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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 E. Miscellaneous Provisions |
§ 1395y. Exclusions from coverage and medicare as secondary payer
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(a) Items or services specifically excluded Notwithstanding any other provision of this subchapter, no payment may be made under part A or part B of this subchapter for any expenses incurred for items or services— (1) (A) which, except for items and services described in a succeeding subparagraph or additional preventive services (as described in section 1395x(ddd)(1) of this title), are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, (B) in the case of items and services described in section 1395x(s)(10) of this title, which are not reasonable and necessary for the prevention of illness, (C) in the case of hospice care, which are not reasonable and necessary for the palliation or management of terminal illness, (D) in the case of clinical care items and services provided with the concurrence of the Secretary and with respect to research and experimentation conducted by, or under contract with, the Medicare Payment Advisory Commission or the Secretary, which are not reasonable and necessary to carry out the purposes of section 1395ww(e)(6) of this title, of this section) providing supplemental or secondary coverage to individuals also entitled to services under this subchapter shall not require a medicare claims determination under this subchapter for dental benefits specifically excluded under subsection (a)(12) of this section as a condition of making a claims determination for such benefits under the group health plan. (2) A group health plan may require a claims determination under this subchapter in cases involving or appearing to involve inpatient dental hospital services or dental services expressly covered under this subchapter pursuant to actions taken by the Secretary. (l) National and local coverage determination process (1) Factors and evidence used in making national coverage determinations The Secretary shall make available to the public the factors considered in making national coverage determinations of whether an item or service is reasonable and necessary. The Secretary shall develop guidance documents to carry out this paragraph in a manner similar to the development of guidance documents under section 371(h) of title 21.
(2) Timeframe for decisions on requests for national coverage determinations In the case of a request for a national coverage determination that— (A) does not require a technology assessment from an outside entity or deliberation from the Medicare Coverage Advisory Committee, the decision on the request shall be made not later than 6 months after the date of the request; or (B) requires such an assessment or deliberation and in which a clinical trial is not requested, the decision on the request shall be made not later than 9 months after the date of the request. (3) Process for public comment in national coverage determinations (A) Period for proposed decision Not later than the end of the 6-month period (or 9-month period for requests described in paragraph (2)(B)) that begins on the date a request for a national coverage determination is made, the Secretary shall make a draft of proposed decision on the request available to the public through the Internet website of the Centers for Medicare & Medicaid Services or other appropriate means.
(B) 30-day period for public comment Beginning on the date the Secretary makes a draft of the proposed decision available under subparagraph (A), the Secretary shall provide a 30-day period for public comment on such draft.
(C) 60-day period for final decision Not later than 60 days after the conclusion of the 30-day period referred to under subparagraph (B), the Secretary shall— (i) make a final decision on the request; (ii) include in such final decision summaries of the public comments received and responses to such comments; (iii) make available to the public the clinical evidence and other data used in making such a decision when the decision differs from the recommendations of the Medicare Coverage Advisory Committee; and (iv) in the case of a final decision under clause (i) to grant the request for the national coverage determination, the Secretary shall assign a temporary or permanent code (whether existing or unclassified) and implement the coding change. (4) Consultation with outside experts in certain national coverage determinations With respect to a request for a national coverage determination for which there is not a review by the Medicare Coverage Advisory Committee, the Secretary shall consult with appropriate outside clinical experts.
(5) Local coverage determination process (A) Plan to promote consistency of coverage determinations The Secretary shall develop a plan to evaluate new local coverage determinations to determine which determinations should be adopted nationally and to what extent greater consistency can be achieved among local coverage determinations.
(B) Consultation The Secretary shall require the fiscal intermediaries or carriers providing services within the same area to consult on all new local coverage determinations within the area.
(C) Dissemination of information The Secretary should serve as a center to disseminate information on local coverage determinations among fiscal intermediaries and carriers to reduce duplication of effort.
(6) National and local coverage determination defined For purposes of this subsection— (A) National coverage determination The term “national coverage determination” means a determination by the Secretary with respect to whether or not a particular item or service is covered nationally under this subchapter.
(B) Local coverage determination The term “local coverage determination” has the meaning given that in section 1395ff(f)(2)(B) of this title.
(m) Coverage of routine costs associated with certain clinical trials of category A devices (1) In general In the case of an individual entitled to benefits under part A of this subchapter, or enrolled under part B of this subchapter, or both who participates in a category A clinical trial, the Secretary shall not exclude under subsection (a)(1) of this section payment for coverage of routine costs of care (as defined by the Secretary) furnished to such individual in the trial.
(2) Category A clinical trial For purposes of paragraph (1), a “category A clinical trial” means a trial of a medical device if— (A) the trial is of an experimental/investigational (category A) medical device (as defined in regulations under section 405.201(b) of title 42, Code of Federal Regulations (as in effect as of September 1, 2003 ));(B) the trial meets criteria established by the Secretary to ensure that the trial conforms to appropriate scientific and ethical standards; and (C) in the case of a trial initiated before January 1, 2010 , the device involved in the trial has been determined by the Secretary to be intended for use in the diagnosis, monitoring, or treatment of an immediately life-threatening disease or condition.(n) Requirement of a surety bond for certain providers of services and suppliers (1) In general The Secretary may require a provider of services or supplier described in paragraph (2) to provide the Secretary on a continuing basis with a surety bond in a form specified by the Secretary in an amount (not less than $50,000) that the Secretary determines is commensurate with the volume of the billing of the provider of services or supplier. The Secretary may waive the requirement of a bond under the preceding sentence in the case of a provider of services or supplier that provides a comparable surety bond under State law.
(2) Provider of services or supplier described A provider of services or supplier described in this paragraph is a provider of services or supplier the Secretary determines appropriate based on the level of risk involved with respect to the provider of services or supplier, and consistent with the surety bond requirements under sections 1395m(a)(16)(B) and 1395x(o)(7)(C) of this title.
(o) Suspension of payments pending investigation of credible allegations of fraud (1) In general The Secretary may suspend payments to a provider of services or supplier under this subchapter pending an investigation of a credible allegation of fraud against the provider of services or supplier, unless the Secretary determines there is good cause not to suspend such payments.
(2) Consultation The Secretary shall consult with the Inspector General of the Department of Health and Human Services in determining whether there is a credible allegation of fraud against a provider of services or supplier.
(3) Promulgation of regulations The Secretary shall promulgate regulations to carry out this subsection and section 1396b(i)(2)(C) of this title.
References In Text
Section 1395ww(e)(6) of this title, referred to in subsec. (a)(1)(D), was repealed by Pub. L. 105–33, title IV, § 4022(b)(1)(A)(i),
The Assisted Suicide Funding Restriction Act of 1997, referred to in subsec. (a)(16), is Pub. L. 105–12,
The Internal Revenue Code of 1986, referred to in subsec. (b), is classified generally to Title 26, Internal Revenue Code.
Section 107(c)(3) of the Drug Amendments of 1962, referred to in subsec. (c)(1)(A), is section 107(c)(3) of Pub. L. 87–781, title I,
Codification
Section 1314(i) of this title, which was transferred and redesignated as subsec. (j) of this section by Pub. L. 108–173, was based on act Aug. 14, 1935, ch. 531, title XI, § 1114(i), as added Pub. L. 106–554, § 1(a)(6) [title V, § 522(c)],
Amendments by section 301(a) to (c) of Pub. L. 108–173 were executed to this section as it read on the date of enactment of Pub. L. 108–173 to reflect the probable intent of Congress, notwithstanding section 301(d) of Pub. L. 108–173, set out as an Effective Date of 2003 Amendment note below, which provided that the amendments by section 301(a) of Pub. L. 108–173 be effective as if included in the enactment of title III of Pub. L. 98–369 and that the amendments by section 301(b), (c) of Pub. L. 108–173 be effective as if included in the enactment of section 953 of Pub. L. 96–499. The amendments by section 301(a) are incapable of being executed to this section as it read on the effective date of title III of Pub. L. 98–369, and the amendments by section 301(b), (c) are incapable of being executed to this section as it read on the effective date of section 953 of Pub. L. 96–499. See 2003 Amendment notes below.
