph (19), the Secretary” for “the Secretary”.
Subsec. (t)(3)(C)(iv). Pub. L. 111–148, § 3401(i)(1), inserted “and subparagraph (F) of this paragraph” after “(17)”.
Subsec. (t)(3)(F). Pub. L. 111–148, § 3401(i)(2), added subpar. (F).
Subsec. (t)(3)(G). Pub. L. 111–152, § 1105(e)(3), struck out cl. (i) designation and heading, redesignated subcls. (I) to (V) of former cl. (i) as cls. (i) to (v), respectively, and realigned margins.
Pub. L. 111–148, § 3401(i)(2), added subpar. (G).
Subsec. (t)(3)(G)(i)(I). Pub. L. 111–148, § 10319(g)(1), struck out “and” at end.
Subsec. (t)(3)(G)(i)(II). Pub. L. 111–152, § 1105(e)(1)(A), placed subcl. (II), which was directed to be inserted after subcl. (II) by Pub. 111–148, § 10319(g)(3), immediately after subcl. (I) and struck out “and” at end. See Amendment note below.
Pub. L. 111–148, § 10319(g)(3), which directed addition of subcl. (II) “after subclause (II)”, could not be executed. See Amendment note above.
Subsec. (t)(3)(G)(i)(III). Pub. L. 111–152, § 1105(e)(1), added subcl. (III) and struck out former subcl. (III) which read as follows: “subject to clause (ii), for each of 2014 through 2019, 0.2 percentage point.”
Pub. L. 111–148, § 10319(g)(4), substituted “2014” for “2012”.
Pub. L. 111–148, § 10319(g)(2), redesignated subcl. (II) as (III).
Subsec. (t)(3)(G)(i)(IV), (V). Pub. L. 111–152, § 1105(e)(1)(B), added subcls. (IV) and (V).
Subsec. (t)(3)(G)(ii). Pub. L. 111–152, § 1105(e)(2), struck out cl. (ii). Prior to amendment, text read as follows: “Clause (i)(II) shall be applied with respect to any of 2014 through 2019 by substituting ‘0.0 percentage points’ for ‘0.2 percentage point’, if for such year—
“(I) the excess (if any) of—
“(aa) the total percentage of the non-elderly insured population for the preceding year (based on the most recent estimates available from the Director of the Congressional Budget Office before a vote in either House on the Patient Protection and Affordable Care Act that, if determined in the affirmative, would clear such Act for enrollment); over
“(bb) the total percentage of the non-elderly insured population for such preceding year (as estimated by the Secretary); exceeds
“(II) 5 percentage points.”
Subsec. (t)(7)(D)(i)(II). Pub. L. 111–309, § 108(1), substituted “2012” for “2011” in first sentence and “2010, or 2011” for “or 2010” in second sentence.
Pub. L. 111–148, § 3121(a)(1)(B), substituted “, 2009, or 2010” for “or 2009”.
Pub. L. 111–148, § 3121(a)(1)(A), substituted “2011” for “2010”.
Subsec. (t)(7)(D)(i)(III). Pub. L. 111–309, § 108(2), which directed substitution of “
Pub. L. 111–148, § 3121(b), inserted at end “In the case of covered OPD services furnished on or after
Pub. L. 111–148, § 3121(a)(2), substituted “2009, and before
Subsec. (t)(18), (19). Pub. L. 111–148, §§ 3138, 10324(b)(2), added pars. (18) and (19).
Subsecs. (x), (y). Pub. L. 111–148, § 5501(a)(1), (b)(1), added subsecs. (x) and (y).
2008—Subsec. (a)(1)(D)(iii). Pub. L. 110–275, § 145(a)(2), before comma at end of subpar. (D), struck out cl. (iii), which read “on the basis of a rate established under a demonstration project under section 1395w–3(e) of this title, the amount paid shall be equal to 100 percent of such rate”.
Subsec. (a)(1)(W). Pub. L. 110–275, § 101(a)(2), added subpar. (W).
Subsec. (a)(8)(A), (B). Pub. L. 110–275, § 143(b)(2), substituted “, outpatient speech-language pathology services,” for “(which includes outpatient speech-language pathology services)” in introductory provisions.
Subsec. (b)(9). Pub. L. 110–275, § 101(b)(2), added par. (9) at end of first sentence.
Subsec. (c). Pub. L. 110–275, § 102, amended subsec. (c) generally. Prior to amendment, text read as follows: “Notwithstanding any other provision of this part, with respect to expenses incurred in any calendar year in connection with the treatment of mental, psychoneurotic, and personality disorders of an individual who is not an inpatient of a hospital at the time such expenses are incurred, there shall be considered as incurred expenses for purposes of subsections (a) and (b) of this section only 62½ percent of such expenses. For purposes of this subsection, the term ‘treatment’ does not include brief office visits (as defined by the Secretary) for the sole purpose of monitoring or changing drug prescriptions used in the treatment of such disorders or partial hospitalization services that are not directly provided by a physician.”
Subsec. (g)(1). Pub. L. 110–275, § 143(b)(3), inserted “and speech-language pathology services of the type described in such section through the application of section 1395x(ll)(2) of this title” after “1395x(p) of this title” and “and speech-language pathology services” after “and physical therapy services”.
Subsec. (g)(5). Pub. L. 110–275, § 141, substituted “
Subsec. (h)(2)(A)(i). Pub. L. 110–275, § 145(b), inserted “minus, for each of the years 2009 through 2013, 0.5 percentage points” after “city average)”.
Subsec. (t)(7)(D)(i)(II). Pub. L. 110–275, § 147(1), substituted “
Subsec. (t)(7)(D)(i)(III). Pub. L. 110–275, § 147(2), added subcl. (III).
Subsec. (t)(16)(C). Pub. L. 110–275, § 142, substituted “
Subsec. (v). Pub. L. 110–275, § 151(a), added subsec. (v).
Subsec. (w). Pub. L. 110–275, § 184, added subsec. (w).
2007—Subsec. (g)(5). Pub. L. 110–173, § 105, substituted “
Subsec. (h)(9). Pub. L. 110–173, § 113, added par. (9).
Subsec. (t)(16)(C). Pub. L. 110–173, § 106, in heading, inserted “and therapeutic radiopharmaceuticals” before “at charges”, in first sentence, substituted “
Subsec. (u)(1). Pub. L. 110–173, § 102(1), substituted “before
Subsec. (u)(4)(D), (E). Pub. L. 110–173, § 102(2), added subpar. (D) and redesignated former subpar. (D) as (E).
2006—Subsec. (b)(7). Pub. L. 109–171, § 5112(e), added par. (7) at end of first sentence.
Subsec. (b)(8). Pub. L. 109–171, § 5113(a), added par. (8) at end of first sentence.
Subsec. (g)(1), (3). Pub. L. 109–171, § 5107(a)(1)(A), substituted “paragraphs (4) and (5)” for “paragraph (4)”.
Subsec. (g)(5). Pub. L. 109–432, § 201, substituted “the period beginning on
Pub. L. 109–171, § 5107(a)(1)(B), added par. (5).
Subsec. (i)(2)(A). Pub. L. 109–171, § 5103(1), inserted “subject to subparagraph (E),” after “subparagraph (D),”.
Subsec. (i)(2)(D)(ii). Pub. L. 109–171, § 5103(2), inserted “and taking into account reduced expenditures that would apply if subparagraph (E) were to continue to apply, as estimated by the Secretary” before period at end.
Subsec. (i)(2)(D)(iv), (v). Pub. L. 109–432, § 109(b)(1), added cl. (iv) and redesignated former cl. (iv) as (v).
Subsec. (i)(2)(E). Pub. L. 109–171, § 5103(3), added subpar. (E).
Subsec. (i)(7). Pub. L. 109–432, § 109(b)(2), added par. (7).
Subsec. (t)(2)(H). Pub. L. 109–432, § 107(b)(1), inserted “and for stranded and non-stranded devices furnished on or after
Subsec. (t)(3)(C)(iv). Pub. L. 109–432, § 109(a)(1)(A), inserted “subject to paragraph (17),” after “this subparagraph,”.
Subsec. (t)(7)(D)(i). Pub. L. 109–171, § 5105, designated existing provisions as subcl. (I) and added subcl. (II).
Subsec. (t)(16)(C). Pub. L. 109–432, § 107(a), substituted “2008” for “2007”.
Subsec. (t)(17). Pub. L. 109–432, § 109(a)(1)(B), added par. (17).
2003—Subsec. (a)(1)(D)(iii). Pub. L. 108–173, § 302(b)(2)(C), added cl. (iii).
Subsec. (a)(1)(G). Pub. L. 108–173, § 626(c), added subpar. (G).
Subsec. (a)(1)(S). Pub. L. 108–173, § 642(b), inserted “(including intravenous immune globulin (as defined in section 1395x(zz) of this title))” after “with respect to drugs and biologicals”.
Pub. L. 108–173, § 303(i)(3)(A), inserted “(or, if applicable, under section 1395w–3, 1395w–3a, or 1395w–3b of this title)” after “1395u(o) of this title”.
Subsec. (a)(1)(V). Pub. L. 108–173, § 302(b)(2)(A), (B), added subpar. (V).
Subsec. (a)(2)(E)(i). Pub. L. 108–173, § 614(b), inserted “and, for services furnished on or after
Subsec. (a)(3). Pub. L. 108–173, § 237(a), amended par. (3) generally. Prior to amendment, par. (3) read as follows: “in the case of services described in section 1395k(a)(2)(D) of this title, the costs which are reasonable and related to the cost of furnishing such services or which are based on such other tests of reasonableness as the Secretary may prescribe in regulations, including those authorized under section 1395x(v)(1)(A) of this title, less the amount a provider may charge as described in clause (ii) of section 1395cc(a)(2)(A) of this title, but in no case may the payment for such services (other than for items and services described in section 1395x(s)(10)(A) of this title) exceed 80 percent of such costs;”.
Subsec. (b). Pub. L. 108–173, § 629, substituted “, $100 for 1991 through 2004, $110 for 2005, and for a subsequent year the amount of such deductible for the previous year increased by the annual percentage increase in the monthly actuarial rate under section 1395r(a)(1) of this title ending with such subsequent year (rounded to the nearest $1)” for “and $100 for 1991 and subsequent years” before semicolon in first sentence.
Subsec. (g)(4). Pub. L. 108–173, § 624(a)(1), substituted “2002, 2004, and 2005” for “and 2002”.
Subsec. (h)(2)(A)(ii)(IV). Pub. L. 108–173, § 628, substituted “, 1998 through 2002, and 2004 through 2008” for “and 1998 through 2002”.
Subsec. (h)(5)(D). Pub. L. 108–173, § 736(b)(1), substituted “clinic,” for “clinic,,”.
Subsec. (h)(8). Pub. L. 108–173, § 942(b), added par. (8).
Subsec. (i)(2)(A). Pub. L. 108–173, § 626(b)(1)(A), substituted “For services furnished prior to the implementation of the system described in subparagraph (D), the” for “The” in introductory provisions.
Subsec. (i)(2)(A)(i). Pub. L. 108–173, § 626(b)(1)(B), struck out “taken not later than
Subsec. (i)(2)(C). Pub. L. 108–173, § 626(a), amended subpar. (C) generally. Prior to amendment, subpar. (C) read as follows: “Notwithstanding the second sentence of subparagraph (A) or the second sentence of subparagraph (B), if the Secretary has not updated amounts established under such subparagraphs with respect to facility services furnished during a fiscal year (beginning with fiscal year 1996), such amounts shall be increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) as estimated by the Secretary for the 12-month period ending with the midpoint of the year involved. In each of the fiscal years 1998 through 2002, the increase under this subparagraph shall be reduced (but not below zero) by 2.0 percentage points.”
Subsec. (i)(2)(D). Pub. L. 108–173, § 626(b)(2), added subpar. (D).
Subsec. (m). Pub. L. 108–173, § 413(b)(1), designated existing provisions as par. (1), inserted “in a year” after “In the case of physicians’ services furnished” and “as identified by the Secretary prior to the beginning of such year” after “as a health professional shortage area”, and added pars. (2) to (4).
Subsec. (o)(1)(B). Pub. L. 108–173, § 627(a)(1), substituted “no more than the amount of payment applicable under paragraph (2)” for “no more than the limits established under paragraph (2)”.
Subsec. (o)(2). Pub. L. 108–173, § 627(a)(2), amended par. (2) generally, substituting provisions relating to determination of amount of payments pursuant to section 1395m of this title for provisions specifying dollar amounts of payments.
Subsec. (t)(1)(B)(iv). Pub. L. 108–173, § 614(a), inserted before period at end “and does not include screening mammography (as defined in section 1395x(jj) of this title) and diagnostic mammography”.
Subsec. (t)(2)(H). Pub. L. 108–173, § 621(b)(2), which directed the amendment of par. (2) by adding a new subpar. (H) at the end, was executed by adding subpar. (H) after subpar. (G), to reflect the probable intent of Congress.
Subsec. (t)(3)(C)(ii). Pub. L. 108–173, § 736(b)(2), substituted “clause (iv)” for “clause (iii)”.
Subsec. (t)(5)(E). Pub. L. 108–173, § 621(a)(3), added subpar. (E).
Subsec. (t)(6)(D)(i). Pub. L. 108–173, § 621(a)(4), inserted “(or if the drug or biological is covered under a competitive acquisition contract under section 1395w–3b of this title, an amount determined by the Secretary equal to the average price for the drug or biological for all competitive acquisition areas and year established under such section as calculated and adjusted by the Secretary for purposes of this paragraph)” after “under section 1395u(o) of this title”.
Subsec. (t)(6)(F). Pub. L. 108–173, § 622, added subpar. (F).
Subsec. (t)(7)(D)(i). Pub. L. 108–173, § 411(a)(1)(A), (C), substituted “certain” for “small” in heading and “2006” for “2004” in text.
Pub. L. 108–173, § 411(a)(1)(B), inserted “or a sole community hospital (as defined in section 1395ww(d)(5)(D)(iii) of this title) located in a rural area” after “100 beds”.
Subsec. (t)(9)(B). Pub. L. 108–173, § 621(a)(5), inserted at end “In determining adjustments under the preceding sentence for 2004 and 2005, the Secretary shall not take into account under this subparagraph or paragraph (2)(E) any expenditures that would not have been made but for the application of paragraph (14).”
Subsec. (t)(13). Pub. L. 108–173, § 411(b)(2), added par. (13). Former par. (13) redesignated (16).
Subsec. (t)(14), (15). Pub. L. 108–173, § 621(a)(1), added pars. (14) and (15).
Subsec. (t)(16). Pub. L. 108–173, § 411(b)(1), redesignated par. (13) as (16).
Subsec. (t)(16)(B). Pub. L. 108–173, § 621(a)(2), added subpar. (B).
Subsec. (t)(16)(C). Pub. L. 108–173, § 621(b)(1), added subpar. (C).
Subsec. (u). Pub. L. 108–173, § 413(a), added subsec. (u).
