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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 A. Hospital Insurance Benefits for Aged and Disabled |
§ 1395f. Conditions of and limitations on payment for services
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(a) Requirement of requests and certifications Except as provided in subsections (d) and (g) of this section and in section 1395mm of this title, payment for services furnished an individual may be made only to providers of services which are eligible therefor under section 1395cc of this title and only if— (1) written request, signed by such individual, except in cases in which the Secretary finds it impracticable for the individual to do so, is filed for such payment in such form, in such manner, and by such person or persons as the Secretary may by regulation prescribe, no later than the close of the period ending 1 calendar year after the date of service; (2) a physician, or, in the case of services described in subparagraph (B), a physician, or a nurse practitioner, a clinical nurse specialist, or a physician assistant (as those terms are defined in section 1395x(aa)(5) of this title) who does not have a direct or indirect employment relationship with the facility but is working in collaboration with a physician,, of this title as applied under paragraphs (3) and (4); and (D) the identification of costs for purposes of paragraph (3)(C).
References In Text
Section 402 of the Social Security Amendments of 1967, referred to in subsec. (b)(3), means section 402 of Pub. L. 90–248, which amended sections 1395b–1 and 1395ll of this title.
Section 222 of the Social Security Amendments of 1972, referred to in subsec. (b)(3), means section 222 of Pub. L. 92–603, which amended sections 1395b–1 and 1395ll of this title and enacted a provision set out as a note under section 1395b–1 of this title.
The Patient Protection and Affordable Care Act, referred to in subsec. (i)(1)(C)(v)(I)(aa), is Pub. L. 111–148,
Amendments
2010—Subsec. (a). Pub. L. 111–148, § 6404(a)(1)(B), inserted at end of concluding provisions “In applying paragraph (1), the Secretary may specify exceptions to the 1 calendar year period specified in such paragraph.”
Pub. L. 111–148, § 3108(a)(2), substituted “clinical nurse specialist, or physician assistant” for “or clinical nurse specialist” in concluding provisions.
Subsec. (a)(1). Pub. L. 111–148, § 6404(a)(1)(A), substituted “period ending 1 calendar year after the date of service;” for “period of 3 calendar years following the year in which such services are furnished (deeming any services furnished in the last 3 calendar months of any calendar year to have been furnished in the succeeding calendar year) except that where the Secretary deems that efficient administration so requires, such period may be reduced to not less than 1 calendar year;”.
Subsec. (a)(2). Pub. L. 111–148, § 6405(b)(1), as amended by Pub. L. 111–148, § 10604, inserted “, or, in the case of services described in subparagraph (C), a physician enrolled under section 1395cc(j) of this title,” after “in collaboration with a physician,” in introductory provisions.
Pub. L. 111–148, § 3108(a)(1), substituted “, a clinical nurse specialist, or a physician assistant (as those terms are defined in section 1395x(aa)(5) of this title)” for “or clinical nurse specialist” in introductory provisions.
Subsec. (a)(2)(C). Pub. L. 111–148, § 10605(a), inserted “, or a nurse practitioner or clinical nurse specialist (as those terms are defined in section 1395x(aa)(5) of this title) who is working in collaboration with the physician in accordance with State law, or a certified nurse-midwife (as defined in section 1395x(gg) of this title) as authorized by State law, or a physician assistant (as defined in section 1395x(aa)(5) of this title) under the supervision of the physician,” after “himself or herself”.
Pub. L. 111–148, § 6407(a)(1), substituted “such services are or were furnished” for “and such services are or were furnished” and inserted “, and, in the case of a certification made by a physician after
Subsec. (a)(7)(D). Pub. L. 111–148, § 3132(b), added subpar. (D).
Subsec. (i)(1)(C)(ii). Pub. L. 111–148, § 3132(a)(2)(A)(i), inserted “(before the first fiscal year in which the payment revisions described in paragraph (6)(D) are implemented)” after “subsequent fiscal year” in introductory provisions.
Subsec. (i)(1)(C)(ii)(VII). Pub. L. 111–148, § 3132(a)(2)(A)(ii), inserted “(before the first fiscal year in which the payment revisions described in paragraph (6)(D) are implemented), subject to clause (iv),” after “subsequent fiscal year”.
Subsec. (i)(1)(C)(iii). Pub. L. 111–148, § 3132(a)(2)(B), added cl. (iii).
Subsec. (i)(1)(C)(iv). Pub. L. 111–148, § 3401(g), added cl. (iv).
Subsec. (i)(1)(C)(iv)(II). Pub. L. 111–148, § 10319(f)(1), substituted “0.3” for “0.5”.
Subsec. (i)(1)(C)(v). Pub. L. 111–148, § 10319(f)(2), substituted “0.3” for “0.5” in introductory provisions.
Pub. L. 111–148, § 3401(g), added cl. (v).
Subsec. (i)(5). Pub. L. 111–148, § 3004(c)(2), added par. (5). Former par. (5) redesignated (6).
Subsec. (i)(6). Pub. L. 111–148, § 3132(a)(1)(B), added par. (6). Former par. (6) redesignated (7).
Pub. L. 111–148, § 3004(c)(1), redesignated par. (5) as (6).
Subsec. (i)(7). Pub. L. 111–148, § 3132(a)(1)(A), redesignated par. (6) as (7).