Amendments
2013—Subsec. (b)(2)(B)(ii). Pub. L. 112–242, § 202(a)(1), substituted “Subject to paragraph (9), a primary plan” for “A primary plan”.
Subsec. (b)(2)(B)(iii). Pub. L. 112–242, § 205(a), inserted at end “An action may not be brought by the United States under this clause with respect to payment owed unless the complaint is filed not later than 3 years after the date of the receipt of notice of a settlement, judgment, award, or other payment made pursuant to paragraph (8) relating to such payment owed.”
Subsec. (b)(2)(B)(vii), (viii). Pub. L. 112–242, § 201, added cls. (vii) and (viii).
Subsec. (b)(8)(B). Pub. L. 112–242, § 204, inserted concluding provisions.
Subsec. (b)(8)(E)(i). Pub. L. 112–242, § 203(1), substituted “may be subject to a civil money penalty of up to $1,000” for “shall be subject to a civil money penalty of $1,000”.
Subsec. (b)(8)(I). Pub. L. 112–242, § 203(2), added subpar. (I).
Subsec. (b)(9). Pub. L. 112–242, § 202(a)(2), added par. (9).
2011—Subsecs. (a)(15)(A), (g). Pub. L. 112–40 substituted “quality improvement” for “utilization and quality control peer review”.
2010—Subsec. (a)(1)(P). Pub. L. 111–148, § 4103(d)(1), added subpar. (P).
Subsec. (a)(7). Pub. L. 111–148, § 4103(d)(2), substituted “(K), or (P)” for “or (K)”.
Subsec. (a)(25). Pub. L. 111–148, § 1104(d), added par. (25).
Subsec. (n). Pub. L. 111–148, § 6402(g)(3), added subsec. (n).
Subsec. (o). Pub. L. 111–148, § 6402(h)(1), added subsec. (o).
2008—Subsec. (a)(1)(A). Pub. L. 110–275, § 101(a)(3), inserted “or additional preventive services (as described in section 1395x(ddd)(1) of this title)” after “succeeding subparagraph”.
Subsec. (a)(1)(K). Pub. L. 110–275, § 101(b)(3), (4), substituted “more” for “not later” and “1 year” for “6 months”.
Subsec. (a)(1)(O). Pub. L. 110–275, § 152(b)(1)(D), added subpar. (O).
Subsec. (a)(20). Pub. L. 110–275, § 143(b)(7), substituted “outpatient physical therapy services, outpatient speech-language pathology services, or outpatient occupational therapy services” for “outpatient occupational therapy services or outpatient physical therapy services” and “subsection (g) or (ll)(2) of section 1395x” for “section 1395x(g)”.
Subsec. (a)(23). Pub. L. 110–275, § 135(a)(2)(A), added par. (23).
Subsec. (a)(24). Pub. L. 110–275, § 153(b)(2), added par. (24).
2007—Subsec. (b)(7), (8). Pub. L. 110–173 added pars. (7) and (8).
2006—Subsec. (a)(1)(N). Pub. L. 109–171 added subpar. (N).
2003—Subsec. (a). Pub. L. 108–173, § 948(a)(2)(A), struck out “established under section 1314(f) of this title” after “meetings of advisory committees” in concluding provisions.
Pub. L. 108–173, § 731(a)(1)(A), inserted “consistent with subsection (l) of this section” after “the Secretary shall ensure” in concluding provisions.
Subsec. (a)(1)(J). Pub. L. 108–173, § 303(i)(3)(B), added subpar. (J).
Subsec. (a)(1)(K). Pub. L. 108–173, § 611(d)(1)(A), added subpar. (K).
Subsec. (a)(1)(L). Pub. L. 108–173, § 612(c), added subpar. (L).
Subsec. (a)(1)(M). Pub. L. 108–173, § 613(c), added subpar. (M).
Subsec. (a)(7). Pub. L. 108–173, § 611(d)(1)(B), substituted “(H), or (K)” for “or (H)”.
Subsec. (b)(1)(A). Pub. L. 108–173, § 301(c)(1), realigned margins.
Subsec. (b)(2)(A). Pub. L. 108–173, § 301(b)(1), inserted at end of concluding provisions “An entity that engages in a business, trade, or profession shall be deemed to have a self-insured plan if it carries its own risk (whether by a failure to obtain insurance, or otherwise) in whole or in part.”
Subsec. (b)(2)(A)(ii). Pub. L. 108–173, § 301(a)(1), struck out “promptly (as determined in accordance with regulations)” after “be expected to be made”.
Subsec. (b)(2)(B)(i). Pub. L. 108–173, § 301(a)(2)(B), added cl. (i). Former cl. (i) redesignated (ii).
Subsec. (b)(2)(B)(ii). Pub. L. 108–173, § 301(b)(2), substituted “A primary plan, and an entity that receives payment from a primary plan, shall reimburse the appropriate Trust Fund for any payment made by the Secretary under this subchapter with respect to an item or service if it is demonstrated that such primary plan has or had a responsibility to make payment with respect to such item or service. A primary plan’s responsibility for such payment may be demonstrated by a judgment, a payment conditioned upon the recipient’s compromise, waiver, or release (whether or not there is a determination or admission of liability) of payment for items or services included in a claim against the primary plan or the primary plan’s insured, or by other means.” for “Any payment under this subchapter with respect to any item or service to which subparagraph (A) applies shall be conditioned on reimbursement to the appropriate Trust Fund established by this subchapter when notice or other information is received that payment for such item or service has been or could be made under such subparagraph.” and “on the date notice of, or information related to, a primary plan’s responsibility for such payment or other information is received” for “on the date such notice or other information is received”.
Pub. L. 108–173, § 301(a)(2)(A), redesignated cl. (i) as (ii). Former cl. (ii) redesignated (iii).
Subsec. (b)(2)(B)(iii). Pub. L. 108–173, § 301(b)(3), substituted “In order to recover payment made under this subchapter for an item or service, the United States may bring an action against any or all entities that are or were required or responsible (directly, as an insurer or self-insurer, as a third-party administrator, as an employer that sponsors or contributes to a group health plan, or large group health plan, or otherwise) to make payment with respect to the same item or service (or any portion thereof) under a primary plan. The United States may, in accordance with paragraph (3)(A) collect double damages against any such entity. In addition, the United States may recover under this clause from any entity that has received payment from a primary plan or from the proceeds of a primary plan’s payment to any entity.” for “In order to recover payment under this subchapter for such an item or service, the United States may bring an action against any entity which is required or responsible (directly, as a third-party administrator, or otherwise) to make payment with respect to such item or service (or any portion thereof) under a primary plan (and may, in accordance with paragraph (3)(A) collect double damages against that entity), or against any other entity (including any physician or provider) that has received payment from that entity with respect to the item or service, and may join or intervene in any action related to the events that gave rise to the need for the item or service.”
Pub. L. 108–173, § 301(a)(2)(A), redesignated cl. (ii) as (iii). Former cl. (iii) redesignated (iv).
Subsec. (b)(2)(B)(iv) to (vi). Pub. L. 108–173, § 301(a)(2)(A), redesignated cls. (iii) to (v) as (iv) to (vi), respectively.
Subsec. (b)(3)(A). Pub. L. 108–173, § 301(c)(2), struck out “such” before “paragraphs”.
Subsec. (b)(5)(A)(ii). Pub. L. 108–173, § 900(e)(1)(J), substituted “Centers for Medicare & Medicaid Services” for “Health Care Financing Administration”.
Subsec. (d). Pub. L. 108–173, § 944(a)(1), added subsec. (d).
Subsec. (j). Pub. L. 108–173, § 948(a)(1), transferred subsec. (i) of section 1314 of this title and redesignated it as subsec. (j) of this section. See Codification note above.