2000—Subsec. (a)(1)(D)(i). Pub. L. 106–554, § 1(a)(6) [title II, § 201(b)(1)], struck out “or which are furnished on an outpatient basis by a critical access hospital” after “on an assignment-related basis”.
Subsec. (a)(1)(R). Pub. L. 106–554, § 1(a)(6) [title II, § 205(b)], substituted “ambulance services, (i)” for “ambulance service,” and inserted before comma at end “and (ii) with respect to ambulance services described in section 1395m(l)(8) of this title, the amounts paid shall be the amounts determined under section 1395m(g) of this title for outpatient critical access hospital services”.
Subsec. (a)(1)(T). Pub. L. 106–554, § 1(a)(6) [title I, § 105(c)], added subpar. (T).
Subsec. (a)(1)(U). Pub. L. 106–554, § 1(a)(6) [title II, § 223(c)], added subpar. (U).
Subsec. (a)(2)(D)(i). Pub. L. 106–554, § 1(a)(6) [title II, § 201(b)(1)], struck out “or which are furnished on an outpatient basis by a critical access hospital” after “on an assignment-related basis”.
Subsec. (f). Pub. L. 106–554, § 1(a)(6) [title II, § 224(a)], substituted “hospitals” for “rural hospitals” in introductory provisions.
Subsec. (g)(4). Pub. L. 106–554, § 1(a)(6) [title IV, § 421(a)], substituted “2000, 2001, and 2002.” for “2000 and 2001.”
Subsec. (h)(4)(B)(viii). Pub. L. 106–554, § 1(a)(6) [title V, § 531(a)], inserted before period at end “(or 100 percent of such median in the case of a clinical diagnostic laboratory test performed on or after
Subsec. (t)(2)(G). Pub. L. 106–554, § 1(a)(6) [title IV, § 430(a)], added subpar. (G).
Subsec. (t)(3)(C)(iii). Pub. L. 106–554, § 1(a)(6) [title IV, § 401(b)(1)(B)], added cl. (iii). Former cl. (iii) redesignated (iv).
Pub. L. 106–554, § 1(a)(6) [title IV, § 401(a)], substituted “in each of 2000 and 2002” for “in each of 2000, 2001, and 2002”.
Subsec. (t)(3)(C)(iv). Pub. L. 106–554, § 1(a)(6) [title IV, § 401(b)(1)(A)], redesignated cl. (iii) as (iv).
Subsec. (t)(6)(A)(ii). Pub. L. 106–554, § 1(a)(6) [title IV, § 406(a)], inserted “or temperature monitored cryoablation” after “device of brachytherapy”.
Subsec. (t)(6)(A)(iv)(II). Pub. L. 106–554, § 1(a)(6) [title IV, § 402(b)(1)], substituted “the cost of the drug or biological or the average cost of the category of devices” for “the cost of the device, drug, or biological”.
Subsec. (t)(6)(B). Pub. L. 106–554, § 1(a)(6) [title IV, § 402(a)(2)], added subpar. (B) and struck out heading and text of former subpar. (B). Text read as follows: “The payment under this paragraph with respect to a medical device, drug, or biological shall only apply during a period of at least 2 years, but not more than 3 years, that begins—
“(i) on the first date this subsection is implemented in the case of a drug, biological, or device described in clause (i), (ii), or (iii) of subparagraph (A) and in the case of a device, drug, or biological described in subparagraph (A)(iv) and for which payment under this part is made as an outpatient hospital service before such first date; or
“(ii) in the case of a device, drug, or biological described in subparagraph (A)(iv) not described in clause (i), on the first date on which payment is made under this part for the device, drug, or biological as an outpatient hospital service.”
Subsec. (t)(6)(C). Pub. L. 106–554, § 1(a)(6) [title IV, § 402(a)(2)], added subpar. (C). Former subpar. (C) redesignated (D).
Subsec. (t)(6)(D). Pub. L. 106–554, § 1(a)(6) [title IV, § 402(b)(2)], substituted “subparagraph (E)(iii)” for “subparagraph (D)(iii)” in introductory provisions.
Pub. L. 106–554, § 1(a)(6) [title IV, § 402(a)(1)], redesignated subpar. (C) as (D). Former subpar. (D) redesignated (E).
Subsec. (t)(6)(E). Pub. L. 106–554, § 1(a)(6) [title IV, § 402(a)(1)], redesignated subpar. (D) as (E).
Subsec. (t)(7)(D)(ii). Pub. L. 106–554, § 1(a)(6) [title IV, § 405(a)], in heading, inserted “and children’s hospitals” after “cancer hospitals” and in text, substituted “clause (iii) or (v) of section 1395ww(d)(1)(B) of this title” for “section 1395ww(d)(1)(B)(v) of this title”.
Subsec. (t)(7)(F)(ii)(I). Pub. L. 106–554, § 1(a)(6) [title IV, § 403(a)], inserted “(or in the case of a hospital that did not submit a cost report for such period, during the first subsequent cost reporting period ending before 2001 for which the hospital submitted a cost report)” after “1996”.
Subsec. (t)(8)(C). Pub. L. 106–554, § 1(a)(6) [title I, § 111(a)(1)], amended heading and text of subpar. (C) generally. Prior to amendment, text read as follows: “In no case shall the copayment amount for a procedure performed in a year exceed the amount of the inpatient hospital deductible established under section 1395e(b) of this title for that year.”
Subsec. (t)(11). Pub. L. 106–554, § 1(a)(6) [title IV, § 405(a)(2)], substituted “clause (iii) or (v) of section 1395ww(d)(1)(B) of this title” for “section 1395ww(d)(1)(B)(v) of this title” in introductory provisions.
Subsec. (t)(12)(E). Pub. L. 106–554, § 1(a)(6) [title IV, § 402(b)(3)], substituted “additional payments, the determination and deletion of initial and new categories (consistent with subparagraphs (B) and (C) of paragraph (6))” for “additional payments (consistent with paragraph (6)(B))”.
1999—Subsec. (a)(1)(D)(i). Pub. L. 106–113, § 1000(a)(6) [title IV, § 403(e)(1)], inserted “or which are furnished on an outpatient basis by a critical access hospital” after “on an assignment-related basis”.
Subsec. (a)(1)(O). Pub. L. 106–113, § 1000(a)(6) [title III, § 321(k)(2)], substituted a comma for the semicolon at end.
Subsec. (a)(2)(D)(i). Pub. L. 106–113, § 1000(a)(6) [title IV, § 403(e)(1)], inserted “or which are furnished on an outpatient basis by a critical access hospital” after “on an assignment-related basis”.
Subsec. (g)(1), (3). Pub. L. 106–113, § 1000(a)(6) [title II, § 221(a)(1)(A)], substituted “Subject to paragraph (4), in the case” for “In the case”.
Subsec. (g)(4). Pub. L. 106–113, § 1000(a)(6) [title II, § 221(a)(1)(B)], added par. (4).
Subsec. (h)(5)(A)(iii). Pub. L. 106–113, § 1000(a)(6) [title III, § 321(g)(2)], substituted “, critical access hospital, or skilled nursing facility,” for “or critical access hospital,” and inserted “or skilled nursing facility” before period at end.
Subsec. (h)(7). Pub. L. 106–113, § 1000(a)(6) [title II, § 224(a)], added par. (7).
Subsec. (l)(4)(A)(i)(VII). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(a)(3)(B)], substituted “1395w–4(d) of this title” for “1395w–4(d)(3) of this title”.
Subsec. (t)(1)(B)(ii). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(e)(1)(A)], substituted “clause (iv)” for “clause (iii)” and directed the striking out of “but” which was executed by striking out “but” after semicolon at end to reflect the probable intent of Congress.
Subsec. (t)(1)(B)(iii), (iv). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(e)(1)(B)], added cl. (iii) and redesignated former cl. (iii) as (iv).
Subsec. (t)(2). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(g)], inserted concluding provisions.
Subsec. (t)(2)(B). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(e)(1)(C)], inserted “and so that an implantable item is classified to the group that includes the service to which the item relates” before semicolon at end.
Subsec. (t)(2)(C). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(f)], inserted “(or, at the election of the Secretary, mean)” after “median”.
Subsec. (t)(2)(E). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(c)], substituted “, in a budget neutral manner, outlier adjustments under paragraph (5) and transitional pass-through payments under paragraph (6) and other adjustments as determined to be necessary to ensure equitable payments, such as” for “other adjustments, in a budget neutral manner, as determined to be necessary to ensure equitable payments, such as outlier adjustments or”.
Subsec. (t)(4). Pub. L. 106–113, § 1000(a)(6) [title II, § 202(a)(1)], inserted “, subject to paragraph (7),” after “is determined” in introductory provisions.
Subsec. (t)(4)(C). Pub. L. 106–113, § 1000(a)(6) [title II, § 204(b)], inserted “, plus the amount of any reduction in the copayment amount attributable to paragraph (8)(C)” before period at end.
Subsec. (t)(5). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(a)(2)], added par. (5). Former par. (5) redesignated (7).
Subsec. (t)(6). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(b)], added par. (6). Former par. (6) redesignated (8).
Subsec. (t)(7). Pub. L. 106–113, § 1000(a)(6) [title II, § 202(a)(3)], added par. (7). Former par. (7) redesignated (8).
Pub. L. 106–113, § 1000(a)(6) [title II, § 201(a)(1)], redesignated par. (5) as (7). Former par. (7) redesignated (9).
Subsec. (t)(7)(D). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(i)], added subpar. (D).
Subsec. (t)(8). Pub. L. 106–113, § 1000(a)(6) [title II, § 202(a)(2)], redesignated par. (7) as (8). Former par. (8) redesignated (9).
Pub. L. 106–113, § 1000(a)(6) [title II, § 201(a)(1)], redesignated par. (6) as (8). Former par. (8) redesignated (10).
Subsec. (t)(8)(A). Pub. L. 106–113, § 1000(a)(6) [title II, § 204(a)(1)], substituted “subparagraphs (B) and (C)” for “subparagraph (B)”.
Pub. L. 106–113, § 1000(a)(6) [title II, § 201(h)(1)(B)], inserted at end “The Secretary shall consult with an expert outside advisory panel composed of an appropriate selection of representatives of providers to review (and advise the Secretary concerning) the clinical integrity of the groups and weights. Such panel may use data collected or developed by entities and organizations (other than the Department of Health and Human Services) in conducting such review.”
Pub. L. 106–113, § 1000(a)(6) [title II, § 201(h)(1)(A)], substituted “shall review not less often than annually” for “may periodically review”.
Subsec. (t)(8)(C) to (E). Pub. L. 106–113, § 1000(a)(6) [title II, § 204(a)(2), (3)], added subpar. (C) and redesignated former subpars. (C) and (D) as (D) and (E), respectively.
Subsec. (t)(9). Pub. L. 106–113, § 1000(a)(6) [title II, § 202(a)(2)], redesignated par. (8) as (9). Former par. (9) redesignated (10).
Pub. L. 106–113, § 1000(a)(6) [title II, § 201(j)], substituted “section 1395x(v)(1)(U) of this title” for “the matter in subsection (a)(1) of this section preceding subparagraph (A)”.
Pub. L. 106–113, § 1000(a)(6) [title II, § 201(a)(1)], redesignated par. (7) as (9). Former par. (9) redesignated (11).
Subsec. (t)(10). Pub. L. 106–113, § 1000(a)(6) [title II, § 202(a)(2)], redesignated par. (9) as (10). Former par. (10) redesignated (11).
Pub. L. 106–113, § 1000(a)(6) [title II, § 201(a)(1)], redesignated par. (8) as (10).
Subsec. (t)(11). Pub. L. 106–113, § 1000(a)(6) [title II, § 202(a)(2)], redesignated par. (10) as (11). Former par. (11) redesignated (12).
Pub. L. 106–113, § 1000(a)(6) [title II, § 201(a)(1)], redesignated par. (9) as (11).
Subsec. (t)(11)(E). Pub. L. 106–113, § 1000(a)(6) [title II, § 201(d)], added subpar. (E).
Subsec. (t)(12). Pub. L. 106–113, § 1000(a)(6) [title II, § 202(a)(2)], redesignated par. (11) as (12).
Subsec. (t)(13). Pub. L. 106–113, § 1000(a)(6) [title IV, § 401(b)(1)], added par. (13).
1997—Subsec. (a)(1)(A). Pub. L. 105–33, § 4002(j)(1)(A), inserted “(and either is sponsored by a union or employer, or does not provide, or arrange for the provision of, any inpatient hospital services)” after “prepayment basis”.
Subsec. (a)(1)(D). Pub. L. 105–33, § 4104(c), inserted “or section 1395m(d)(1) of this title” after “subsection (h)(1) of this section”.
Subsec. (a)(1)(O). Pub. L. 105–33, § 4512(b)(1), substituted “section 1395x(s)(2)(K) of this title” for “section 1395x(s)(2)(K)(ii) of this title” and “services furnished by physician assistants, nurse practitioners, or clinic nurse specialists” for “nurse practitioner or clinical nurse specialist services”.
Pub. L. 105–33, § 4511(b)(1), amended subpar. (O) generally. Prior to amendment, subpar. (O) read as follows: “with respect to services described in section 1395x(s)(2)(K)(iii) of this title (relating to nurse practitioner or clinical nurse specialist services provided in a rural area), the amounts paid shall be 80 percent of the lesser of the actual charge or the prevailing charge that would be recognized (or, for services furnished on or after
Subsec. (a)(1)(Q). Pub. L. 105–33, § 4315(b), added subpar. (Q).
Subsec. (a)(1)(R). Pub. L. 105–33, § 4531(b)(1), added subpar. (R).
Subsec. (a)(1)(S). Pub. L. 105–33, § 4556(b), added subpar. (S).
Subsec. (a)(2). Pub. L. 105–33, § 4541(a)(1)(A), inserted “(C),” before “(D)” in introductory provisions.
Subsec. (a)(2)(A). Pub. L. 105–33, § 4603(c)(2)(A)(i), amended subpar. (A) generally. Prior to amendment, subpar. (A) read as follows: “with respect to home health services (other than a covered osteoporosis drug (as defined in section 1395x(kk) of this title)) and to items and services described in section 1395x(s)(10)(A) of this title, the lesser of—
“(i) the reasonable cost of such services, as determined under section 1395x(v) of this title, or
“(ii) the customary charges with respect to such services,
or, if such services are furnished by a public provider of services, or by another provider which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this provision), free of charge or at nominal charges to the public, the amount determined in accordance with section 1395f(b)(2) of this title;”.
Subsec. (a)(2)(B). Pub. L. 105–33, § 4432(b)(5)(C), inserted “or section 1395yy(e)(9) of this title” after “1395ww of this title” in introductory provisions.
Pub. L. 105–33, § 4523(d)(3), inserted “furnished before
Subsec. (a)(2)(D). Pub. L. 105–33, § 4104(c)(1), inserted “or section 1395m(d)(1) of this title” after “subsection (h)(1) of this section”.
Subsec. (a)(2)(E). Pub. L. 105–33, § 4523(d)(2)(B), inserted “or, for services or procedures performed on or after
Subsec. (a)(2)(G). Pub. L. 105–33, § 4603(c)(2)(A)(ii)–(iv), added subpar. (G).
Subsec. (a)(3). Pub. L. 105–33, § 4541(a)(1)(B), substituted “section 1395k(a)(2)(D) of this title” for “subparagraphs (D) and (E) of section 1395k(a)(2) of this title”.
Subsec. (a)(4). Pub. L. 105–33, § 4523(d)(1)(B), inserted “or subsection (t) of this section” before semicolon at end.
Subsec. (a)(6). Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.
Subsec. (a)(8), (9). Pub. L. 105–33, § 4541(a)(1)(C)–(E), added pars. (8) and (9).
Subsec. (b)(5). Pub. L. 105–33, § 4101(b), added par. (5) at end of first sentence.
Subsec. (b)(6). Pub. L. 105–33, § 4102(b), added par. (6) at end of first sentence.
Subsec. (f). Pub. L. 105–33, § 4205(a)(1)(A), substituted “rural health clinics (other than such clinics in rural hospitals with less than 50 beds)” for “independent rural health clinics” in introductory provisions.
Subsec. (f)(1). Pub. L. 105–33, § 4205(a)(2), inserted “per visit” after “$46”.
Subsec. (g). Pub. L. 105–33, § 4541(d)(1), substituted “the amount specified in paragraph (2) for the year” for “$900” in two places, redesignated first sentence as par. (1) and last sentence as par. (3), and added par. (2).
Pub. L. 105–33, § 4541(c), (d)(1)(A), substituted, in first sentence, “physical therapy services of the type described in section 1395x(p) of this title, but not described in subsection (a)(8)(B) of this section, and physical therapy services of such type which are furnished by a physician or as incident to physicians’ services” for “services described in the second sentence of section 1395x(p) of this title”, and substituted, in last sentence, “occupational therapy services (of the type that are described in section 1395x(p) of this title (but not described in subsection (a)(8)(B) of this section) through the operation of section 1395x(g) of this title and of such type which are furnished by a physician or as incident to physicians’ services)” for “outpatient occupational therapy services which are described in the second sentence of section 1395x(p) of this title through the operation of section 1395x(g) of this title”.
Subsec. (h)(1)(A). Pub. L. 105–33, § 4104(c)(2), substituted “Subject to section 1395m(d)(1) of this title, the Secretary” for “The Secretary”.
Pub. L. 105–33, § 4103(b), inserted “(including prostate cancer screening tests under section 1395x(oo) of this title consisting of prostate-specific antigen blood tests)” after “laboratory tests”.
Subsec. (h)(2)(A)(ii)(IV). Pub. L. 105–33, § 4553(a), inserted “and 1998 through 2002” after “1995”.
Subsec. (h)(4)(B)(vii). Pub. L. 105–33, § 4553(b)(2)(A), inserted “and before
Subsec. (h)(4)(B)(viii). Pub. L. 105–33, § 4553(b)(1), (2)(B), (3), added cl. (viii).
Subsec. (h)(5)(A)(iii). Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.
Subsec. (i)(1)(A). Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.
Subsec. (i)(2)(C). Pub. L. 105–33, § 4555, inserted at end “In each of the fiscal years 1998 through 2002, the increase under this subparagraph shall be reduced (but not below zero) by 2.0 percentage points.”
Subsec. (i)(3)(A). Pub. L. 105–33, § 4523(d)(1)(A)(i), inserted “before
Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.
Subsec. (i)(3)(B)(i)(II). Pub. L. 105–33, § 4521(a), struck out “of 80 percent” before “of the standard overhead amount” and inserted before period at end “, less the amount a provider may charge as described in clause (ii) of section 1395cc(a)(2)(A) of this title”.
Subsec. (l)(5). Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care” wherever appearing.
Subsec. (n)(1)(A). Pub. L. 105–33, § 4523(d)(2)(A), inserted “and before
Subsec. (n)(1)(B)(i)(II). Pub. L. 105–33, § 4521(b), struck out “of 80 percent” before “of the prevailing charge” and inserted before period at end “, less the amount a provider may charge as described in clause (ii) of section 1395cc(a)(2)(A) of this title”.
Subsec. (r)(1). Pub. L. 105–33, § 4511(b)(2)(A), substituted “section 1395x(s)(2)(K)(ii) of this title (relating to nurse practitioner or clinical nurse specialist services)” for “section 1395x(s)(2)(K)(iii) of this title (relating to nurse practitioner or clinical nurse specialist services provided in a rural area)”.
Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.
Subsec. (r)(2). Pub. L. 105–33, § 4511(b)(2)(B), (D), redesignated par. (3) as (2) and struck out former par. (2) which read as follows:
“(2)(A) For purposes of subsection (a)(1)(O) of this section, the prevailing charge for services described in section 1395x(s)(2)(K)(iii) of this title may not exceed the applicable percentage (as defined in subparagraph (B)) of the prevailing charge (or, for services furnished on or after
“(B) In subparagraph (A), the term ‘applicable percentage’ means—
“(i) 75 percent in the case of services performed in a hospital, and
“(ii) 85 percent in the case of other services.”
Subsec. (r)(3). Pub. L. 105–33, § 4511(b)(2)(C), (D), redesignated par. (3) as (2) and substituted “section 1395x(s)(2)(K)(ii) of this title” for “section 1395x(s)(2)(K)(iii) of this title”.
Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care”.
Subsec. (t). Pub. L. 105–33, § 4523(a), added subsec. (t).
1994—Subsec. (a)(1)(D)(i). Pub. L. 103–432, § 156(a)(2)(B)(i), struck out “, or for tests furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion)” after “assignment-related basis”.
Subsec. (a)(1)(G). Pub. L. 103–432, § 156(a)(2)(B)(ii), struck out subpar. (G) which read as follows: “with respect to items and services (other than clinical diagnostic laboratory tests) furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion), the amounts paid shall be 100 percent of the reasonable charges for such items and services,”.
Subsec. (a)(2)(A). Pub. L. 103–432, § 156(a)(2)(B)(iii), struck out “, to items and services (other than clinical diagnostic laboratory tests) furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion),” before “and to items and services” in introductory provisions.
Pub. L. 103–432, § 147(f)(6)(C)(i), substituted “health services (other than a covered osteoporosis drug (as defined in section 1395x(kk) of this title))” for “health services” in introductory provisions.
Subsec. (a)(2)(D)(i). Pub. L. 103–432, § 156(a)(2)(B)(iv), substituted “assignment-related basis or” for “assignment-related basis,” and struck out “, or for tests furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion)” after “section 1395cc of this title”.
Subsec. (a)(2)(F). Pub. L. 103–432, § 147(f)(6)(C)(ii)–(iv), added subpar. (F).
Subsec. (a)(3). Pub. L. 103–432, § 156(a)(2)(B)(v), struck out “and for items and services furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title, or a third opinion, if the second opinion was in disagreement with the first opinion)” after “section 1395x(s)(10)(A) of this title”.
Subsec. (b)(2). Pub. L. 103–432, § 147(f)(6)(D), inserted “(other than a covered osteoporosis drug (as defined in section 1395x(kk) of this title))” after “services”.
Subsec. (b)(4), (5). Pub. L. 103–432, § 156(a)(2)(B)(vi), redesignated par. (5) as (4) and struck out former par. (4) which read as follows: “such deductible shall not apply with respect to items and services furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion),”.
Subsec. (h)(5)(D). Pub. L. 103–432, § 123(e), substituted “paragraph (2) of section 1395u(j)” for “paragraphs (2) and (3) of section 1395u(j)” and inserted at end “Paragraph (4) of such section shall apply in this subparagraph in the same manner as such paragraph applies to such section.”
Subsec. (i)(1). Pub. L. 103–432, § 141(a)(3), inserted before period at end of last sentence “, in consultation with appropriate trade and professional organizations”.
Subsec. (i)(2)(A). Pub. L. 103–432, § 141(a)(2)(A), struck out “and may be adjusted by the Secretary, when appropriate,” after “annually thereafter” in last sentence.
Subsec. (i)(2)(A)(i). Pub. L. 103–432, § 141(a)(1), inserted before comma at end “, as determined in accordance with a survey (based upon a representative sample of procedures and facilities) taken not later than
Subsec. (i)(2)(B). Pub. L. 103–432, § 141(a)(2)(A), struck out “and may be adjusted by the Secretary, when appropriate,” after “annually thereafter” in last sentence.
Subsec. (i)(2)(C). Pub. L. 103–432, § 141(a)(2)(B), added subpar. (C).
Subsec. (i)(3)(B)(ii). Pub. L. 103–432, § 141(c)(1), in subcls. (I) and (II) substituted “for portions of cost reporting periods” for “for reporting periods” and “and ending on or before
Subsec. (l)(5)(B), (C). Pub. L. 103–432, § 123(b)(2)(A)(i), redesignated subpar. (C) as (B) and struck out former subpar. (B) which read as follows:
“(B)(i) Payment for the services of a certified registered nurse anesthetist under this part may be made only on an assignment-related basis, and any such assignment agreed to by a certified registered nurse anesthetist shall be binding upon any other person presenting a claim or request for payment for such services.
“(ii) Except for deductible and coinsurance amounts applicable under this section, any person who knowingly and willfully presents, or causes to be presented, to an individual enrolled under this part a bill or request for payment for services of a certified registered nurse anesthetist for which payment may be made under this part only on an assignment-related basis is subject to a civil money penalty of not to exceed $2,000 for each such bill or request. The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.”
Subsec. (n)(1)(B)(i)(II). Pub. L. 103–432, § 147(d)(2), substituted “
Pub. L. 103–432, § 147(d)(1), inserted “and for services described in subsection (a)(2)(E)(ii) of this section furnished on or after
Subsec. (p). Pub. L. 103–432, § 123(b)(2)(A)(ii), struck out subsec. (p) which read as follows: “In the case of certified nurse-midwife services for which payment may be made under this part only pursuant to section 1395x(s)(2)(L) of this title, in the case of qualified psychologists services for which payment may be made under this part only pursuant to section 1395x(s)(2)(M) of this title, and in the case of clinical social worker services for which payment may be made under this part only pursuant to section 1395x(s)(2)(N) of this title, payment may only be made under this part for such services on an assignment-related basis. Except for deductible and coinsurance amounts applicable under this section, whoever knowingly and willfully presents, or causes to be presented, to an individual enrolled under this part a bill or request for payment for services described in the previous sentence, is subject to a civil money penalty of not to exceed $2,000 for each such bill or request. The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.”
Subsec. (q)(1). Pub. L. 103–432, § 147(a), substituted “unique physician identification number” for “provider number” and struck out “and indicate whether or not the referring physician is an interested investor (within the meaning of section 1395nn(h)(5) of this title)” after “for the referring physician”.
Subsec. (r). Pub. L. 103–432, § 160(d)(1), redesignated subsec. (r), relating to other prepaid organizations, as (s).
Subsec. (r)(1). Pub. L. 103–432, § 147(e)(2), substituted “or ambulatory” for “ambulatory” in two places and “center” for “center,” before “with which the nurse”.
Subsec. (r)(2)(A). Pub. L. 103–432, § 147(e)(3), substituted “subsection (a)(1)(O) of this section” for “subsection (a)(1)(M) of this section”.
Subsec. (r)(3), (4). Pub. L. 103–432, § 123(b)(2)(A)(iii), redesignated par. (4) as (3) and struck out former par. (3) which read as follows:
“(3)(A) Payment under this part for services described in section 1395x(s)(2)(K)(iii) of this title may be made only on an assignment-related basis, and any such assignment agreed to by a nurse practitioner or clinical nurse specialist shall be binding upon any other person presenting a claim or request for payment for such services.
“(B) Except for deductible and coinsurance amounts applicable under this section, any person who knowingly and willfully presents, or causes to be presented, to an individual enrolled under this part a bill or request for payment for services described in section 1395x(s)(2)(K)(iii) of this title in violation of subparagraph (A) is subject to a civil money penalty of not to exceed $2,000 for each such bill or request. The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.”
Subsec. (s). Pub. L. 103–432, § 160(d)(1), redesignated subsec. (r), relating to other prepaid organizations, as (s).
1993—Subsec. (a)(1). Pub. L. 103–66, § 13544(b)(2), redesignated subpar. (M) relating to nurse practitioner and clinical nurse specialist services as (O), inserted comma before “(O)”, transferred and inserted such subpar. to appear before semicolon at end, struck out “and” before “(N)”, and inserted “, and” and subpar. (P) following subpar. (O) and before semicolon at end.
Subsec. (g). Pub. L. 103–66, § 13555(a), substituted “$900” for “$750” in two places.
Subsec. (h)(2)(A)(ii)(IV). Pub. L. 103–66, § 13551(a), added subcl. (IV).
Subsec. (h)(4)(B)(iv) to (vii). Pub. L. 103–66, § 13551(b), added cls. (iv) to (vii), and struck out former cl. (iv) which read as follows: “after
Subsec. (i)(3)(B)(ii). Pub. L. 103–66, § 13532(a)(1), in introductory provisions substituted “paragraph (4)” for “the last sentence of this clause” and struck out concluding provisions which read as follows: “In the case of a hospital that makes application to the Secretary and demonstrates that it specializes in eye services or eye and ear services (as determined by the Secretary), receives more than 30 percent of its total revenues from outpatient services and was an eye specialty hospital or an eye and ear specialty hospital on
Subsec. (i)(4). Pub. L. 103–66, § 13532(a)(2), added par. (4).
Subsec. (l)(4)(B)(i). Pub. L. 103–66, § 13516(b)(1), inserted “and before
Subsec. (l)(4)(B)(ii). Pub. L. 103–66, § 13516(b)(2), inserted “and” at end of subcl. (II), substituted a period for the comma at end of subcl. (III), and struck out subcls. (IV) to (VII) which read as follows:
“(IV) for services furnished in 1994, $11.25,
“(V) for services furnished in 1995, $11.50,
“(VI) for services furnished in 1996, $11.70, and
“(VII) for services furnished in calendar years after 1997, the previous year’s conversion factor increased by the update determined under section 1395w–4(d)(3) of this title for physician anesthesia services for that year.”
Subsec. (l)(4)(B)(iii). Pub. L. 103–66, § 13516(b)(3), added cl. (iii).
1990—Subsec. (a)(1)(H). Pub. L. 101–508, § 4118(f)(2)(D), struck out “, as the case may be” after “section 1395w–4 of this title”.
Subsec. (a)(1)(J). Pub. L. 101–508, § 4104(b)(1), struck out “or physician pathology services” after “1395m(b)(6) of this title)” and “or section 1395m(f) of this title, respectively” after “1395m(b) of this title”.
Subsec. (a)(1)(K). Pub. L. 101–508, § 4155(b)(2)(A), which directed amendment of subpar. (K) by striking “and” at the end, could not be executed because of prior amendment by Pub. L. 101–508, § 4153(a)(2)(B)(i), see below.