Subsec. (j)(1). Pub. L. 108–173, § 948(a)(2)(B), in introductory provisions, struck out “under subsection (f) of this section” after “appointed” and substituted “subsection (a)(1) of this section” for “section 1395y(a)(1) of this title”.
Subsec. (k). Pub. L. 108–173, § 950(a), added subsec. (k).
Subsec. (l). Pub. L. 108–173, § 731(a)(1)(B), added subsec. (l).
Subsec. (m). Pub. L. 108–173, § 731(b)(1), added subsec. (m).
2001—Subsec. (a)(22). Pub. L. 107–105, § 3(a)(1), added par. (22).
Subsec. (h). Pub. L. 107–105, § 3(a)(2), added subsec. (h).
2000—Subsec. (a). Pub. L. 106–554, § 1(a)(6) [title V, § 522(b)], inserted at end “In making a national coverage determination (as defined in paragraph (1)(B) of section 1395ff(f) of this title) the Secretary shall ensure that the public is afforded notice and opportunity to comment prior to implementation by the Secretary of the determination; meetings of advisory committees established under section 1314(f) of this title with respect to the determination are made on the record; in making the determination, the Secretary has considered applicable information (including clinical experience and medical, technical, and scientific evidence) with respect to the subject matter of the determination; and in the determination, provide a clear statement of the basis for the determination (including responses to comments received from the public), the assumptions underlying that basis, and make available to the public the data (other than proprietary data) considered in making the determination.”
Subsec. (a)(1)(F). Pub. L. 106–554, § 1(a)(6) [title I, § 102(c)], struck out “and,” after “section 1395m(c)(1)(B) of this title,” and inserted at end “and, in the case of screening for glaucoma, which is performed more frequently than is provided under section 1395x(uu) of this title,”.
Subsec. (a)(3). Pub. L. 106–554, § 1(a)(6) [title IV, § 432(b)(1)], struck out second comma after “section 1395x(aa)(1) of this title” and inserted “in the case of services for which payment may be made under section 1395qq(e) of this title,” after “section 1395x(aa)(3) of this title,”.
Subsec. (a)(18). Pub. L. 106–554, § 1(a)(6) [title III, § 313(a)], substituted “during a period in which the resident is provided covered post-hospital extended care services (or, for services described in section 1395x(s)(2)(D) of this title, which are furnished to such an individual without regard to such period),” for “or of a part of a facility that includes a skilled nursing facility (as determined under regulations),”.
1999—Subsec. (a)(7). Pub. L. 106–113, § 1000(a)(6) [title III, § 321(k)(10)], substituted “subparagraph” for “subparagraphs”.
Subsec. (a)(21). Pub. L. 106–113, § 1000(a)(6) [title III, § 305(b)], inserted “(including medical supplies described in section 1395x(m)(5) of this title, but excluding durable medical equipment to the extent provided for in such section)” after “home health services”.
1997—Subsec. (a)(1)(D). Pub. L. 105–33, § 4022(b)(1)(B), substituted “Medicare Payment Advisory Commission” for “Prospective Payment Assessment Commission”.
Subsec. (a)(1)(F). Pub. L. 105–33, § 4102(c), inserted “and screening pelvic exam” after “screening pap smear”.
Subsec. (a)(1)(G). Pub. L. 105–33, § 4103(c)(1), added subpar. (G).
Subsec. (a)(1)(H). Pub. L. 105–33, § 4104(c)(3)(A), added subpar. (H).
Subsec. (a)(1)(I). Pub. L. 105–33, § 4614(a), added subpar. (I).
Subsec. (a)(7). Pub. L. 105–33, § 4104(c)(3)(B), substituted “(G), or (H)” for “or (G)”.
Pub. L. 105–33, § 4103(c)(2), substituted “subparagraphs (B), (F), or (G) of paragraph (1)” for “paragraph (1)(B) or under paragraph (1)(F)”.
Subsec. (a)(14). Pub. L. 105–33, § 4511(a)(2)(C), substituted “section 1395x(s)(2)(K) of this title” for “section 1395x(s)(2)(K)(i) or 1395x(s)(2)(K)(iii) of this title”.
Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care” wherever appearing.
Subsec. (a)(16). Pub. L. 105–12 added par. (16).
Subsec. (a)(17). Pub. L. 105–33, § 4319(b), added par. (17).
Subsec. (a)(18). Pub. L. 105–33, § 4432(b)(1), added par. (18).
Subsec. (a)(19). Pub. L. 105–33, § 4507(a)(2)(B), added par. (19).
Subsec. (a)(20). Pub. L. 105–33, § 4541(b), added par. (20).
Subsec. (a)(21). Pub. L. 105–33, § 4603(c)(2)(C), added par. (21).
Subsec. (b)(1)(B)(i). Pub. L. 105–33, § 4631(a)(1)(A), substituted “in clause (iii))” for “in clause (iv))”.
Subsec. (b)(1)(B)(iii), (iv). Pub. L. 105–33, § 4631(a)(1)(B), (C), redesignated cl. (iv) as (iii) and struck out heading and text of former cl. (iii). Text read as follows: “Clause (i) shall only apply to items and services furnished on or after
Subsec. (b)(1)(C). Pub. L. 105–33, § 4631(b), in concluding provisions, substituted “
Subsec. (b)(1)(F). Pub. L. 105–33, § 4633(b), added subpar. (F).
Subsec. (b)(2)(B)(ii). Pub. L. 105–33, § 4633(a), substituted “(directly, as a third-party administrator, or otherwise) to make payment” for “under this subsection to pay” and inserted at end “The United States may not recover from a third-party administrator under this clause in cases where the third-party administrator would not be able to recover the amount at issue from the employer or group health plan and is not employed by or under contract with the employer or group health plan at the time the action for recovery is initiated by the United States or for whom it provides administrative services due to the insolvency or bankruptcy of the employer or plan.”
Subsec. (b)(2)(B)(v). Pub. L. 105–33, § 4632(a), added cl. (v).
Subsec. (b)(5)(C)(iii). Pub. L. 105–33, § 4631(c)(1), struck out heading and text of cl. (iii). Text read as follows: “Clause (ii) shall not apply to inquiries made after
Subsec. (i). Pub. L. 105–33, § 4022(b)(1)(B), substituted “Medicare Payment Advisory Commission” for “Prospective Payment Assessment Commission” in introductory provisions.
1996—Subsec. (b)(5)(B). Pub. L. 104–226, § 1(b)(1)(A), substituted “under subparagraph (A) for purposes of carrying out this subsection” for “under—
“(i) subparagraph (A), and
“(ii) section 1320b–14 of this title,
for purposes of carrying out this subsection”.
Subsec. (b)(5)(C)(i). Pub. L. 104–226, § 1(b)(1)(B), substituted “disclosed under subparagraph (B)” for “disclosed under subparagraph (B)(i)”.
Subsec. (h). Pub. L. 104–224 struck out subsec. (h) which required Secretary to provide registry of all cardiac pacemaker devices and pacemaker leads for which payment was made under this chapter.
1994—Subsec. (a)(1)(F). Pub. L. 103–432, § 145(c)(1), substituted “is not conducted by a facility described in section 1395m(c)(1)(B) of this title” for “or which does not meet the standards established under section 1395m(c)(3) of this title”.
Subsec. (a)(14). Pub. L. 103–432, § 156(a)(2)(D)(i), inserted “or” at end.
Pub. L. 103–432, § 147(e)(6), substituted “section 1395x(s)(2)(K)(i) or 1395x(s)(2)(K)(iii) of this title” for “section 1395x(s)(2)(K)(i) of this title”.
Subsec. (a)(15). Pub. L. 103–432, § 156(a)(2)(D)(ii), substituted period for “; or” at end.
Subsec. (a)(16). Pub. L. 103–432, § 156(a)(2)(D)(iii), struck out par. (16) which read as follows: “furnished in connection with a surgical procedure for which a second opinion is required under section 1320c–13(c)(2) of this title and has not been obtained.”