Pub. L. 101–508, § 4153(a)(2)(B)(i), struck out “and” after “by a physician),”.
Subsec. (a)(1)(L). Pub. L. 101–508, § 4153(a)(2)(B)(ii), substituted “subparagraph,” for “subparagraph and” at end.
Subsec. (a)(1)(M). Pub. L. 101–508, § 4155(b)(2)(B), added subpar. (M) relating to nurse practitioner and clinical nurse specialist services.
Pub. L. 101–508, § 4153(a)(2)(B)(ii), added subpar. (M) relating to prosthetic devices and orthotics.
Subsec. (a)(2). Pub. L. 101–508, § 4153(a)(2)(C)(i), substituted “(H), and (I)” for “and (H)” in introductory provisions.
Subsec. (a)(2)(E)(i). Pub. L. 101–508, § 4163(d)(1), inserted “, but excluding screening mammography” after “imaging services”.
Subsec. (a)(7). Pub. L. 101–508, § 4153(a)(2)(C)(ii)–(iv), added par. (7).
Subsec. (b). Pub. L. 101–508, § 4302, inserted “for calendar years before 1991 and $100 for 1991 and subsequent years” after “$75”.
Subsec. (b)(5). Pub. L. 101–508, § 4161(a)(3)(B), added par. (5) at end of first sentence.
Subsec. (h)(2)(A)(ii). Pub. L. 101–508, § 4154(a)(1), substituted “clause (i)” for “any other provision of this subsection” in introductory provisions.
Subsec. (h)(2)(A)(ii)(III). Pub. L. 101–508, § 4154(a)(2)–(4), added subcl. (III).
Subsec. (h)(4)(B). Pub. L. 101–508, § 4154(b)(1)(B), struck out “and” at end of cl. (ii), inserted “and before
Subsec. (h)(5)(A)(ii)(II). Pub. L. 101–508, § 4154(e)(1)(A), substituted “wholly owned by” for “a wholly-owned subsidiary of”.
Subsec. (h)(5)(A)(ii)(III). Pub. L. 101–508, § 4154(e)(1)(C), substituted “receives requests for testing during the year in which the test is performed” for “submits bills or requests for payment in any year”.
Pub. L. 101–508, § 4154(e)(1)(B), which directed substitution of “laboratory (but not including a laboratory described in subclause (II)),” for “laboratory”, was executed by making the substitution for “laboratory” the second time appearing to reflect the probable intent of Congress.
Subsec. (h)(5)(A)(iii). Pub. L. 101–508, § 4008(m)(2)(C), which directed technical correction to Pub. L. 101–239, § 6003(g)(3)(C)(vii)(I), was executed by making technical correction to Pub. L. 101–239, § 6003(g)(3)(D)(vii)(I), resulting in no change in text. See 1989 Amendment note below.
Subsec. (h)(5)(C). Pub. L. 101–508, § 4154(c)(1)(A), substituted “test, including a test performed in a physician’s office but excluding a test performed by a rural health clinic” for “test performed by a laboratory other than a rural health clinic”.
Subsec. (h)(5)(D). Pub. L. 101–508, § 4154(c)(1)(B), substituted “test, including a test performed in a physician’s office but excluding a test performed by a rural health clinic,” for “test performed by a laboratory, other than a rural health clinic”.
Subsec. (i)(3)(B)(ii). Pub. L. 101–508, § 4151(c)(1)(B), substituted “on or after
Subsec. (i)(3)(B)(ii)(I). Pub. L. 101–508, § 4151(c)(1)(A)(i), substituted “50 percent for reporting periods beginning on or after
Subsec. (i)(3)(B)(ii)(II). Pub. L. 101–508, § 4151(c)(1)(A)(ii), substituted “50 percent for reporting periods beginning on or after
Subsec. (l)(1). Pub. L. 101–508, § 4160(1), designated existing provisions as subpar. (A) and added subpars. (B) and (C).
Subsec. (l)(2). Pub. L. 101–508, § 4160(2), struck out at end “The fee schedule shall be adjusted annually (to become effective on January 1 of each calendar year) by the percentage increase in the MEI (as defined in section 1395u(i)(3) of this title) for that year.”
Subsec. (l)(4). Pub. L. 101–508, § 4160(3), added par. (4) and struck out former par. (4) which read as follows: “In establishing the fee schedule under paragraph (1), the Secretary may utilize a system of time units, a system of base and time units, or any appropriate methodology. The Secretary may establish a nationwide fee schedule or adjust the fee schedule for geographic areas (as the Secretary may determine to be appropriate).”
Subsec. (m). Pub. L. 101–597 substituted “health professional shortage area” for “health manpower shortage area”.
Subsec. (n)(1)(B)(ii)(I). Pub. L. 101–508, § 4151(c)(2), inserted before period at end “, and such term means 42 percent in the case of outpatient radiology services for portions of cost reporting periods beginning on or after
Subsec. (r). Pub. L. 101–508, § 4206(b)(2), added subsec. (r) relating to other prepaid organizations.
Pub. L. 101–508, § 4155(b)(3), added subsec. (r) relating to cap on prevailing charge and billing on assignment-related basis.
1989—Subsec. (a). Pub. L. 101–234, § 202(a), repealed Pub. L. 100–360, § 212(c)(2), and provided that the provisions of law amended or repealed by such section are restored or revised as if such section had not been enacted, see 1988 Amendment note below.
Pub. L. 101–234, § 201(a), repealed Pub. L. 100–360, § 205(c)(3), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (a)(1)(F). Pub. L. 101–239, § 6113(b)(3)(A), added subpar. (F).
Subsec. (a)(1)(H). Pub. L. 101–239, § 6102(e)(5), inserted “(or, for services furnished on or after
Subsec. (a)(1)(J). Pub. L. 101–239, § 6102(f)(2), inserted “or physician pathology services” after “1395m(b)(6) of this title)” and “or section 1395m(f) of this title, respectively” after “1395m(b) of this title”.
Pub. L. 101–239, § 6102(e)(6)(A), inserted “subject to section 1395w–4 of this title,” before “the amounts”.
Subsec. (a)(1)(K). Pub. L. 101–239, § 6102(e)(7), inserted “, or, for services furnished on or after
Subsec. (a)(1)(M). Pub. L. 101–234, § 201(a), repealed Pub. L. 100–360, § 201(b)(1), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (a)(1)(N). Pub. L. 101–239, § 6102(e)(1)(B), added subpar. (N).
Subsec. (a)(2). Pub. L. 101–239, § 6116(b)(1)(A), substituted “(G), and (H)” for “and (G)” in introductory provisions.
Pub. L. 101–234, § 201(a), repealed Pub. L. 100–360, §§ 202(b)(2), 203(c)(1)(A)–(D), 204(d)(1), and 205(c)(1), and provided that the provisions of law amended or repealed by such sections are restored or revived as if such sections had not been enacted, see 1988 Amendment notes below.
Subsec. (a)(3). Pub. L. 101–234, § 201(a), repealed Pub. L. 100–360, § 205(c)(2), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (a)(6). Pub. L. 101–239, § 6116(b)(1)(B)–(D), added par. (6).
Subsec. (b). Pub. L. 101–234, § 201(a), repealed Pub. L. 100–360, §§ 202(b)(3), 203(c)(1)(E), and provided that the provisions of law amended or repealed by such sections are restored or revived as if such sections had not been enacted, see 1988 Amendment notes below.
Subsec. (c). Pub. L. 101–234, § 201(a), repealed Pub. L. 100–360, § 201(a)(1), (4), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment notes below.
Subsec. (d). Pub. L. 101–234, § 201(a), repealed Pub. L. 100–360, § 201(a)(1)(D), (2), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment notes below.
Subsec. (d)(1). Pub. L. 101–239, § 6113(d), substituted “62½ percent of such expenses.” for “whichever of the following amounts is the smaller:
“(A) $1375.00, or
“(B) 62½ percent of such expenses.”
Subsec. (g). Pub. L. 101–239, § 6133(a), substituted “$750” for “$500” in two places.
Pub. L. 101–234, § 201(a), repealed Pub. L. 100–360, § 201(a)(3), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (h)(1)(B), (C). Pub. L. 101–239, § 6111(a)(1), substituted “on or after
Subsec. (h)(1)(D). Pub. L. 101–239, § 6003(e)(2)(A), substituted “section 1395ww(d)(5)(D)(iii) of this title” for “the last sentence of section 1395ww(d)(5)(C)(ii) of this title”.
Subsec. (h)(4)(B)(ii). Pub. L. 101–239, § 6111(a)(3)(A), (B), substituted “after
Subsec. (h)(4)(B)(iii). Pub. L. 101–239, § 6111(a)(2), (3)(C), (4), added cl. (iii).
Subsec. (h)(5)(A)(ii). Pub. L. 101–239, § 6111(b)(1), substituted “referring laboratory but only if—” for “referring laboratory, and” in introductory provisions, and added subcls. (I) through (III).
Subsec. (h)(5)(A)(iii). Pub. L. 101–239, § 6003(g)(3)(D)(vii)(I), as amended by Pub. L. 101–508, § 4008(m)(2)(C), substituted “hospital or rural primary care hospital,” for “hospital,”.
Subsec. (i)(1)(A). Pub. L. 101–239, § 6003(g)(3)(D)(vii)(II), inserted “, rural primary care hospital,” after “section 1395k(a)(2)(F)(i) of this title)”.
Subsec. (i)(3)(A). Pub. L. 101–239, § 6003(g)(3)(D)(vii)(III), inserted “or rural primary care hospital services” after “facility services” in introductory provisions.
Subsec. (l)(5)(A). Pub. L. 101–239, § 6003(g)(3)(D)(vii)(IV), inserted “rural primary care hospital,” after “hospital,” in two places.
Subsec. (l)(5)(C). Pub. L. 101–239, § 6003(g)(3)(D)(vii)(V), substituted “hospital or rural primary care hospital” for “hospital” in two places.
Subsec. (m). Pub. L. 101–239, § 6102(c)(1), struck out “class 1 or class 2” before “health manpower shortage area” and substituted “10 percent” for “5 percent”.
Subsec. (o)(1). Pub. L. 101–239, § 6131(a)(1)(C), inserted “(or inserts)” after “shoes” in two places in last sentence.
Subsec. (o)(1)(A). Pub. L. 101–239, § 6131(a)(1)(A), amended subpar. (A) generally. Prior to amendment, subpar. (A) read as follows: “no payment may be made under this part for the furnishing of more than one pair of shoes for any individual for any calendar year, and”.
Subsec. (o)(1)(B), (2)(A). Pub. L. 101–239, § 6131(a)(1)(B), substituted “limits” for “limit”.
Subsec. (o)(2)(A)(i). Pub. L. 101–239, § 6131(a)(1)(D), amended cl. (i) generally. Prior to amendment, cl. (i) read as follows: “for the furnishing of one pair of custom molded shoes is $300”.
Subsec. (o)(2)(A)(ii)(II). Pub. L. 101–239, § 6131(a)(1)(E), inserted “any pairs of” after “$50 for”.
Subsec. (o)(2)(D). Pub. L. 101–239, § 6131(b), added subpar. (D).
Subsec. (p). Pub. L. 101–239, § 6113(b)(3)(B), substituted “1395x(s)(2)(L) of this title,” for “1395x(s)(2)(L) of this title and” and inserted “and in the case of clinical social worker services for which payment may be made under this part only pursuant to section 1395x(s)(2)(N) of this title,” after “section 1395x(s)(2)(M) of this title,”.
Subsec. (q). Pub. L. 101–239, § 6204(b), added subsec. (q).
1988—Subsec. (a). Pub. L. 100–360, § 212(c)(2), inserted “or, as provided in section 1395t–1(c) of this title, from the Federal Catastrophic Drug Insurance Trust Fund” after “Fund” in introductory provisions.
Pub. L. 100–360, § 205(c)(3), inserted provision at end relating to payment for in-home care for chronically dependent individuals.
Subsec. (a)(1)(D)(i). Pub. L. 100–360, § 411(i)(4)(C)(i), amended Pub. L. 100–203, § 4085(i)(1)(A), see 1987 Amendment note below.
Subsec. (a)(1)(F). Pub. L. 100–360, § 411(f)(12)(A), (14), added and renumbered Pub. L. 100–203, § 4055(a)(1), see 1987 Amendment note below.
Pub. L. 100–360, § 411(i)(4)(C)(iv), made technical amendment to directory language of Pub. L. 100–203, § 4085(i)(21)(D)(i), see 1987 Amendment note below.
Pub. L. 100–360, § 411(i)(4)(C)(ii), repealed Pub. L. 100–203, § 4085(i)(1)(B), see 1987 Amendment note below.
Pub. L. 100–360, § 411(h)(4)(B)(i), (ii), redesignated and amended directory language of Pub. L. 100–203, § 4073(b)(1)(A), see 1987 Amendment note below.
Subsec. (a)(1)(G). Pub. L. 100–360, § 411(h)(7)(C)(ii), repealed Pub. L. 100–203, § 4077(b)(3)(A), see 1987 Amendment note below.
Pub. L. 100–360, § 411(h)(4)(B)(iii), repealed Pub. L. 100–203, § 4073(b)(2)(B), see 1987 Amendment note below.
Subsec. (a)(1)(H). Pub. L. 100–360, § 411(h)(7)(C)(ii), repealed Pub. L. 100–203, § 4077(b)(3)(B), see 1987 Amendment note below.
Pub. L. 100–360, § 411(g)(1)(E), which directed the amendment of subpar. (H) by striking “and” before “(I)” could not be executed because of the prior amendment by section 4049(a)(1) of Pub. L. 100–203, see 1987 Amendment note below.
Pub. L. 100–360, § 411(i)(3), added Pub. L. 100–203, § 4084(c)(2), see 1987 Amendment note below.
Subsec. (a)(1)(J). Pub. L. 100–360, § 411(f)(8)(B)(i), made technical amendment to directory language of Pub. L. 100–203, § 4049(a)(1), see 1987 Amendment note below.
Pub. L. 100–360, § 411(f)(8)(C), substituted “section 1395m(b)(6) of this title” for “section 1395m(b)(5) of this title”.
Subsec. (a)(1)(K). Pub. L. 100–360, § 411(h)(7)(C)(iii), (F), redesignated and amended Pub. L. 100–203, § 4077(b)(2)(A), see 1987 Amendment note below.
Pub. L. 100–360, § 411(h)(4)(B)(i), (iv), (v), redesignated and amended Pub. L. 100–203, § 4073(b)(1)(B), see 1987 Amendment note below.
Subsec. (a)(1)(L). Pub. L. 100–360, § 411(h)(7)(C)(i), (iv), (v), (F), redesignated and amended Pub. L. 100–203, § 4077(b)(2)(B), see 1987 Amendment note below.
Subsec. (a)(1)(M). Pub. L. 100–360, § 202(b)(1), added subpar. (M) relating to expenses incurred for covered outpatient drugs.
Subsec. (a)(2). Pub. L. 100–360, § 205(c)(1), inserted “(A)(ii),” after “subparagraphs” in introductory provisions.
Pub. L. 100–360, § 202(b)(2), inserted “(other than covered outpatient drugs)” after “in the case of services” in introductory provisions.
Subsec. (a)(2)(B). Pub. L. 100–360, § 203(c)(1)(A), substituted “(E), or (F)” for “or (E)” in introductory provisions.
Subsec. (a)(2)(D)(i). Pub. L. 100–360, § 411(i)(4)(C)(i), amended Pub. L. 100–203, § 4085(i)(1)(A), see 1987 Amendment note below.
Subsec. (a)(2)(E)(i). Pub. L. 100–360, § 204(d)(1), inserted “, but excluding screening mammography” after “imaging services”.
Subsec. (a)(2)(F). Pub. L. 100–360, § 203(c)(1)(B)–(D), added subpar. (F) relating to home intravenous drug therapy services.
Subsec. (a)(3). Pub. L. 100–360, § 205(c)(2), substituted “subparagraphs (A)(ii), (D),” for “subparagraphs (D)”.
Subsec. (b). Pub. L. 100–360, § 104(d)(7), as added by Pub. L. 100–485, § 608(d)(3)(G), inserted at end “The deductible under the previous sentence for blood or blood cells furnished an individual in a year shall be reduced to the extent that a deductible has been imposed under section 1395e(a)(2) of this title to blood or blood cells furnished the individual in the year.”
Subsec. (b)(1). Pub. L. 100–360, § 202(b)(3)(A), inserted “or for covered outpatient drugs” after “section 1395x(s)(10)(A) of this title”.
Subsec. (b)(2). Pub. L. 100–360, § 203(c)(1)(E), substituted “services and home intravenous drug therapy services” for “services”.
Pub. L. 100–360, § 202(b)(3)(B), inserted “or with respect to covered outpatient drugs” after “home health services”.
Subsec. (b)(3) to (5). Pub. L. 100–360, § 411(f)(12)(A), (14), added and renumbered Pub. L. 100–203, § 4055(a)(2), see 1987 Amendment note below.
Subsec. (c). Pub. L. 100–360, § 201(a)(4), added subsec. (c) relating to limitation on out-of-pocket catastrophic cost-sharing, adjustment, buy-out plans, and conditions for payments with respect to plans other than buy-out plans. Former subsec. (c) redesignated (d)(1).
Pub. L. 100–360, § 411(h)(1)(A), substituted “monitoring or changing drug prescriptions” for “prescribing or monitoring prescription drugs” in last sentence.
Pub. L. 100–360, § 201(a)(1)(A), as amended by Pub. L. 100–485, § 608(d)(4), substituted “subsections (a) through (c)” for “subsections (a) and (b)” in introductory provisions.
Pub. L. 100–360, § 201(a)(1)(B), (C), redesignated former pars. (1) and (2) as subpars. (A) and (B) and substituted “this paragraph” for “this subsection” in last sentence.
Subsec. (d)(1). Pub. L. 100–360, § 201(a)(1)(D), redesignated former subsec. (c) as subsec. (d)(1). Former subsec. (d) redesignated subsec. (d)(2).
Subsec. (d)(2). Pub. L. 100–360, § 201(a)(2), redesignated former subsec. (d) as subsec. (d)(2).
Subsec. (f). Pub. L. 100–360, § 411(g)(5), substituted “MEI (as defined in section 1395u(i)(3) of this title) applicable to primary care services (as defined in section 1395u(i)(4) of this title)” for “medicare economic index (referred to in the fourth sentence of section 1395u(b)(3) of this title) applicable to physicians’ services”.
Subsec. (g). Pub. L. 100–360, § 201(a)(3), substituted “subsections (a) through (c) of this section” for “subsections (a) and (b) of this section” in two places.
Subsec. (h)(1)(D). Pub. L. 100–360, § 411(g)(3)(E), (F), amended and redesignated Pub. L. 100–203, § 4064(c)(1), see 1987 Amendment note below.
Subsec. (h)(2)(A)(i). Pub. L. 100–360, § 411(g)(3)(A), added Pub. L. 100–203, § 4064(a)(1), see 1987 Amendment note below.
Subsec. (h)(2)(A)(ii). Pub. L. 100–360, § 411(g)(3)(A), added Pub. L. 100–203, § 4064(a)(3), see 1987 Amendment note below.
Subsec. (h)(2)(A)(iii). Pub. L. 100–360, § 411(g)(3)(B), (C), amended Pub. L. 100–203, § 4064(b)(1), see 1987 Amendment note below.
Subsec. (h)(2)(B). Pub. L. 100–360, § 411(g)(3)(A), added Pub. L. 100–203, § 4064(a)(2), see 1987 Amendment note below.
Subsec. (h)(3). Pub. L. 100–647, § 8421(a), inserted at end “In establishing a fee to cover the transportation and personnel expenses for trained personnel to travel to the location of an individual to collect a sample, the Secretary shall provide a method for computing the fee based on the number of miles traveled and the personnel costs associated with the collection of each individual sample, but the Secretary shall only be required to apply such method in the case of tests furnished during the period beginning on
Subsec. (h)(4)(B)(ii). Pub. L. 100–360, § 411(g)(3)(D), inserted “after” before “
Subsec. (h)(5)(A). Pub. L. 100–360, § 411(i)(4)(C)(vi), added Pub. L. 100–203, § 4085(i)(22)(B), see 1987 Amendment note below.
Subsec. (h)(5)(C). Pub. L. 100–360, § 411(i)(4)(C)(vi), added Pub. L. 100–203, § 4085(i)(22)(B), see 1987 Amendment note below.
Subsec. (h)(5)(D). Pub. L. 100–360, § 411(i)(4)(B), substituted “A person may not bill for a clinical diagnostic laboratory test performed by a laboratory, other than a rural health clinic, other than on an assignment-related basis. If a person knowingly and willfully and on a repeated basis bills for a clinical diagnostic laboratory test in violation of the previous sentence” for “If a person knowingly and willfully and on a repeated basis bills an individual enrolled under this part for charges for a clinical diagnostic laboratory test for which payment may only be made on an assignment-related basis under subparagraph (C)” and “paragraphs (2) and (3) of section 1395u(j) of this title in the same manner such paragraphs apply with respect to a physician” for “section 1395u(j)(2) of this title”.
Subsec. (i)(2)(A)(iii). Pub. L. 100–360, § 411(g)(2)(D), substituted “insertion” for “implantation” and inserted “or subsequent to” after “during”.
Subsec. (i)(4). Pub. L. 100–360, § 411(f)(12)(A), (14), added and renumbered Pub. L. 100–203, § 4055(a)(3), see 1987 Amendment note below.
Subsec. (i)(6). Pub. L. 100–485, § 608(d)(22)(B), substituted “Any person, including” for “Any person, other than”.
Pub. L. 100–360, § 411(g)(2)(E), added Pub. L. 100–203, § 4063(e)(1), see 1987 Amendment note below.
Subsec. (l)(2). Pub. L. 100–360, § 411(f)(2)(D), added Pub. L. 100–203, § 4042(b)(2)(B), see 1987 Amendment note below.
Subsec. (l)(3)(B). Pub. L. 100–647, § 8422(a), inserted “plus applicable coinsurance” after “would have been paid”.
Subsec. (l)(5)(B)(ii). Pub. L. 100–360, § 411(i)(4)(C)(vi), added Pub. L. 100–203, § 4085(i)(23), see 1987 Amendment note below.
Subsec. (n)(1)(A). Pub. L. 100–360, § 411(g)(4)(C)(i), as amended by Pub. L. 100–485, § 608(d)(22)(D), substituted “for services described in subsection (a)(2)(E)(i) of this section furnished under this part on or after
Subsec. (n)(1)(B)(i)(II). Pub. L. 100–360, § 411(g)(4)(C)(ii), inserted “or (for services described in subsection (a)(2)(E)(i) of this section furnished on or after
Subsec. (n)(1)(B)(ii). Pub. L. 100–360, § 411(g)(4)(C)(iii), amended subcls. (I) and (II) generally. Prior to amendment, subcls. (I) and (II) read as follows:
“(I) The term ‘cost proportion’ means 65 percent for all or any part of cost reporting periods which occur in fiscal year 1989 and 50 percent for other cost reporting periods.
“(II) The term ‘charge proportion’ means 35 percent for all or any parts of cost reporting periods which occur in fiscal year 1989 and 50 percent for other cost reporting periods.”
Subsec. (o). Pub. L. 100–360, § 411(h)(3)(B), as amended by Pub. L. 100–485, § 608(d)(23)(A), amended Pub. L. 100–203, § 4072(b), see 1987 Amendment note below.
Subsec. (p). Pub. L. 100–360, § 411(h)(7)(D), (F), redesignated and amended Pub. L. 100–203, § 4077(b)(3), see 1987 Amendment note below.
Pub. L. 100–360, § 411(h)(4)(C), redesignated and amended Pub. L. 100–203, § 4073(b)(2), see 1987 Amendment note below.
1987—Subsec. (a)(1)(D)(i). Pub. L. 100–203, § 4085(i)(1)(A), as amended by Pub. L. 100–360, § 411(i)(4)(C)(i), substituted “on an assignment-related basis,” for “on the basis of an assignment described in section 1395u(b)(3)(B)(ii) of this title, under the procedure described in section 1395gg(f)(1) of this title,”.
Subsec. (a)(1)(F). Pub. L. 100–203, § 4055(a)(1), formerly § 4054(a)(1), as added and renumbered by Pub. L. 100–360, § 411(f)(12)(A), (14), struck out subpar. (F) which read as follows: “with respect to expenses incurred for services described in subsection (i)(4) of this section under the conditions specified in such subsection, the amounts paid shall be the reasonable charge for such services,”.
Pub. L. 100–203, § 4085(i)(21)(D)(i), as amended by Pub. L. 100–360, § 411(i)(4)(C)(iv), amended Pub. L. 99–509, § 9343(e)(2)(A), see 1986 Amendment note below.
Pub. L. 100–203, § 4085(i)(1)(B), which directed striking out “and” at end, was repealed by Pub. L. 100–360, § 411(i)(4)(C)(ii).
Pub. L. 100–203, § 4073(b)(1)(A), formerly § 4073(b)(2)(A), as redesignated and amended by Pub. L. 100–360, § 411(h)(4)(B)(i), (ii), struck out “and” at end.
Subsec. (a)(1)(G). Pub. L. 100–203, § 4077(b)(3)(A), which directed striking out “and” at end, was repealed by Pub. L. 100–360, § 411(h)(7)(C)(ii).
Pub. L. 100–203, § 4073(b)(2)(B), which directed substituting “services,” for “services; and”, was repealed by Pub. L. 100–360, § 411(h)(4)(B)(iii).
Pub. L. 100–203, § 4062(d)(3)(A)(i), substituted “services,” for “services; and”.
Subsec. (a)(1)(H). Pub. L. 100–203, § 4077(b)(3)(B), which directed substituting “services,” for “services; and”, was repealed by Pub. L. 100–360, § 411(h)(7)(C)(ii).
Pub. L. 100–203, § 4084(c)(2), as added by Pub. L. 100–360, § 411(i)(3), substituted “least of the actual charge, the prevailing charge that would be recognized if the services had been performed by an anesthesiologist,” for “lesser of the actual charge”.
Pub. L. 100–203, § 4062(d)(3)(A)(ii), inserted “and” before the subpar. (I) added by section 4062(d)(3)(A)(ii) of Pub. L. 100–203, see below.
Pub. L. 100–203, § 4049(a)(1), struck out “and” before the subpar. (I) added by section 4062(d)(3)(A)(ii) of Pub. L. 100–203, see below.
Subsec. (a)(1)(I). Pub. L. 100–203, § 4062(d)(3)(A)(ii), added subpar. (I).
Subsec. (a)(1)(J). Pub. L. 100–203, § 4049(a)(1), as amended by Pub. L. 100–360, § 411(f)(8)(B)(i), added subpar. (J).
Subsec. (a)(1)(K). Pub. L. 100–203, § 4077(b)(2)(A), formerly § 4077(b)(3)(C), as redesignated and amended by Pub. L. 100–360, § 411(h)(7)(C)(iii), (F), inserted “and” after “performed by a physician),”.
Pub. L. 100–203, § 4073(b)(1)(B), formerly § 4073(b)(2)(C), as redesignated and amended by Pub. L. 100–360, § 411(h)(4)(B)(i), (iv), (v), added subpar. (K), formerly (I), relating to amounts paid with respect to certified nurse-midwife services under section 1395x(s)(2)(L) of this title.
Subsec. (a)(1)(L). Pub. L. 100–203, § 4077(b)(2)(B), formerly § 4077(b)(3)(D), as redesignated and amended by Pub. L. 100–360, § 411(h)(7)(C)(i), (iv), (v), (F), added subpar. (L), formerly (J), relating to amounts paid with respect to qualified psychologist services under section 1395x(s)(2)(M) of this title.
Subsec. (a)(2). Pub. L. 100–203, § 4062(d)(3)(B)(i), inserted reference to subpar. (G).
Subsec. (a)(2)(A). Pub. L. 100–203, § 4062(d)(3)(B)(ii), struck out “(other than durable medical equipment)” after “home health services”.
Subsec. (a)(2)(B). Pub. L. 100–203, § 4066(b), inserted reference to subpar. (E).
Subsec. (a)(2)(D)(i). Pub. L. 100–203, § 4085(i)(1)(A), as amended by Pub. L. 100–360, § 411(i)(4)(C)(i), substituted “on an assignment-related basis,” for “on the basis of an assignment described in section 1395u(b)(3)(B)(ii) of this title, under the procedure described in section 1395gg(f)(1) of this title,”.
Subsec. (a)(2)(E). Pub. L. 100–203, § 4066(a)(1), added subpar. (E).
Subsec. (a)(5). Pub. L. 100–203, § 4062(d)(3)(C)–(E), added par. (5).
Subsec. (b)(3). Pub. L. 100–203, § 4055(a)(2), formerly § 4054(a)(2), as added and renumbered by Pub. L. 100–360, § 411(f)(12)(A), (14), redesignated par. (4) as (3) and struck out former par. (3) which read as follows: “such total amount shall not include expenses incurred for services the amount of payment for which is determined under subsection (a)(1)(F) of this section,”.
Pub. L. 100–203, § 4085(i)(21)(D)(i), amended Pub. L. 99–509, § 9343(e)(2)(A), see 1986 Amendment note below.
Subsec. (b)(4). Pub. L. 100–203, § 4055(a)(2), formerly § 4054(a)(2), as added and renumbered by Pub. L. 100–360, § 411(f)(12)(A), (14), redesignated par. (5) as (4). Former par. (4) redesignated (3).
Subsec. (b)(4)(A). Pub. L. 100–203, § 4085(i)(1)(C), substituted “on an assignment-related basis” for “on the basis of an assignment described in section 1395u(b)(3)(B)(ii) of this title, under the procedure described in section 1395gg(f)(1) of this title”.