Subsec. (b)(1)(A)(i)(II). Pub. L. 103–432, § 151(c)(1)(A), substituted “older (and the spouse age 65 or older of any individual) who has current employment status with an employer” for “over (and the individual’s spouse age 65 or older) who is covered under the plan by virtue of the individual’s current employment status with an employer”.
Subsec. (b)(1)(A)(ii). Pub. L. 103–432, § 151(c)(1)(B), substituted “employer that has 20 or more employees” for “employer or employee organization that has 20 or more individuals in current employment status”.
Subsec. (b)(1)(A)(v). Pub. L. 103–432, § 151(c)(9)(B), made technical amendment to directory language of Pub. L. 103–66, § 13561(e)(1)(D). See 1993 Amendment note below.
Subsec. (b)(1)(C). Pub. L. 103–432, § 151(c)(5), substituted “paying benefits secondary to this subchapter when” for “taking into account that” in closing provisions.
Pub. L. 103–432, § 151(c)(4), substituted “this subparagraph” for “clauses (i) and (ii)” after “
Subsec. (b)(2)(B)(i). Pub. L. 103–432, § 151(b)(3)(A), (B), substituted “Repayment required” for “Primary plans” in heading and inserted at end “If reimbursement is not made to the appropriate Trust Fund before the expiration of the 60-day period that begins on the date such notice or other information is received, the Secretary may charge interest (beginning with the date on which the notice or other information is received) on the amount of the reimbursement until reimbursement is made (at a rate determined by the Secretary in accordance with regulations of the Secretary of the Treasury applicable to charges for late payments).”
Subsec. (b)(2)(C). Pub. L. 103–432, § 151(a)(1)(C), added subpar. (C).
Subsec. (b)(3)(C). Pub. L. 103–432, § 157(b)(7), substituted “group health plan or a large group health plan” for “group health plan” in heading and text, struck out “, unless such incentive is also offered to all individuals who are eligible for coverage under the plan” after “(as defined in paragraph (2)(A))”, and substituted “(other than subsections (a) and (b))” for “(other than the first sentence of subsection (a) and other than subsection (b))”.
Subsec. (b)(5)(C)(i). Pub. L. 103–432, § 151(c)(6), substituted “section 6103(l)(12)(E)(iii) of such Code” for “section 6103(l)(12)(D)(iii) of such Code”.
Subsec. (b)(5)(D). Pub. L. 103–432, § 151(a)(1)(A), added subpar. (D).
Subsec. (b)(6). Pub. L. 103–432, § 151(a)(2)(A), added par. (6).
1993—Subsec. (b)(1)(A)(i). Pub. L. 103–66, § 13561(e)(1)(A), amended subcls. (I) and (II) generally. Prior to amendment, subcls. (I) and (II) read as follows:
“(I) may not take into account, for any item or service furnished to an individual 65 years of age or older at the time the individual is covered under the plan by reason of the current employment of the individual (or the individual’s spouse), that the individual is entitled to benefits under this subchapter under section 426(a) of this title, and
“(II) shall provide that any employee age 65 or older, and any employee’s spouse age 65 or older, shall be entitled to the same benefits under the plan under the same conditions as any employee, and the spouse of such employee, under age 65.”
Subsec. (b)(1)(A)(ii). Pub. L. 103–66, § 13561(e)(1)(B), substituted “unless the plan is a plan of, or contributed to by, an employer or employee organization that has 20 or more individuals in current employment status” for “unless the plan is sponsored by or contributed to by an employer that has 20 or more employees”.
Subsec. (b)(1)(A)(iii). Pub. L. 103–66, § 13561(e)(1)(C), substituted “by virtue of current employment status with an employer that does not have 20 or more individuals in current employment status for each working day in each of 20 or more calendar weeks in the current calendar year and” for “by virtue of employment with an employer that does not have 20 or more employees for each working day in each of 20 or more calendar weeks in the current calendar year or”.
Subsec. (b)(1)(A)(iv). Pub. L. 103–66, § 13561(c)(2), substituted “Subparagraph (C) shall apply instead of clause (i)” for “Clause (i) shall not apply” and inserted “(without regard to entitlement under section 426 of this title)” after “individual is, or”.
Subsec. (b)(1)(A)(v). Pub. L. 103–66, § 13561(e)(1)(D), as amended by Pub. L. 103–432, § 151(c)(9)(B), inserted before period at end “, without regard to section 5000(d) of such Code”.
Subsec. (b)(1)(B). Pub. L. 103–66, § 13561(e)(1)(E), substituted “individuals” for “active individuals” in heading.
Subsec. (b)(1)(B)(i). Pub. L. 103–66, § 13561(e)(1)(F), substituted “clause (iv)) may not take into account that an individual (or a member of the individual’s family) who is covered under the plan by virtue of the individual’s current employment status with an employer” for “clause (iv)(II)) may not take into account that an active individual (as defined in clause (iv)(I))”.
Subsec. (b)(1)(B)(ii). Pub. L. 103–66, § 13561(c)(2), substituted “Subparagraph (C) shall apply instead of clause (i)” for “Clause (i) shall not apply” and inserted “(without regard to entitlement under section 426 of this title)” after “individual is, or”.
Subsec. (b)(1)(B)(iii). Pub. L. 103–66, § 13561(b), substituted “1998” for “1995”.
Subsec. (b)(1)(B)(iv). Pub. L. 103–66, § 13561(e)(1)(G), amended heading and text generally. Prior to amendment, text defined “active individual” and “large group health plan”.
Subsec. (b)(1)(C). Pub. L. 103–66, § 13561(c)(1), (3), substituted “or eligible for benefits under this subchapter under” for “benefits under this subchapter solely by reason of” in cl. (i) and concluding provisions and substituted “before
Subsec. (b)(1)(E). Pub. L. 103–66, § 13561(e)(1)(H), added cls. (ii) and (iii).
Pub. L. 103–66, § 13561(d)(1), added subpar. (E).
Subsec. (b)(5)(B). Pub. L. 103–66, § 13581(b)(1)(A), substituted “under—” for “under subparagraph (A) for the purposes of carrying out this subsection.” and added cls. (i) and (ii) and concluding provisions.
Subsec. (b)(5)(C)(i). Pub. L. 103–66, § 13581(b)(1)(B), substituted “subparagraph (B)(i)” for “subparagraph (B)”.
Subsec. (b)(5)(C)(iii). Pub. L. 103–66, § 13561(a)(1), substituted “1998” for “1995”.
1990—Subsec. (a). Pub. L. 101–508, § 4161(a)(3)(C)(iii), inserted at end “Paragraph (7) shall not apply to Federally qualified health center services described in section 1395x(aa)(3)(B) of this title.”
Subsec. (a)(1)(A). Pub. L. 101–508, § 4163(d)(2)(A)(i), substituted “a succeeding subparagraph” for “subparagraph (B), (C), (D), or (E)”.
Subsec. (a)(1)(F). Pub. L. 101–508, § 4163(d)(2)(A)(ii)–(iv), added subpar. (F).
Subsec. (a)(2). Pub. L. 101–508, § 4161(a)(3)(C)(i), inserted before semicolon at end “, except in the case of Federally qualified health center services”.
Subsec. (a)(3). Pub. L. 101–508, § 4161(a)(3)(C)(ii), inserted “, in the case of Federally qualified health center services, as defined in section 1395x(aa)(3) of this title,” after “section 1395x(aa)(1) of this title,”.
Subsec. (a)(7). Pub. L. 101–508, § 4163(d)(2)(B), inserted “or under paragraph (1)(F)” after “paragraph (1)(B)”.
Pub. L. 101–508, § 4153(b)(2)(B), inserted “(other than eyewear described in section 1395x(s)(8) of this title)” after first reference to “eyeglasses”.
Subsec. (a)(14). Pub. L. 101–508, § 4157(c)(1), inserted “, services described by section 1395x(s)(2)(K)(i) of this title, certified nurse-midwife services, qualified psychologist services, and services of a certified registered nurse anesthetist,” after “this paragraph)” and struck out before semicolon at end “or are services of a certified registered nurse anesthetist”.
Subsec. (a)(15). Pub. L. 101–508, § 4107(b), designated existing provisions as par. (A), substituted “, or” for “; or” at end, and added par. (B).
Subsec. (b)(1)(B)(iii). Pub. L. 101–508, § 4203(b), substituted “
Subsec. (b)(1)(C). Pub. L. 101–508, § 4203(c)(1)(B), inserted at end “Effective for items and services furnished on or after
Subsec. (b)(1)(C)(i). Pub. L. 101–508, § 4203(c)(1)(A), substituted “during the 12-month period which begins with the first month in which the individual becomes entitled to benefits under part A of this subchapter under the provisions of section 426–1 of this title, or, if earlier, the first month in which the individual would have been entitled to benefits under such part under the provisions of section 426–1 of this title if the individual had filed an application for such benefits; and” for “during the 12-month period which begins with the earlier of—
“(I) the month in which a regular course of renal dialysis is initiated, or
“(II) in the case of an individual who receives a kidney transplant, the first month in which he would be eligible for benefits under part A of this subchapter (if he had filed an application for such benefits) under the provisions of section 426–1(b)(1)(B) of this title; and”.
Subsec. (b)(3)(C). Pub. L. 101–508, § 4204(g)(1), added subpar. (C).
Subsec. (b)(5)(C)(iii). Pub. L. 101–508, § 4203(a)(1), substituted “
1989—Pub. L. 101–239, § 6202(b)(1)(A), inserted “and medicare as secondary payer” in section catchline.
Subsec. (a)(1)(A). Pub. L. 101–234 repealed Pub. L. 100–360, § 204(d)(2)(A)(i), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (a)(1)(E). Pub. L. 101–239, § 6103(b)(3)(B), substituted “section 1320b–12” for “section 1395ll(c)”.
Subsec. (a)(1)(F). Pub. L. 101–239, § 6115(b), inserted before semicolon at end “, and, in the case of screening pap smear, which is performed more frequently than is provided under 1395x(nn) of this title”.
Pub. L. 101–234 repealed Pub. L. 100–360, § 204(d)(2)(A)(ii)–(iv), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (a)(1)(G), (6), (7). Pub. L. 101–234 repealed Pub. L. 100–360, §§ 204(d)(2)(B), 205(e)(1), and provided that the provisions of law amended or repealed by such sections are restored or revived as if such sections had not been enacted, see 1988 Amendment notes below.
Subsec. (a)(14). Pub. L. 101–239, § 6003(g)(3)(D)(xi), substituted “hospital or rural primary care hospital” for “hospital” in three places.
Subsec. (b). Pub. L. 101–239, § 6202(b)(1)(B), amended heading and text generally, substituting pars. (1) to (4) relating to medicare as secondary payer for former pars. (1) to (5) relating to items or services paid under workmen’s compensation laws and end stage renal disease program.
Subsec. (b)(1)(D). Pub. L. 101–239, § 6202(e)(1), added subpar. (D).
Subsec. (b)(5). Pub. L. 101–239, § 6202(a)(2)(A), added par. (5).
Subsec. (c). Pub. L. 101–234 repealed Pub. L. 100–360, § 202(d), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (e)(1). Pub. L. 101–239, § 6411(d)(2), inserted “, not including items or services furnished in an emergency room of a hospital” after “(other than an emergency item or service”.
1988—Subsec. (a)(1)(A). Pub. L. 100–360, § 204(d)(2)(A)(i), substituted “a succeeding subparagraph” for “subparagraph (B), (C), (D), or (E)”.
Subsec. (a)(1)(F). Pub. L. 100–360, § 204(d)(2)(A)(ii)–(iv), added subpar. (F) relating to screening mammography.
Subsec. (a)(1)(G). Pub. L. 100–360, § 205(e)(1)(A), as amended by Pub. L. 100–485, § 608(d)(7), added subpar. (G) relating to in-home care for chronically dependent individuals.
Subsec. (a)(6). Pub. L. 100–360, § 205(e)(1)(B), inserted “and except, in the case of in-home care, as is otherwise permitted under paragraph (1)(G)” after “paragraph (1)(C)”.
Subsec. (a)(7). Pub. L. 100–360, § 204(d)(2)(B), inserted “or under paragraph (1)(F)” after “(1)(B)”.
Subsec. (a)(15). Pub. L. 100–360, § 411(f)(4)(D)(i), inserted “(including subsequent insertion of an intraocular lens)” after “operation”.
Subsec. (c). Pub. L. 100–360, § 202(d), designated existing provisions as par. (1), redesignated former par. (1) as subpar. (A), redesignated former subpars. (A) to (D) as cls. (i) to (iv), redesignated former par. (2) as subpar. (B), redesignated former subpar. (A) as cl. (i) and substituted “subparagraph (A)” for “paragraph (1)”, redesignated former subpar. (B) as cl. (ii), and added par. (2) prohibiting payment for expenses incurred for a covered outpatient drug if the drug is dispensed in a quantity exceeding a supply of 30 days with an exception.
Subsec. (e)(1). Pub. L. 100–360, § 411(i)(4)(D)(i), as amended by Pub. L. 100–485, § 608(d)(24)(C)(i), designated existing provisions of subsec. (e) as par. (1), redesignated former par. (1) as subpar. (A), substituted “, 1320a–7a, 1320c–5 or 1395u(j)(2)” for “or section 1320a–7a”, redesignated former par. (2) as subpar. (B), and substituted “, 1320a–7a, 1320c–5 or 1395u(j)(2)” for “or section 1320a–7a”.
Subsec. (e)(2). Pub. L. 100–360, § 411(i)(4)(D)(ii), as amended by Pub. L. 100–485, § 608(d)(24)(C)(ii), amended former section 1395aaa of this title by striking out the catchline “Limitation of liability of beneficiaries with respect to services furnished by excluded individuals and entities”, substituting “(2)” for the section designation, inserting “1395u(j)(2),” in text, and transferring the text to par. (2) of subsec. (e) of this section.
1987—Subsec. (a)(1)(A). Pub. L. 100–203, § 4085(i)(15), substituted “(D), or (E)” for “or (D)”.
Subsec. (a)(8). Pub. L. 100–203, § 4072(c), inserted “, other than shoes furnished pursuant to section 1395x(s)(12) of this title” before semicolon.
Subsec. (a)(14). Pub. L. 100–203, § 4085(i)(16), substituted “a patient” for “an patient”.
Pub. L. 100–203, § 4009(j)(6)(C), made technical amendment to Pub. L. 99–509, § 9320(h)(1). See 1986 Amendment note below.
Subsec. (b)(2)(A)(ii). Pub. L. 100–203, § 4036(a)(1), substituted “can reasonably be expected to be made under such a plan” for “the Secretary determines will be made under such a plan as promptly as would otherwise be the case if payment were made by the Secretary under this subchapter”.
Subsec. (b)(4)(B)(i). Pub. L. 100–203, § 4034(a), substituted “subsection (b) of section 5000 of the Internal Revenue Code of 1986 without regard to subsection (d) of such section” for “section 5000(b) of the Internal Revenue Code of 1986”.
Subsec. (d). Pub. L. 100–93, § 8(c)(1)(A), struck out subsec. (d), which provided that no payment be made under this subchapter for any item or services to an individual by a person where Secretary determines such person knowingly and willfully made any false statement or representation of a material fact, submitted excessive bills or requests, or furnished excessive services or supplies, and provided a dissatisfied person with a hearing on determination of the Secretary.
Subsec. (e) [formerly § 1395aaa]. Pub. L. 100–93, § 10, added par. (2). See 1988 Amendment note above.