Subsec. (b)(5). Pub. L. 100–203, § 4055(a)(2), formerly § 4054(a)(2), as added and renumbered by Pub. L. 100–360, § 411(f)(12)(A), (14), redesignated par. (5) as (4).
Subsec. (c). Pub. L. 100–203, § 4070(b)(4), inserted “or partial hospitalization services that are not directly provided by a physician” before period at end of last sentence.
Pub. L. 100–203, § 4070(a)(2), inserted sentence at end defining “treatment”.
Subsec. (c)(1). Pub. L. 100–203, § 4070(a)(1), substituted “$1375.00” for “$312.50”.
Subsec. (f). Pub. L. 100–203, § 4067(a), added subsec. (f).
Subsec. (h)(1)(C). Pub. L. 100–203, § 4085(i)(2), inserted before period at end “, and ending on
Subsec. (h)(1)(D). Pub. L. 100–203, § 4064(c)(1), formerly § 4064(c), as amended and redesignated by Pub. L. 100–360, § 411(g)(3)(E), (F), inserted “, in a sole community hospital (as defined in the last sentence of section 1395ww(d)(5)(C)(ii) of this title),”.
Subsec. (h)(2). Pub. L. 100–203, § 4064(c), which had directed that “laboratory in a sole community hospital” be substituted for “hospital laboratory” in subsec. (h)(2), was redesignated § 4064(c)(1) by section 411(g)(3)(F) of Pub. L. 100–360 and amended by section 411(g)(3)(E) of Pub. L. 100–360 to provide for amendment of subsec. (h)(1)(D) instead of subsec. (h)(2).
Subsec. (h)(2)(A)(i). Pub. L. 100–203, § 4064(a)(1), as added by Pub. L. 100–360, § 411(g)(3)(A), inserted “(A)(i)” after “(2)”.
Subsec. (h)(2)(A)(ii). Pub. L. 100–203, § 4064(a)(3), as added by Pub. L. 100–360, § 411(g)(3)(A), added cl. (ii).
Subsec. (h)(2)(A)(iii). Pub. L. 100–203, § 4064(b)(1), as amended by Pub. L. 100–360, § 411(g)(3)(B), (C), set out as cl. (iii) provisions formerly set out in an otherwise undesignated sentence in par. (2) relating to the rebasing of fee schedules for certain automated and similar tests for 1988 and for the continuation of such reduced fee schedules as the base for 1989 and subsequent years.
Subsec. (h)(2)(B). Pub. L. 100–203, § 4064(a)(2), as added by Pub. L. 100–360, § 411(g)(3)(A), inserted subpar. (B) designation preceding second sentence and redesignated former subpars. (A) and (B) of par. (2) as cls. (i) and (ii).
Subsec. (h)(4)(B)(i). Pub. L. 100–203, § 4064(b)(2)(A), substituted “April” for “January”.
Subsec. (h)(4)(B)(ii). Pub. L. 100–203, § 4064(b)(2)(B), amended cl. (ii) generally. Prior to amendment, cl. (ii) read as follows: “after
Subsec. (h)(5)(A). Pub. L. 100–203, § 4085(i)(22)(B), as added by Pub. L. 100–360, § 411(i)(4)(C)(vi), substituted “on an assignment-related basis” for “on the basis of an assignment described in section 1395u(b)(3)(B)(ii) of this title, under the procedure described in section 1395gg(f)(1) of this title,” in introductory provisions.
Subsec. (h)(5)(A)(iii). Pub. L. 100–203, § 4085(i)(3), added cl. (iii).
Subsec. (h)(5)(C). Pub. L. 100–203, § 4085(i)(22)(B), as added by Pub. L. 100–360, § 411(i)(4)(C)(vi), substituted “on an assignment-related basis” for “on the basis of an assignment described in section 1395u(b)(3)(B)(ii) of this title, in accordance with section 1395u(b)(6)(B) of this title, under the procedure described in section 1395gg(f)(1) of this title,”.
Subsec. (h)(5)(D). Pub. L. 100–203, § 4085(b)(1), added subpar. (D).
Subsec. (i)(2)(A)(iii). Pub. L. 100–203, § 4063(b), added cl. (iii).
Subsec. (i)(3)(B)(ii). Pub. L. 100–203, § 4068(a)(1), substituted “Subject to the last sentence of this clause, in” for “In”.
Pub. L. 100–203, § 4068(a)(2), inserted sentence at end relating to cost and ASC proportions in the case of an eye or eye and ear specialty hospital.
Subsec. (i)(4). Pub. L. 100–203, § 4055(a)(3), formerly § 4054(a)(3), as added and renumbered by Pub. L. 100–360, § 411(f)(12)(A), (14), struck out par. (4) which read as follows: “In the case of services (including all pre- and post-operative services) described in paragraphs (1) and (2)(A) of section 1395x(s) of this title and furnished in connection with surgical procedures (specified pursuant to paragraph (1) of this subsection) in a physician’s office, an ambulatory surgical center described in such paragraph, or a hospital outpatient department, payment for such services shall be determined in accordance with subsection (a)(1)(F) of this section if the physician accepts an assignment described in section 1395u(b)(3)(B)(ii) of this title with respect to payment for such services.”
Subsec. (i)(6). Pub. L. 100–203, § 4063(e)(1), as added by Pub. L. 100–360, § 411(g)(2)(E), added par. (6).
Subsec. (l)(2). Pub. L. 100–203, § 4084(a)(1), substituted “1985 and such other data as the Secretary determines necessary” for “1985”.
Pub. L. 100–203, § 4042(b)(2)(B), as added by Pub. L. 100–360, § 411(f)(2)(D), substituted “1395u(i)(3)” for “1395u(b)(4)(E)(ii)”.
Subsec. (l)(5)(A). Pub. L. 100–203, § 4084(a)(2), substituted “group practice, or ambulatory surgical center” for “or group practice” in two places.
Subsec. (l)(5)(B)(ii). Pub. L. 100–203, § 4085(i)(23), as added by Pub. L. 100–360, § 411(i)(4)(C)(vi), substituted “money penalty” for “monetary penalty” and amended second sentence generally. Prior to amendment, second sentence read as follows: “Such a penalty shall be imposed in the same manner as civil monetary penalties are imposed under section 1320a–7a of this title with respect to actions described in subsection (a) of that section.”
Subsec. (l)(6). Pub. L. 100–203, § 4045(c)(2)(A)(i), (ii), struck out subpar. (A) designation and substituted “after the effective date of the reduction, the physician’s actual charge is subject to a limit under section 1395u(j)(1)(D) of this title.” for “(subject to subparagraph (D)), the physician may not charge the individual more than the limiting charge (as defined in subparagraph (B)) plus (for services furnished during the 12-month period beginning on the effective date of the reduction) ½ of the amount by which the physician’s actual charges for the service for the previous 12-month period exceeds the limiting charge.”
Pub. L. 100–203, § 4045(c)(2)(A)(iii), struck out subpars. (B) to (D) which read as follows:
“(B) In subparagraph (A), the term ‘limiting charge’ means, with respect to a service, 125 percent of the prevailing charge for the service after the reduction referred to in subparagraph (A).
“(C) If a physician knowingly and willfully imposes charges in violation of subparagraph (A), the Secretary may apply sanctions against such physician in accordance with subsection (j)(2) of this section.
“(D) This paragraph shall not apply to services furnished after the earlier of (i)
Subsec. (m). Pub. L. 100–203, § 4043(a), added subsec. (m).
Subsec. (n). Pub. L. 100–203, § 4066(a)(2), added subsec. (n).
Subsec. (o). Pub. L. 100–203, § 4072(b), as amended by Pub. L. 100–360, § 411(h)(3)(B), as amended by Pub. L. 100–485, § 608(d)(23)(A), added subsec. (o) [originally added as subsec. (f)].
Subsec. (p). Pub. L. 100–203, § 4077(b)(3), formerly § 4077(b)(4), as redesignated and amended by Pub. L. 100–360, § 411(h)(7)(D), (F), inserted “and in the case of qualified psychologists services for which payment may be made under this part only pursuant to section 1395x(s)(2)(M) of this title”.
Pub. L. 100–203, § 4073(b)(2), formerly § 4073(b)(3), as redesignated and amended by Pub. L. 100–360, § 411(h)(4)(C), added subsec. (p) [originally added as subsec. (m)] and inserted provision relating to monetary penalty for whoever knowingly and willfully presents, or causes to be presented, to an enrolled individual a bill or request for payment for described services.
1986—Subsec. (a)(1)(D). Pub. L. 99–272, § 9401(b)(2)(B), substituted “, under the procedure described in section 1395gg(f)(1) of this title, or for tests furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion)” for “or under the procedure described in section 1395gg(f)(1) of this title”.
Subsec. (a)(1)(D)(i). Pub. L. 99–272, § 9303(b)(1), inserted “, the limitation amount for that test determined under subsection (h)(4)(B) of this section,” after “lesser of the amount determined under such fee schedule”.
Subsec. (a)(1)(F). Pub. L. 99–509, § 9343(e)(2)(A), as amended by Pub. L. 100–203, § 4085(i)(21)(D)(i), substituted “(i)(4)” for “(i)(3)”.
Subsec. (a)(1)(G). Pub. L. 99–272, § 9401(b)(2)(A), added subpar. (G).
Subsec. (a)(1)(H). Pub. L. 99–509, § 9320(e)(1), added subpar. (H).
Subsec. (a)(2)(A). Pub. L. 99–272, § 9401(b)(2)(C), inserted “, to items and services (other than clinical diagnostic laboratory tests) furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion),” after “(other than durable medical equipment)”.
Subsec. (a)(2)(D). Pub. L. 99–272, § 9401(b)(2)(D), substituted “to a provider having an agreement under section 1395cc of this title, or for tests furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title (or a third opinion, if the second opinion was in disagreement with the first opinion)” for “or to a provider having an agreement under section 1395cc of this title”.
Subsec. (a)(2)(D)(i). Pub. L. 99–272, § 9303(b)(1), inserted “, the limitation amount for that test determined under subsection (h)(4)(B) of this section,” after “lesser of the amount determined under such fee schedule”.
Subsec. (a)(3). Pub. L. 99–272, § 9401(b)(2)(E), inserted “and for items and services furnished in connection with obtaining a second opinion required under section 1320c–13(c)(2) of this title, or a third opinion, if the second opinion was in disagreement with the first opinion” after “1395x(s)(10)(A) of this title”.
Subsec. (a)(4). Pub. L. 99–509, § 9343(a)(1)(A), amended par. (4) generally. Prior to amendment, par. (4) read as follows: “in the case of facility services described in subparagraph (F) of section 1395k(a)(2) of this title, the applicable amount described in paragraph (2) of subsection (i) of this section.”
Subsec. (b)(3). Pub. L. 99–509, § 9343(e)(2)(A), as amended by Pub. L. 100–203, § 4085(i)(21)(D)(i), which directed that par. (3) be amended by striking “or under subsection (i)(2) or (i)(4) of this section”, was executed by striking “or under subsection (i)(2) or (i)(5) of this section”, to reflect the probable intent of Congress and an earlier amendment by Pub. L. 99–509, § 9343(a)(2), see below.
Pub. L. 99–509, § 9343(a)(2), substituted “(i)(5)” for “(i)(4)”.
Subsec. (b)(5). Pub. L. 99–272, § 9401(b)(1), added par. (5).
Subsec. (g). Pub. L. 99–509, § 9337(b), substituted “second sentence” for “next to last sentence”, and inserted at end “In the case of outpatient occupational therapy services which are described in the second sentence of section 1395x(p) of this title through the operation of section 1395x(g) of this title, with respect to expenses incurred in any calendar year, no more than $500 shall be considered as incurred expenses for purposes of subsections (a) and (b) of this section.”
Subsec. (h)(1)(B). Pub. L. 99–509, § 9339(b)(1), substituted “
Pub. L. 99–509, § 9339(a)(1)(A), substituted “qualified hospital laboratory (as defined in subparagraph (D))” for “hospital laboratory”.
Pub. L. 99–272, § 9303(a)(1)(A), substituted “
Subsec. (h)(1)(C). Pub. L. 99–509, § 9339(a)(1)(B), substituted “qualified hospital laboratory (as defined in subparagraph (D))” for “hospital laboratory”, struck out “, and ending on
Pub. L. 99–272, § 9303(a)(1)(A), substituted “
Subsec. (h)(1)(D). Pub. L. 99–509, § 9339(a)(1)(C), added subpar. (D).
Subsec. (h)(2). Pub. L. 99–509, § 9339(b)(2), struck out “(or, effective
Pub. L. 99–509, § 9339(a)(1)(D), substituted “qualified hospital laboratory (as defined in paragraph (1)(D))” for “hospital laboratory”.
Pub. L. 99–272, § 9303(a)(1), substituted “
Subsec. (h)(3). Pub. L. 99–509, § 9339(c)(1), inserted subpar. (A) designation after “provide for and establish”, and added subpar. (B).
Subsec. (h)(4). Pub. L. 99–272, § 9303(b)(2), designated existing provisions as subpar. (A) and added subpar. (B).
Subsec. (h)(5)(C). Pub. L. 99–272, § 9303(b)(3), substituted “laboratory other than” for “laboratory which is independent of a physician’s office or”.
Subsec. (i)(1). Pub. L. 99–509, § 9343(b)(2), inserted at end “The lists of procedures established under subparagraphs (A) and (B) shall be reviewed and updated not less often than every 2 years.”
Subsec. (i)(2). Pub. L. 99–509, § 9343(e)(2)(B), inserted “80 percent of” before “a standard overhead amount” in introductory provisions of subpars. (A) and (B).
Pub. L. 99–509, § 9343(b)(1), substituted “shall be reviewed and updated not later than
Subsec. (i)(3) to (5). Pub. L. 99–509, § 9343(a)(1)(B), added par. (3) and redesignated former pars. (3) and (4) as (4) and (5), respectively.
Subsec. (l). Pub. L. 99–509, § 9320(e)(2), added subsec. (l).
1984—Subsec. (a)(1). Pub. L. 98–369, § 2354(b)(7), struck out “and” at the end.
Subsec. (a)(1)(B). Pub. L. 98–369, § 2323(b)(1), substituted “section 1395x(s)(10)(A) of this title” for “section 1395x(s)(10) of this title”.
Subsec. (a)(1)(D). Pub. L. 98–369, § 2303(a), amended subpar. (D) generally. Prior to amendment, subpar. (D) read as follows: “with respect to diagnostic tests performed in a laboratory for which payment is made under this part to the laboratory, the amounts paid shall be equal to 100 percent of the negotiated rate for such tests (as determined pursuant to subsection (h) of this section),”.
Subsec. (a)(1)(F), (G). Pub. L. 98–369, § 2305(a), redesignated subpar. (G) as (F), and struck out former subpar. (F) which related to payment of reasonable charges for preadmission diagnostic services furnished by a physician to individuals enrolled under this part which are furnished in the outpatient department of a hospital within seven days of such individual’s admission to the same hospital or another hospital or furnished in the physician’s office within seven days of such individual’s admission to a hospital as an inpatient.