Pub. L. 100–93, § 8(c)(1)(B), amended subsec. (e) generally. Prior to amendment, subsec. (e) read as follows: “No payment may be made under this subchapter with respect to any item or service furnished by a physician or other individual during the period when he is barred pursuant to section 1320a–7 of this title from participation in the program under this subchapter.”
Subsec. (h)(1)(B). Pub. L. 100–203, § 4039(c)(1)(A), substituted “law (and any amount paid to a provider under any such warranty),” for “law,”.
Subsec. (h)(1)(D). Pub. L. 100–203, § 4039(c)(1)(B), inserted “in determining the amount subject to repayment under paragraph (2)(C),” after “(3),”.
Subsec. (h)(2)(C). Pub. L. 100–203, § 4039(c)(1)(C), added subpar. (C).
Subsec. (h)(4). Pub. L. 100–93, § 8(c)(3), substituted “subsections (c), (f), and (g) of section 1320a–7 of this title” for “paragraphs (2) and (3) of subsection (d) of this section”.
Subsec. (h)(4)(B). Pub. L. 100–203, § 4039(c)(1)(D), substituted “, has improperly” for “or has improperly” and inserted “or has failed to make repayment to the Secretary as required under paragraph (2)(C),” after “(2)(B),”.
1986—Subsec. (a)(1)(E). Pub. L. 99–509, § 9316(b), added subpar. (E).
Subsec. (a)(14). Pub. L. 99–509, § 9343(c)(1), substituted “patient” for “inpatient”.
Pub. L. 99–509, § 9320(h)(1), as amended by Pub. L. 100–203, § 4009(j)(6)(C), inserted “or are services of a certified registered nurse anesthetist” after “hospital” at end.
Subsec. (a)(15). Pub. L. 99–272, § 9307(a), added par. (15).
Subsec. (a)(16). Pub. L. 99–272, § 9401(c)(1), added par. (16).
Subsec. (b)(2)(A). Pub. L. 99–514 substituted “Internal Revenue Code of 1986” for “Internal Revenue Code of 1954”.
Subsec. (b)(3)(A)(i). Pub. L. 99–272, § 9201(a)(1), substituted “(or to the spouse of such individual)” for “who is under 70 years of age during any part of such month (or to the spouse of such individual, if the spouse is under 70 years of age during any part of such month)”.
Subsec. (b)(3)(A)(iii). Pub. L. 99–272, § 9201(a)(2), struck out “and ending with the month before the month in which such individual attains the age of 70” after “section 426(a) of this title”.
Subsec. (b)(3)(A)(iv). Pub. L. 99–514 substituted “Internal Revenue Code of 1986” for “Internal Revenue Code of 1954”.
Subsec. (b)(4). Pub. L. 99–509, § 9319(a), added par. (4).
Subsec. (b)(5). Pub. L. 99–509, § 9319(b), added par. (5).
1984—Subsec. (a)(12). Pub. L. 98–369, § 2354(b)(30), struck out second comma after “dental procedure”.
Subsec. (b)(1). Pub. L. 98–369, § 2344(a), substituted “to be made promptly” for “to be made” and “has been or could be made under such a law” for “has been made under such a law”, and inserted “In order to recover payment made under this subchapter for an item or service, the United States may bring an action against any entity which would be responsible for payment with respect to such item or service (or any portion thereof) under such a law, policy, plan, or insurance, or against any entity (including any physician or provider) which has been paid with respect to such item or service under such law, policy, plan, or insurance, and may join or intervene in any action related to the events that gave rise to the need for such item or service. The United States shall be subrogated (to the extent of payment made under this subchapter for an item or service) to any right of an individual or any other entity to payment with respect to such item or service under such a law, policy, plan, or insurance.”
Subsec. (b)(2)(B). Pub. L. 98–369, § 2344(b), substituted “has been or could be made under a plan” for “has been made under a plan”, and inserted “In order to recover payment made under this subchapter for an item or service, the United States may bring an action against any entity which would be responsible for payment with respect to such item or service (or any portion thereof) under such a plan, or against any entity (including any physician or provider) which has been paid with respect to such item or service under such plan, and may join or intervene in any action related to the events that gave rise to the need for such item or service. The United States shall be subrogated (to the extent of payment made under this subchapter for an item or service) to any right of an individual or any other entity to payment with respect to such item or service under such a plan.”
Subsec. (b)(3)(A)(i). Pub. L. 98–369, § 2301(a), struck out “over 64 but” before “under 70 years” in two places.
Subsec. (b)(3)(A)(ii). Pub. L. 98–369, § 2344(c), substituted “has been or could be made under a group health plan” for “has been made under a group health plan”, and inserted “In order to recover payment made under this title for an item or service, the United States may bring an action against any entity which would be responsible for payment with respect to such item or service (or any portion thereof) under such a plan, or against any entity (including any physician or provider) which has been paid with respect to such item or service under such plan, and may join or intervene in any action related to the events that gave rise to the need for such item or service. The United States shall be subrogated (to the extent of payment made under this title for an item or service) to any right of an individual or any other entity to payment with respect to such item or service under such a plan.”
Subsec. (b)(3)(A)(iii). Pub. L. 98–369, § 2354(b)(31), inserted “before the month” after “ending with the month”.
Subsec. (h). Pub. L. 98–369, § 2304(c), added subsec. (h).
Subsec. (i). Pub. L. 98–369, § 2313(c), added subsec. (i).
1983—Subsec. (a)(1)(A). Pub. L. 98–21, § 601(f)(1), inserted reference to subpar. (D).
Subsec. (a)(1)(D). Pub. L. 98–21, § 601(f)(2)–(4), added subpar. (D).
Subsec. (a)(14). Pub. L. 98–21, § 602(e), added par. (14).
Subsec. (b)(3)(A)(i). Pub. L. 97–448 inserted “in any month” after “service furnished”, and “during any part of such month” after “70 years of age” wherever appearing.
1982—Subsec. (a)(1). Pub. L. 97–248, § 122(f)(1), designated existing provisions as subpars. (A) and (B), in subpar. (A) as so designated inserted exception to provisions for items and services described in subpar. (B) or (C), substituted “and” for “or” as the connector between provisions, and added subpar. (C).
Subsec. (a)(6). Pub. L. 97–248, § 122(f)(2), inserted “(except, in the case of hospice care, as is otherwise permitted under paragraph (1)(C))”.
Subsec. (a)(7). Pub. L. 97–248, § 122(f)(3), substituted “paragraph (1)(B)” for “paragraph (1)”.
Subsec. (a)(9). Pub. L. 97–248, § 122(f)(4), inserted “(except, in the case of hospice care, as is otherwise permitted under paragraph (1)(C))”.
Subsec. (b)(1). Pub. L. 97–248, § 128(a)(2), struck out “or plan” after “service has been made under such a law”.
Subsec. (b)(2)(A). Pub. L. 97–248, § 128(a)(3), substituted “section 162(i)(2)” for “section 162(h)(2)”.
Subsec. (b)(2)(B). Pub. L. 97–248, § 128(a)(4), inserted “furnished” before “to an individual”.
Subsec. (b)(3). Pub. L. 97–248, § 116(b), added par. (3).
Subsec. (d)(1)(C). Pub. L. 97–248, § 148(a), substituted “on the basis of information acquired by the Secretary in the administration of this subchapter” for “, on the basis of reports transmitted to him in accordance with section 1320c–6 of this title (or, in the absence of any such report, on the basis of such data as he acquires in the administration of the program under this subchapter),”.
Subsec. (f). Pub. L. 97–248, § 122(g)(1), substituted “paragraph (1)(A)” for “paragraph (1)”.
Subsec. (g). Pub. L. 97–248, § 142, added subsec. (g).
1981—Subsec. (b). Pub. L. 97–35, § 2146(a), designated existing provisions as par. (1) and added par. (2).
Subsec. (c). Pub. L. 97–35, § 2103(a)(1), added subsec. (c).