Subsec. (a)(2). Pub. L. 98–369, § 2305(c), struck out “and in paragraph (5) of this subsection” after “of such section”.
Subsec. (a)(2)(A). Pub. L. 98–617, § 3(b)(2), inserted “, or by another provider which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this provision),”.
Pub. L. 98–369, § 2354(b)(5), realigned margin of subpar. (A).
Pub. L. 98–369, § 2321(b)(1), inserted in provision preceding cl. (i) “(other than durable medical equipment)”.
Pub. L. 98–369, § 2323(b)(1), substituted “section 1395x(s)(10)(A) of this title” for “section 1395x(s)(10) of this title”.
Subsec. (a)(2)(B). Pub. L. 98–369, § 2354(b)(5), realigned margin of subpar. (B).
Pub. L. 98–369, § 2321(b)(2), inserted in provision preceding cl. (i) “items and” after “to other”.
Pub. L. 98–369, § 2303(b)(1), inserted “or (D)” after “subparagraph (C)”.
Subsec. (a)(2)(B)(ii). Pub. L. 98–369, § 2308(b)(2)(B), inserted “, or by another provider which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this clause),”.
Subsec. (a)(2)(D). Pub. L. 98–369, § 2303(b)(2)–(4), added subpar. (D).
Subsec. (a)(3). Pub. L. 98–369, § 2323(b)(1), substituted “section 1395x(s)(10)(A) of this title” for “section 1395x(s)(10) of this title”.
Subsec. (a)(5). Pub. L. 98–369, § 2305(b), struck out par. (5) which related to payment of reasonable costs for preadmission diagnostic services described in section 1395x(s)(2)(C) of this title furnished to an individual by the outpatient department of a hospital within seven days of such individual’s admission to the same hospital as an inpatient or to another hospital.
Subsec. (b)(1). Pub. L. 98–369, § 2323(b)(2), substituted “section 1395x(s)(10)(A) of this title” for “section 1395x(s)(10) of this title”.
Subsec. (b)(3). Pub. L. 98–369, § 2305(d), substituted “subsection (a)(1)(F)” for “subsection (a)(1)(G)”.
Subsec. (b)(4). Pub. L. 98–369, § 2303(c), added par. (4).
Subsec. (f). Pub. L. 98–369, § 2321(d)(4)(A), transferred subsec. (f) to part C of this subchapter and redesignated its provisions as section 1889 of the Social Security Act, which is classified to section 1395zz of this title.
Subsec. (h). Pub. L. 98–369, § 2303(d), amended subsec. (h) generally, substituting provisions directing the Secretary to establish fee schedules for clinical diagnostic laboratory tests at a percentage of the prevailing charge level and nominal fees to cover costs in collecting samples and authorizing the Secretary to make adjustments in the fee schedule, setting forth the recipients of payments, and authorizing the Secretary to establish a negotiated payment rate for provision authorizing the Secretary to establish a negotiated rate of payment with the laboratory which would be considered the full charge for such tests.
Subsec. (h)(5)(C). Pub. L. 98–617, § 3(b)(3), inserted a comma before “under the procedure described in section”.
Subsec. (i)(3). Pub. L. 98–369, § 2305(d), substituted “subsection (a)(1)(F)” for “subsection (a)(1)(G)”.
Subsec. (k). Pub. L. 98–369, § 2323(b)(4), added subsec. (k).
1982—Subsec. (a)(1)(B). Pub. L. 97–248, § 112(a)(1), substituted provisions that with respect to items and services described in section 1395x(s)(10) of this title, amounts paid shall be 100 percent of reasonable charges for such items and services for provision that with respect to expenses incurred for radiological or pathological services for which payment could be made under this part, furnished to any inpatient of a hospital by a physician in field of radiology or pathology who had in effect an agreement with Secretary by which the physician agreed to accept an assignment (as provided for in section 1395u(b)(3)(B)(ii) of this title) for all physicians’ services furnished by him to hospital inpatients enrolled under this part, the amounts paid would be equal to 100 percent of the reasonable charges for such services.
Subsec. (a)(1)(H). Pub. L. 97–248, § 112(a)(2), (3), struck out subpar. (H) which provided that, with respect to items and services described in section 1395x(s)(10) of this title, the amount of benefits paid would be 100 percent of reasonable charges for such items and services.
Subsec. (a)(2)(B). Pub. L. 97–248, § 101(c)(2), inserted “and except as may be provided in section 1395ww of this title”.
Subsec. (b)(1). Pub. L. 97–248, § 112(b), struck out subpar. (A) provision that total amount of expenses shall not include expenses incurred for radiological or pathological services furnished an individual as an inpatient of a hospital by a physician in field of radiology or pathology who has an agreement with Secretary by which physician agrees to accept an assignment (as provided for in section 1395u(b)(3)(B)(ii) of this title) for all physicians’ services furnished by him to hospital inpatients under this part, and redesignated subpar. (B) provisions as par. (1).
Subsec. (i)(1). Pub. L. 97–248, § 148(d), struck out requirement of consultation with National Professional Standards Review Council.
Subsec. (j). Pub. L. 97–248, § 117(a)(2), added subsec. (j).
1981—Subsec. (a)(2)(A). Pub. L. 97–35, § 2106(a), substituted provisions that with respect to home health services and to items and services described in section 1395x(s)(10) of this title, the lesser of reasonable cost of such services as determined under section 1395x(v) of this title or customary charges with respect to such services, or if such services are furnished by a public provider of services free of charge or at nominal charges to the public, the amount determined in accordance with section 1395f(b)(2) of this title for provisions that with respect to home health services and to items and services described in section 1395x(s)(10) of this title, the reasonable cost of such services, as determined under section 1395x(v) of this title.
Subsec. (a)(2)(B). Pub. L. 97–35, § 2106(a), substituted new formula in cls. (i) to (iii) with respect to other services for provisions providing for reasonable costs of such services less the amount a provider may charge as described in section 1395cc(a)(2)(A) of this title and that in no case may payment for such other services exceed 80 percent of such costs.
Subsec. (b). Pub. L. 97–35, §§ 2133(a), 2134(a), redesignated pars. (2) to (4) as (1) to (3), and struck out former par. (1), which provided that amount of deductible for such calendar year as so determined shall first be reduced by amount of any expenses incurred by such individual in last three months of preceding calendar year and applied toward such individual’s deductible under this section for such preceding year.
Pub. L. 97–35, § 2134(a), substituted “by a deductible of $75” for “by a deductible of $60”.
1980—Subsec. (a)(1)(B). Pub. L. 96–499, § 943(a), inserted “who has in effect an agreement with the Secretary by which the physician agrees to accept an assignment (as provided for in section 1395u(b)(3)(B)(ii) of this title) for all physicians’ services furnished by him to hospital inpatients enrolled under this part” after “radiology or pathology”.
Subsec. (a)(1)(D). Pub. L. 96–499, § 918(a)(4), substituted “subsection (h)” for “subsection (g)”.
Subsec. (a)(1)(F). Pub. L. 96–499, § 932(a)(1)(B), added subpar. (F).
Subsec. (a)(1)(G). Pub. L. 96–499, § 934(d)(1), added subpar. (G).
Subsec. (a)(1)(H). Pub. L. 96–611, § 1(b)(1)(A), (B), added subpar. (H).
Subsec. (a)(2). Pub. L. 96–611, § 1(b)(1)(C), inserted in subpar. (A) “and to items and services described in section 1395x(s)(10) of this title”.
Pub. L. 96–499, § 942, authorized payment of reasonable cost of home health services and prescribed formulae for determining payment amounts for services other than home health services.
Subsec. (a)(3). Pub. L. 96–611, § 1(b)(1)(D), inserted “(other than for items and services described in section 1395x(s)(10) of this title)”.
Pub. L. 96–499, § 942, prescribed a formula for determining payment amounts for services described in subpars. (D) and (E) of section 1395k(a)(2) of this title.
Subsec. (a)(4), (5). Pub. L. 96–499, § 942, added pars. (4) and (5).
Subsec. (b)(2). Pub. L. 96–611, § 1(b)(2), inserted “(A)” after “expenses incurred” and added subpar. (B).
Pub. L. 96–499, § 943(a), inserted “who has in effect an agreement with the Secretary by which the physician agrees to accept an assignment (as provided for in section 1395u(b)(3)(B)(ii) of this title) for all physicians’ services furnished by him to hospital inpatients enrolled under this part”.
Subsec. (b)(3). Pub. L. 96–499, § 930(h)(2), added par. (3).
Subsec. (b)(4). Pub. L. 96–499, § 934(d)(3), added par. (4).
Subsec. (g). Pub. L. 96–499, § 935(a), substituted “$500” for “$100”.
Subsec. (h). Pub. L. 96–473 redesignated subsec. (g) as added by section 279(b) of Pub. L. 92–603 as (h), which for purposes of codification had been editorially set out as subsec. (h), thereby requiring no change in text. See 1972 Amendment note below.
Subsec. (i). Pub. L. 96–499, § 934(b), added subsec. (i).
1978—Subsec. (a)(1)(E). Pub. L. 95–292, § 4(b)(2), added subpar. (E).
Subsec. (a)(2). Pub. L. 95–292, § 4(c), inserted “(unless otherwise specified in section 1395rr of this title)” after “and with respect to other services” in provisions preceding subpar. (A).
1977—Subsec. (a)(2). Pub. L. 95–210, § 1(b)(2), inserted parenthetical provisions preceding subpar. (A) excepting those services described in subpar. (D) of section 1395k(a)(2) of this title.
Subsec. (a)(3). Pub. L. 95–210, § 1(b)(1), (3), (4), added par. (3).
Subsec. (f)(1). Pub. L. 95–142 substituted provisions relating to determinations by Secretary with respect to presumptions regarding purchase price or practicality of buying or renting durable medical equipment, for provisions relating to purchase price of durable medical equipment authorized to be paid by Secretary.
Subsec. (f)(2). Pub. L. 95–142 substituted provisions relating to waiver of coinsurance amount in purchase of used durable medical equipment, for provisions relating to reimbursement procedures established by Secretary in cases of rental of durable medical equipment.
Subsec. (f)(3), (4). Pub. L. 95–142 added pars. (3) and (4).
1972—Subsec. (a). Pub. L. 92–603, § 226(c)(2), inserted reference to section 1395mm of this title in provisions preceding par. (1).
Subsec. (a)(1). Pub. L. 92–603, §§ 211(c)(4), 279(a), added subpars. (C) and (D).
Subsec. (a)(2). Pub. L. 92–603, §§ 233(b), 251(a)(3), 299K(a), substituted subpars. (A) and (B) for provisions relating to the amount payable by reference to section 1395x(v) of this title, added subpar. (C), and in provisions preceding subpar. (A), inserted “with respect to home health services, 100 percent, and with respect to other services,” before “80 percent”.
Subsec. (b). Pub. L. 92–603, § 204(a), substituted “$60” for “$50”.
Subsec. (f). Pub. L. 92–603, § 245(d), designated existing provisions as par. (1)(A) and added par. (1)(B) and (2).
Subsec. (g). Pub. L. 92–603, § 251(a)(2), added subsec. (g).
Subsec. (h). Pub. L. 92–603, § 279(b), added subsec. (h). Subsec. was in the original (g) and was changed to accommodate subsec. (g) as added by section 251(a)(2) of Pub. L. 92–603.
1968—Subsec. (a)(1). Pub. L. 90–248, § 131(a)(1), (2), designated existing provisions as subpar. (A) and added subpar. (B).
Subsec. (b). Pub. L. 90–248, §§ 129(c)(7), 131(b), struck out reference in par. (1) to expenses regarded under former par. (2) as incurred for services furnished in last three months of preceding year, struck out former par. (2) which provided that amount of any deduction imposed by section 1395e(a)(2)(A) of this title for outpatient hospital diagnostic services furnished in any calendar year is to be regarded as an incurred expense for such year; and added par. (2).
Pub. L. 90–248, § 135(c), inserted last sentence providing that there shall be a deductible equal to expenses incurred for first three pints of whole blood (or equivalent quantities of packed red blood cells as defined under regulations) furnished to an individual during a calendar year which deductible is to be appropriately reduced to extent that such blood has been replaced, and such blood will be deemed to have been replaced when institution or person furnishing such blood is given one pint of blood for each pint of blood (or equivalent quantities of packed red blood cells) furnished individual to which three pint deductible applies.
Subsec. (d). Pub. L. 90–248, § 129(c)(8), struck out reference to subsection (a)(2)(A) of section 1395e of this title.
Subsec. (f). Pub. L. 90–248, § 132(b), added subsec. (f).
Effective Date Of Amendment
Pub. L. 112–96, title III, § 3005(e),
Pub. L. 111–148, title IV, § 4103(e),
Pub. L. 111–148, title IV, § 4104(d),
Pub. L. 110–275, title I, § 101(c),
Amendment by section 143(b)(2), (3), of Pub. L. 110–275 applicable to services furnished on or after
Pub. L. 110–275, title I, § 145(a)(3),
Pub. L. 109–432, div. B, title I, § 109(c),
Pub. L. 109–171, title V, § 5112(f),
Pub. L. 109–171, title V, § 5113(c),
Amendment by section 237(a) of Pub. L. 108–173 applicable to services provided on or after
Pub. L. 108–173, title IV, § 411(a)(2),
Pub. L. 108–173, title IV, § 413(b)(2),
Pub. L. 108–173, title VI, § 614(c),
Pub. L. 108–173, title VI, § 621(a)(6),
Pub. L. 108–173, title VI, § 627(c),
Pub. L. 108–173, title VI, § 642(c),
Pub. L. 106–554, § 1(a)(6) [title I, § 105(e)],
Pub. L. 106–554, § 1(a)(6) [title I, § 111(a)(2)],
Pub. L. 106–554, § 1(a)(6) [title II, § 201(c)],
Pub. L. 106–554, § 1(a)(6) [title II, § 205(c)],
Pub. L. 106–554, § 1(a)(6) [title II, § 223(e)],
Pub. L. 106–554, § 1(a)(6) [title II, § 224(b)],
Pub. L. 106–554, § 1(a)(6) [title IV, § 401(b)(2)],
Pub. L. 106–554, § 1(a)(6) [title IV, § 402(c)],
Pub. L. 106–554, § 1(a)(6) [title IV, § 403(b)],
Pub. L. 106–554, § 1(a)(6) [title IV, § 405(b)],
Pub. L. 106–554, § 1(a)(6) [title IV, § 406(b)],
Pub. L. 106–554, § 1(a)(6) [title IV, § 430(c)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 201(h)(2)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 201(m)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 202(b)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 204(c)],
Amendment by section 1000(a)(6) [title III, § 321(g)(2), (k)(2)] of Pub. L. 106–113 effective as if included in the enactment of the Balanced Budget Act of 1997, Pub. L. 105–33, except as otherwise provided, see section 1000(a)(6) [title III, § 321(m)] of Pub. L. 106–113, set out as a note under section 1395d of this title.