Subsec. (f). Pub. L. 97–35, § 2152(a), added subsec. (f).
1980—Subsec. (a)(1). Pub. L. 96–611, § 1(a)(3)(A), inserted “, or, in the case of items and services described in section 1395x(s)(10) of this title, which are not reasonable and necessary for the prevention of illness” after “of a malformed body member”.
Subsec. (a)(7). Pub. L. 96–611, § 1(a)(3)(B), inserted “(except as otherwise allowed under section 1395x(s)(10) of this title and paragraph (1))” after “immunizations”.
Subsec. (a)(12). Pub. L. 96–499, § 936(c), inserted “or because of the severity of the dental procedure,” after “and clinical status”.
Subsec. (a)(13)(C). Pub. L. 96–499, § 939(a), struck out “, warts,” after “corns”.
Subsec. (b). Pub. L. 96–499, § 953, inserted “or under an automobile or liability insurance policy or plan (including a self-insured plan) or under no fault insurance” and “, policy, plan, or insurance” after “or a State” and “, policy, plan, or insurance” after “law or plan” and inserted provision authorizing the Secretary to waive the provisions of this subsection in the case of an individual claim if he determined that the probability of recovery or amount involved did not warrant the pursuit of the claim.
Subsec. (d)(4). Pub. L. 96–272 added par. (4).
Subsec. (e). Pub. L. 96–499, § 913(b), substituted provisions barring payment under this subchapter with respect to items or services furnished by a physician or other individual during a period when such physician or other individual was barred pursuant to section 1320a–7 of this title from participation under this subchapter for provisions authorizing the Secretary to suspend a physician or individual practitioner from participation under this subchapter upon determining that such physician or practitioner had been convicted of a criminal offense related to such physician’s or practitioner’s involvement in the programs under this subchapter or the program under subchapter XIX of this chapter.
1977—Subsec. (a)(3). Pub. L. 95–210 substituted “except in the case of rural health clinic services, as defined in section 1395x(aa)(1) of this title, and in such other cases as the Secretary may specify” for “except in such cases as the Secretary may specify”.
Subsec. (d)(1)(B). Pub. L. 95–142, § 13(b)(1), struck out requirement for concurrence of appropriate program review team for finding of Secretary under this paragraph.
Subsec. (d)(1)(C). Pub. L. 95–142, § 13(b)(2), substituted provisions relating to determinations by the Secretary on the basis of reports transmitted to him in accordance with section 1320c–6 of this title or other data acquired in the administration of this subchapter, for provisions relating to determinations by the Secretary with the concurrence of appropriate review team members.
Subsec. (d)(4). Pub. L. 95–142, § 13(a), struck out par. (4) which set forth provisions relating to appointment and functions of program review teams.
Subsec. (e). Pub. L. 95–142, § 7(a), added subsec. (e).
1975—Subsec. (c). Pub. L. 94–182 struck out subsec. (c) prohibiting payments to Federal employees under this subchapter unless a determination and certification by the Secretary of a modification of any health benefits plan under chapter 89 of Title 5 was made which would allow a Federal employee benefits under part A or B of this subchapter.
1974—Subsec. (c). Pub. L. 93–480 substituted “
1973—Subsec. (a)(12). Pub. L. 93–233 substituted “the provision of such dental services if the individual, because of his underlying medical condition and clinical status, requires hospitalization in connection with the provision of such services” for “a dental procedure where the individual suffers from impairments of such severity as to require hospitalization”.
1972—Subsec. (a)(4). Pub. L. 92–603, § 211(c)(1), inserted reference to physicians’ services and ambulance services furnished an individual in conjunction with emergency inpatient hospital services.
Subsec. (a)(12). Pub. L. 92–603, § 256(c), authorized payment under part A in the case of inpatient hospital services in connection with a dental procedure where the individual suffers from impairments of such severity as to require hospitalization.
Subsec. (c). Pub. L. 92–603, § 210, added subsec. (c).
Subsec. (d). Pub. L. 92–603, § 229(a), added subsec. (d).
1968—Subsec. (a)(7). Pub. L. 90–248, § 128, prohibited payment for procedures performed (during the course of any eye examination) to determine the refractive state of the eyes.
Subsec. (a)(13). Pub. L. 90–248, § 127(b), added par. (13).
Effective Date Of Amendment
Pub. L. 112–242, title II, § 202(b),
Pub. L. 112–242, title II, § 205(b),
Amendment by Pub. L. 112–40 applicable to contracts entered into or renewed on or after
Amendment by section 4103(d) of Pub. L. 111–148 applicable to services furnished on or after
Amendment by section 101(a)(3), (b)(3), (4) of Pub. L. 110–275 applicable to services furnished on or after
Pub. L. 110–275, title I, § 135(a)(2)(B),
Amendment by section 143(b)(7) of Pub. L. 110–275 applicable to services furnished on or after
Amendment by section 152(b)(1)(D) of Pub. L. 110–275 applicable to services furnished on or after
Amendment by Pub. L. 109–171 applicable to services furnished on or after
Pub. L. 108–173, title III, § 301(d),
Amendment by section 611(d)(1) of Pub. L. 108–173 applicable to services furnished on or after
Amendment by section 612(c) of Pub. L. 108–173 applicable to tests furnished on or after
Amendment by section 613(c) of Pub. L. 108–173 applicable to tests furnished on or after
Pub. L. 108–173, title VII, § 731(a)(2),
Pub. L. 108–173, title VII, § 731(b)(2),
Pub. L. 108–173, title IX, § 944(a)(2),
Amendment by section 948(a) of Pub. L. 108–173 effective, except as otherwise provided, as if included in the enactment of BIPA [the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, H.R. 5661, as enacted by section 1(a)(6) of Public Law 106–554], see section 948(e) of Pub. L. 108–173, set out as a note under section 1314 of this title.
Pub. L. 108–173, title IX, § 950(b),
Pub. L. 107–105, § 3(b),
Amendment by section 1(a)(6) [title I, § 102(c)] of Pub. L. 106–554 applicable to services furnished on or after
Amendment by section 1(a)(6) [title III, § 313(a)] of Pub. L. 106–554 applicable to services furnished on or after
Amendment by section 1(a)(6) [title IV, § 432(b)(1)] of Pub. L. 106–554 applicable to services furnished on or after
Amendment by section 1(a)(6) [title V, § 522(b)] of Pub. L. 106–554 applicable with respect to a review of any national or local coverage determination filed, a request to make such a determination made, and a national coverage determination made, on or after
Amendment by section 1000(a)(6) [title III, § 305(b)] of Pub. L. 106–113 applicable to payments for services provided on or after
Amendment by section 1000(a)(6) [title III, § 321(k)(10)] 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 Pub. L. 105–12 effective
Amendment by section 4022(b)(1)(B) of Pub. L. 105–33 effective
Amendment by section 4102(c) of Pub. L. 105–33 applicable to items and services furnished on or after
Amendment by section 4103(c) of Pub. L. 105–33 applicable to items and services furnished on or after
Amendment by section 4104(c)(3) of Pub. L. 105–33 applicable to items and services furnished on or after
Amendment by section 4201(c)(1) of Pub. L. 105–33 applicable to services furnished on or after
Amendment by section 4432(b)(1) of Pub. L. 105–33 applicable to items and services furnished on or after
Amendment by section 4507(a)(2)(B) of Pub. L. 105–33 applicable with respect to contracts entered into on and after
Amendment by section 4511(a)(2)(C) of Pub. L. 105–33 applicable with respect to services furnished and supplies provided on and after
Amendment by section 4541(b) of Pub. L. 105–33 applicable to services furnished on or after
Amendment by section 4603(c)(2)(C) of Pub. L. 105–33 applicable to cost reporting periods beginning on or after
Pub. L. 105–33, title IV, § 4614(c),
Pub. L. 105–33, title IV, § 4632(b),
Pub. L. 105–33, title IV, § 4633(c),
Amendment by section 145(c)(1) of Pub. L. 103–432 applicable to mammography furnished by a facility on and after the first date that the certificate requirements of section 263b(b) of this title apply to such mammography conducted by such facility, see section 145(d) of Pub. L. 103–432, set out as a note under section 1395m of this title.
Amendment by section 147(e)(6) 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, § 151(a)(2)(B),
Pub. L. 103–432, title I, § 151(b)(3)(C),
Pub. L. 103–432, title I, § 151(c)(1), (9),
Pub. L. 103–432, title I, § 151(c)(4),
Pub. L. 103–432, title I, § 151(c)(5), (6),
Amendment by section 156(a)(2)(D) of Pub. L. 103–432 applicable to services provided on or after
Pub. L. 103–432, title I, § 157(b)(8),
Pub. L. 103–432, title I, § 151(c)(10),
Amendment by section 13561(d)(1) of Pub. L. 103–66 effective 90 days after
Pub. L. 103–66, title XIII, § 13561(e)(1)(D),
Pub. L. 103–66, title XIII, § 13581(d),
Amendment by section 4153(b)(2)(B) of Pub. L. 101–508 applicable to items furnished on or after
Amendment by section 4157(c)(1) of Pub. L. 101–508 applicable to services furnished on or after
Amendment by section 4161(a)(3)(C) of Pub. L. 101–508 applicable to services furnished on or after
Amendment by section 4163(d)(2)(A)(i)–(iii), (B) of Pub. L. 101–508 applicable to screening mammography performed on or after
Pub. L. 101–508, title IV, § 4163(d)(3), as added by Pub. L. 103–432, title I, § 147(f)(5)(A),
Pub. L. 101–508, title IV, § 4204(g)(2),
Amendment by section 6115(b) of Pub. L. 101–239 applicable to screening pap smears performed on or after
Amendment by section 6202(b)(1) of Pub. L. 101–239 applicable to items and services furnished after
Pub. L. 101–239, title VI, § 6202(e)(2),
Amendment by Pub. L. 101–234 effective
Amendment by Pub. L. 100–485 effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100–360, see section 608(g)(1) of Pub. L. 100–485, set out as a note under section 704 of this title.
Amendment by section 202(d) of Pub. L. 100–360 applicable to items dispensed on or after
Amendment by section 204(d)(2) of Pub. L. 100–360 applicable to screening mammography performed on or after
Amendment by section 205(e)(1) 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(i)(4)(D) of Pub. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203, effective as if included in the enactment of that provision in Pub. L. 100–203, see section 411(a) of Pub. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.
Pub. L. 100–360, title IV, § 411(f)(4)(D)(ii),
Pub. L. 100–203, title IV, § 4009(j)(6),
Pub. L. 100–203, title IV, § 4034(b),
Pub. L. 100–203, title IV, § 4036(a)(2),
Pub. L. 100–203, title IV, § 4039(c)(2),
For effective date of amendment by section 4072(c) of Pub. L. 100–203, see section 4072(e) of Pub. L. 100–203, set out as a note under section 1395x of this title.
Amendment by Pub. L. 100–93 effective at end of fourteen-day period beginning
Pub. L. 99–509, title IX, § 9319(f),
Amendment by section 9320(h)(1) of Pub. L. 99–509 applicable to services furnished on or after
Amendment by section 9343(c)(1) of Pub. L. 99–509 applicable to services furnished after
Pub. L. 99–272, title IX, § 9201(d)(1),
Amendment by section 9307(a) of Pub. L. 99–272 applicable to services performed on or after
Pub. L. 98–369, div. B, title III, § 2301(c)(1),
Amendment by section 2304(c) of Pub. L. 98–369 applicable to pacemaker devices and leads implanted or removed on or after the effective date of final regulations promulgated to carry out such amendment, see section 2304(d) of Pub. L. 98–369, set out as a note below.
Pub. L. 98–369, div. B, title III, § 2313(e),
Pub. L. 98–369, div. B, title III, § 2344(d),
Amendment by section 2354(b)(30), (31) of Pub. L. 98–369 effective
Amendment by section 601(f) of Pub. L. 98–21 applicable to items and services furnished by or under arrangement with a hospital beginning with its first cost reporting period that begins on or after
Amendment by Pub. L. 97–448 effective as if originally included as a part of this section as this section was amended by the Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97–248, see section 309(c)(2) of Pub. L. 97–448, set out as a note under section 426–1 of this title.
Amendment by section 116(b) of Pub. L. 97–248 applicable with respect to items and services furnished on or after
Amendment by section 122(f), (g)(1) of Pub. L. 97–248 applicable to hospice care provided on or after
Amendment by section 128(a)(2)–(4) of Pub. L. 97–248 effective as if originally included as part of this section as this section was amended by the Omnibus Budget Reconciliation Act of 1981, Pub. L. 97–35, see section 128(e)(2) of Pub. L. 97–248, set out as a note under section 1395x of this title.
Amendment by sections 142 and 148(a) of Pub. L. 97–248 effective with respect to contracts entered into or renewed on or after
Pub. L. 97–35, title XXI, § 2103(a)(2),
Pub. L. 97–35, title XXI, § 2146(c)(1),
Amendment by Pub. L. 96–611 effective
Amendment by section 936(c) of Pub. L. 96–499 applicable with respect to services provided on or after
Pub. L. 96–499, title IX, § 939(b),
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, § 13(c),
Amendment by Pub. L. 93–233 effective with respect to admissions subject to the provisions of section 1395(a)(2) of this title which occur after
Amendment by section 211(c)(1) of Pub. L. 92–603 applicable to services furnished with respect to admissions occurring after
Amendment by section 256(c) of Pub. L. 92–603 applicable with respect to admissions occurring after the second month following the month of enactment of Pub. L. 92–603 which was approved on
Amendment by section 127(b) of Pub. L. 90–248 applicable with respect to services furnished after
Miscellaneous
For construction of amendment by section 153(b)(2) of Pub. L. 110–275, see section 153(b)(4) of Pub. L. 110–275, set out as a note under section 1395rr of this title.
Pub. L. 110–173, title I, § 111(b),
Pub. L. 108–173, title VII, § 731(b)(3),
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 IX, § 943,
Pub. L. 108–173, title IX, § 953(b),
Pub. L. 105–33, title IV, § 4614(b),
Pub. L. 103–432, title I, § 151(a)(1)(B),
Pub. L. 103–66, title XIII, § 13561(f),
Pub. L. 101–508, title IV, § 4203(c)(2),
Pub. L. 101–239, title VI, § 6202(a)(2)(B),
Pub. L. 100–203, title IV, § 4009(b),
Pub. L. 99–514, title XVIII, § 1895(b)(16)(C),
Pub. L. 99–509, title IX, § 9305(f),
[Pub. L. 101–508, title IV, § 4008(a)(3),
Pub. L. 99–509, title IX, § 9319(e),
Pub. L. 99–272, title IX, § 9126(c),
Pub. L. 99–272, title IX, § 9205,
[Pub. L. 103–432, title I, § 158(b)(2),
Pub. L. 99–272, title IX, § 9307(d),
Pub. L. 98–369, div. B, title III, § 2304(d),
Pub. L. 98–369, div. B, title III, § 2325,
Pub. L. 98–21, title VI, § 602(k),
[Pub. L. 99–272, title IX, § 9112(b),
[“(1) Section 602(k)(2) of the Social Security Amendments of 1983 (as added by subsection (a)) [set out above] shall apply to cost reporting periods beginning on or after
[“(2) Section 602(k)(3) of the Social Security Amendments of 1983 (as added by subsection (a)) [set out above] shall apply to items and services furnished after the end of the 10-day period beginning on the date of the enactment of this Act [
Pub. L. 97–248, title I, § 115(b),
Pub. L. 97–35, title XXI, § 2152(b),
Pub. L. 93–480, § 4(b),