Amendment by section 1000(a)(6) [title IV, § 401(b)(1)] of Pub. L. 106–113 effective
Pub. L. 106–113, div. B, § 1000(a)(6) [title IV, § 403(e)(2)],
Pub. L. 105–33, title IV, § 4002(j)(1)(B),
Pub. L. 105–33, title IV, § 4101(d),
Pub. L. 105–33, title IV, § 4102(e),
Pub. L. 105–33, title IV, § 4103(e),
Pub. L. 105–33, title IV, § 4104(e),
Amendment by section 4201(c)(1) of Pub. L. 105–33 applicable to services furnished on or after
Pub. L. 105–33, title IV, § 4205(a)(1)(B),
Pub. L. 105–33, title IV, § 4315(c),
Amendment by section 4432(b)(5)(C) of Pub. L. 105–33 applicable to items and services furnished on or after
Amendment by section 4511(b) of Pub. L. 105–33 applicable with respect to services furnished and supplies provided on and after
Pub. L. 105–33, title IV, § 4512(d),
Pub. L. 105–33, title IV, § 4521(c),
Pub. L. 105–33, title IV, § 4523(d)(1)(A)(ii),
Pub. L. 105–33, title IV, § 4531(b)(3),
Pub. L. 105–33, title IV, § 4541(e),
Pub. L. 105–33, title IV, § 4556(d),
Amendment by section 4603(c)(2)(A) of Pub. L. 105–33 applicable to cost reporting periods beginning on or after
Pub. L. 103–432, title I, § 123(f)(1), (2),
Pub. L. 103–432, title I, § 141(c)(2),
Amendment by section 147(a), (e)(2), (3), (f)(6)(C), (D) of Pub. L. 103–432 effective as if included in the enactment of Pub. L. 101–508, see section 147(g) of Pub. L. 103–432, set out as a note under section 1320a–3a of this title.
Pub. L. 103–432, title I, § 147(d)(1), (2),
Amendment by section 156(a)(2)(B) of Pub. L. 103–432 applicable to services provided on or after
Pub. L. 103–66, title XIII, § 13532(b),
Pub. L. 103–66, title XIII, § 13544(b)(3),
Pub. L. 103–66, title XIII, § 13555(b),
Pub. L. 101–508, title IV, § 4104(d),
Amendment by section 4153(a)(2)(B), (C) of Pub. L. 101–508 applicable to items furnished on or after
Pub. L. 101–508, title IV, § 4154(b)(2),
Pub. L. 101–508, title IV, § 4154(c)(2),
Pub. L. 101–508, title IV, § 4154(e)(5),
Amendment by section 4155(b)(2), (3) of Pub. L. 101–508 applicable to services furnished on or after
Amendment by section 4161(a)(3)(B) of Pub. L. 101–508 applicable to services furnished on or after
Pub. L. 101–508, title IV, § 4163(e),
Pub. L. 101–508, title IV, § 4206(e)(2),
Pub. L. 101–239, title VI, § 6102(c)(2),
Pub. L. 101–239, title VI, § 6102(f)(3),
Pub. L. 101–239, title VI, § 6102(g),
Pub. L. 101–239, title VI, § 6111(b)(2),
Pub. L. 101–239, title VI, § 6113(e),
Pub. L. 101–239, title VI, § 6131(c),
Pub. L. 101–239, title VI, § 6133(b),
Amendment by section 6204(b) of Pub. L. 101–239 effective with respect to referrals made on or after
Amendment by section 201(a) of Pub. L. 101–234 effective
Amendment by section 202(a) of Pub. L. 101–234 effective
Pub. L. 100–647, title VIII, § 8422(b),
Amendment by Pub. L. 100–485 effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100–360, see section 608(g) of Pub. L. 100–485, set out as a note under section 704 of this title.
Amendment by section 202(b)(1)–(3) of Pub. L. 100–360 applicable to items dispensed on or after
Amendment by section 203(c)(1)(A)–(E) of Pub. L. 100–360 applicable to items and services furnished on or after
Amendment by section 204(d)(1) of Pub. L. 100–360 applicable to screening mammography performed on or after
Amendment by section 205(c) of Pub. L. 100–360 applicable to items and services furnished on or after
Except as specifically provided in section 411 of Pub. L. 100–360, amendment by section 411(f)(2)(D), (8)(B)(i), (C), (12)(A), (14), (g)(1)(E), (2)(D), (E), (3)(A)–(F), (4)(C), (5), (h)(1)(A), (3)(B), (4)(B), (C), (7)(C), (D), (F), (i)(3), (4)(B)–(C)(ii), (iv), and (vi) of Pub. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203, effective as if included in the enactment of that provision in Pub. L. 100–203, see section 411(a) of Pub. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.
Pub. L. 100–203, title IV, § 4043(c),
Amendment by section 4045(c)(2)(A) of Pub. L. 100–203 applicable to items and services furnished on or after
Amendment by section 4049(a)(1) of Pub. L. 100–203 applicable to services performed on or after
Pub. L. 100–203, title IV, § 4055(b), formerly § 4054(b), as added and renumbered by Pub. L. 100–360, title IV, § 411(f)(12)(A), (14),
Amendment by section 4062(d)(3) of Pub. L. 100–203 applicable to covered items (other than oxygen and oxygen equipment) furnished on or after
Pub. L. 100–203, title IV, § 4063(c),
Pub. L. 100–203, title IV, § 4064(b)(3),
Pub. L. 100–203, title IV, § 4064(c)(2), as added by Pub. L. 100–360, title IV, § 411(g)(3)(F),
Pub. L. 100–203, title IV, § 4066(c),
Pub. L. 100–203, title IV, § 4067(c),
Pub. L. 100–203, title IV, § 4068(c),
Pub. L. 100–203, title IV, § 4070(c)(1),
For effective date of amendment by section 4072(b) of Pub. L. 100–203, see section 4072(e) of Pub. L. 100–203, set out as a note under section 1395x of this title.
Amendment by section 4073(b) of Pub. L. 100–203 effective with respect to services performed on or after
Amendment by section 4077(b)(2), (3) of Pub. L. 100–203 effective with respect to services performed on or after
Pub. L. 100–203, title IV, § 4084(b),
Pub. L. 100–203, title IV, § 4084(c)(3), as added by Pub. L. 100–360, title IV, § 411(i)(3),
Pub. L. 100–203, title IV, § 4085(b)(2),
Pub. L. 100–203, title IV, § 4085(i)(21),
Amendment by section 9320(e)(1), (2) of Pub. L. 99–509 applicable to services furnished on or after
Amendment by section 9337(b) of Pub. L. 99–509 applicable to expenses incurred for outpatient occupational therapy services furnished on or after
Pub. L. 99–509, title IX, § 9339(a)(2),
Pub. L. 99–509, title IX, § 9339(c)(2),
Pub. L. 99–509, title IX, § 9343(h),
Pub. L. 99–272, title IX, § 9303(a)(2),
Pub. L. 99–272, title IX, § 9303(b)(5)(A), (B),
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.
Pub. L. 98–369, div. B, title III, § 2303(j),
Pub. L. 98–369, div. B, title III, § 2305(e),
Amendment by section 2321(b), (d)(4)(A) of Pub. L. 98–369 applicable to items and services furnished on or after
Pub. L. 98–369, div. B, title III, § 2323(d),
Amendment by section 2354(b)(5), (7) of Pub. L. 98–369 effective
Pub. L. 97–248, title I, § 112(c),
Amendment by section 117(a)(2) of Pub. L. 97–248 applicable to final determinations made on or after
Amendment by section 148(d) of Pub. L. 97–248 effective with respect to contracts entered into or renewed on or after
Pub. L. 97–35, title XXI, § 2106(c),
Pub. L. 97–35, title XXI, § 2133(b),
Pub. L. 97–35, title XXI, § 2134(b),
Pub. L. 96–611, § 2,
Amendment by section 930(h) of Pub. L. 96–499, effective with respect to services furnished on or after
Pub. L. 96–499, title IX, § 935(b),
Pub. L. 96–499, title IX, § 943(b),
Amendment by Pub. L. 95–292 effective with respect to services, supplies, and equipment furnished after the third calendar month beginning after
Amendment by Pub. L. 95–210 applicable to services rendered on or after first day of third calendar month which begins after
Pub. L. 95–142, § 16(b),
Pub. L. 92–603, title II, § 204(c),
Amendment by section 211(c)(4) of Pub. L. 92–603 applicable to services furnished with respect to admissions occurring after
Amendment by section 226(c)(2) of Pub. L. 92–603 effective with respect to services provided on or after
Amendment by section 233(b) of Pub. L. 92–603 applicable to services furnished by hospitals, extended care facilities, and home health agencies in accounting periods beginning after
Amendment by section 251(a)(2), (3) of Pub. L. 92–603 applicable with respect to services furnished on or after
Pub. L. 92–603, title II, § 299K(b),
Amendment by section 129(c)(7), (8) of Pub. L. 90–248 applicable with respect to services furnished after
Pub. L. 90–248, title I, § 131(c),
Pub. L. 90–248, title I, § 132(c),
Amendment by section 135(c) of Pub. L. 90–248 applicable with respect to payment for blood (or packed red blood cells) furnished an individual after
Miscellaneous
Pub. L. 110–275, title I, § 101(a)(4),
Pub. L. 106–554, § 1(a)(6) [title I, § 111(b)],
Pub. L. 112–242, title I, § 101,
Pub. L. 112–240, title VI, § 603(d),
Pub. L. 112–96, title III, § 3005(d),
Pub. L. 112–96, title III, § 3005(g),
Pub. L. 111–148, title III, § 3113,
Pub. L. 110–275, title I, § 139(b),
Pub. L. 109–432, div. B, title I, § 107(b)(2),
Pub. L. 109–171, title V, § 5107(a)(2),
Pub. L. 109–171, title V, § 5107(b),
Amendment by section 303 of Pub. L. 108–173, insofar as applicable to payments for drugs or biologicals and drug administration services furnished by physicians, is applicable only to physicians in the specialties of hematology, hematology/oncology, and medical oncology under this subchapter, see section 303(j) of Pub. L. 108–173, set out as a note under section 1395u of this title.
Notwithstanding section 303(j) of Pub. L. 108–173 (see note above), amendment by section 303 of Pub. L. 108–173 also applicable to payments for drugs or biologicals and drug administration services furnished by physicians in specialties other than the specialties of hematology, hematology/oncology, and medical oncology, see section 304 of Pub. L. 108–173, set out as a note under section 1395u of this title.
Pub. L. 108–173, title III, § 305(b),
Pub. L. 108–173, title IV, § 416,
[Pub. L. 109–432, div. B, title I, § 105,
Pub. L. 108–173, title VI, § 621(b)(3),
Pub. L. 108–173, title VI, § 624(a)(2),
Pub. L. 108–173, title VI, § 624(b),
Pub. L. 108–173, title VI, § 626(d),
Pub. L. 108–173, title VI, § 641,
Pub. L. 108–173, title VII, § 733,
Pub. L. 106–554, § 1(a)(6) [title I, § 111(c)],
Pub. L. 106–554, § 1(a)(6) [title II, § 225],
Pub. L. 106–554, § 1(a)(6) [title IV, § 401(c)],
Pub. L. 106–554, § 1(a)(6) [title IV, § 402(d)],
Pub. L. 106–554, § 1(a)(6) [title IV, § 421(c)],
Pub. L. 106–554, § 1(a)(6) [title IV, § 424(a)],
Pub. L. 106–554, § 1(a)(6) [title IV, § 434],
Pub. L. 106–554, § 1(a)(6) [title IV, § 438],
Pub. L. 106–554, § 1(a)(6) [title V, § 531(b)],
Pub. L. 106–554, § 1(a)(6) [title V, § 531(c)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 201(l)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 203],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 213],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 221(a)(2)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 221(d)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 226],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 229(a)],
Pub. L. 105–33, title IV, § 4206,
Pub. L. 105–33, title IV, § 4541(d)(2),
[Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 221(c)(2)],
Pub. L. 105–33, title IV, § 4553(c),
Pub. L. 103–432, title I, § 141(b),
Pub. L. 103–432, title I, § 142,
Pub. L. 103–432, title I, § 143,
Pub. L. 103–66, title XIII, § 13531,
Pub. L. 103–66, title XIII, § 13533,
Pub. L. 101–508, title IV, § 4151(c)(3),
[Pub. L. 103–432, title I, § 141(d),
Pub. L. 101–508, title IV, § 4158,
Conscientious objections of health care provider under State law unaffected by enactment of subsecs. (a)(1)(Q) and (f) of this section, see section 4206(c) of Pub. L. 101–508, set out as a note under section 1395cc of this title.
Pub. L. 101–239, title VI, § 6113(c),
[Pub. L. 103–432, title I, § 147(b),
Pub. L. 101–239, title VI, § 6136,
Pub. L. 101–239, title VI, § 6137,
Pub. L. 100–647, title VIII, § 8421(b),
For requirement that Secretary of Health and Human Services modify contracts under subsection (a)(1)(A) of this section to take into account amendments made by Pub. L. 100–360 and that such organizations make appropriate adjustments in their agreements with medicare beneficiaries to take into account such amendments, see section 222 of Pub. L. 100–360, set out as a note under section 1395mm of this title.
Pub. L. 100–203, title IV, § 4043(b),
Pub. L. 100–203, title IV, § 4050,
Pub. L. 100–203, title IV, § 4054,
Pub. L. 100–203, title IV, § 4056(c), formerly § 4055(c),
Pub. L. 100–203, title IV, § 4056(d), formerly § 4055(d),
Pub. L. 100–203, title IV, § 4064(a),
Pub. L. 100–203, title IV, § 4064(b)(4),
Pub. L. 100–203, title IV, § 4067(b),
Pub. L. 99–509, title IX, § 9339(b)(3),
Pub. L. 99–509, title IX, § 9339(d),
Pub. L. 99–272, title IX, § 9303(a)(3),
Amount of payment under this part for physicians’ services furnished between
Pub. L. 98–369, div. B, title III, § 2303(i),
Pub. L. 98–369, div. B, title III, § 2304(a),
Pub. L. 98–369, div. B, title III, § 2305(f),
For provision directing the Secretary to issue regulations requiring providers of services to calculate and report the lesser-of-cost-or-charges determinations separately with respect to payments for services under parts A and B of this subchapter other than diagnostic tests under subsec. (h) of this section, see section 2308(a) of Pub. L. 98–369, set out as a note under section 1395f of this title.
For provision directing the Secretary to provide, in addition to other rules deemed appropriate, that charges representing 60 percent or less of costs be considered nominal for purposes of applying the nominality test under subsec. (a)(2)(B)(ii) of this section, see section 2308(b)(1) of Pub. L. 98–369, set out as a note under section 1395f of this title.
Pub. L. 98–369, div. B, title III, § 2309,
Pub. L. 98–369, div. B, title III, § 2323(e),
Pub. L. 96–499, title IX, § 932(b),
Pub. L. 95–210, § 1(c),
Pub. L. 89–97, title I, § 104(b)(1),