2009—Subsec. (b). Pub. L. 111–5, § 4102(d)(1)(B), inserted at end of concluding provisions “For purposes of applying paragraph (3), there shall be taken into account incentive payments, and payment adjustments under subsection (b)(3)(B)(ix) or (n) of section 1395ww of this title.”
Subsec. (b)(3). Pub. L. 111–5, § 4102(d)(1)(A), inserted “, subject to section 1395ww(d)(3)(B)(ix)(III) of this title,” before “the Secretary may provide” in introductory provisions.
Subsec. (l)(1). Pub. L. 111–5, § 4102(a)(2)(A), substituted “the subsequent paragraphs of this subsection” for “paragraph (2)”.
Subsec. (l)(3) to (5). Pub. L. 111–5, § 4102(a)(2)(B), (b)(2), added pars. (3) to (5).
2003—Subsec. (a). Pub. L. 108–173, § 736(a)(1)(A), (c)(2)(A), in concluding provisions, substituted “leave home and” for “leave home,” in sixth sentence and struck out “The certification regarding terminal illness of an individual under paragraph (7) shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.” after “taxing effort by the individual.”
Subsec. (a)(7)(A)(i). Pub. L. 108–173, § 736(a)(1)(B)(i), inserted “based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness” before “, and” in concluding provisions.
Subsec. (a)(7)(A)(i)(I). Pub. L. 108–173, § 408(b), inserted “(which for purposes of this subparagraph does not include a nurse practitioner)” after “attending physician (as defined in section 1395x(dd)(3)(B) of this title)”.
Subsec. (a)(7)(A)(ii). Pub. L. 108–173, § 736(a)(1)(B)(ii), inserted “based on such clinical judgment” before semicolon at end.
Subsec. (b). Pub. L. 108–173, § 736(a)(2), inserted comma after “1395e” in introductory provisions.
Subsec. (i)(4). Pub. L. 108–173, § 512(b), added par. (4).
Subsec. (i)(5). Pub. L. 108–173, § 946(b), added par. (5).
Subsec. (l). Pub. L. 108–173, § 405(g)(2), designated existing provisions as par. (1), substituted “Except as provided in paragraph (2), the amount” for “The amount”, and added par. (2).
Pub. L. 108–173, § 405(a)(1), inserted “equal to 101 percent of” before “the reasonable costs”.
2000—Subsec. (a). Pub. L. 106–554, § 1(a)(6) [title V, § 507(a)(1)(B)], inserted at end “Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be ‘confined to his home’. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration.”
Pub. L. 106–554, § 1(a)(6) [title V, § 507(a)(1)(A)], which directed amendment of subsec. (a) by striking out in the last sentence “, and that absences of the individual from home are infrequent or of relatively short duration, or are attributable to the need to receive medical treatment”, was executed by striking out that language after “taxing effort by the individual” in the penultimate sentence, to reflect the probable intent of Congress and the amendment by Pub. L. 106–554, § 1(a)(6) [title III, § 322(a)(1)]. See note below.
Pub. L. 106–554, § 1(a)(6) [title III, § 322(a)(1)], inserted at end “The certification regarding terminal illness of an individual under paragraph (7) shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.”
Subsec. (a)(7)(A)(ii). Pub. L. 106–554, § 1(a)(6) [title III, § 321(e)], substituted a semicolon for period at end.
Subsec. (i)(1)(C)(ii)(VI). Pub. L. 106–554, § 1(a)(6) [title III, § 321(a)], inserted “, plus, in the case of fiscal year 2001, 5.0 percentage points” before semicolon.
1997—Subsec. (a)(2)(C). Pub. L. 105–33, § 4615(a), inserted “(other than solely venipuncture for the purpose of obtaining a blood sample)” after “skilled nursing care”.
Subsec. (a)(7)(A)(i). Pub. L. 105–33, §§ 4443(b)(2)(A), 4448, in concluding provisions, substituted “at the beginning of the period” for “ not later than 2 days after hospice care is initiated (or, if each certify verbally not later than 2 days after hospice care is initiated, not later than 8 days after such care is initiated)” and inserted “and” at end.
Subsec. (a)(7)(A)(ii). Pub. L. 105–33, § 4443(b)(2)(B), substituted “60-day” for “30-day” and substituted a period for “, and” at end.
Subsec. (a)(7)(A)(iii). Pub. L. 105–33, § 4443(b)(2)(C), struck out cl. (iii) which read as follows: “in a subsequent extension period, the medical director or physician described in clause (i)(II) recertifies at the beginning of the period that the individual is terminally ill;”.
Subsec. (a)(8). Pub. L. 105–33, § 4201(c)(1), (3)(A), substituted “critical access” for “rural primary care” in two places and “96 hours” for “72 hours”.
Subsec. (b). Pub. L. 105–33, § 4603(c)(1), substituted “1395ww, and 1395fff of this title” for “and 1395ww of this title” in introductory provisions.
Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care” in two places in introductory provisions.
Subsec. (i)(1)(C)(ii)(V) to (VII). Pub. L. 105–33, § 4441(a), struck out “and” at end of subcl. (V), added subcl. (VI), and redesignated former subcl. (VI) as (VII).
Subsec. (i)(2)(D). Pub. L. 105–33, § 4442(a), added subpar. (D).
Subsec. (i)(3). Pub. L. 105–33, § 4441(b), added par. (3).
Subsec. (l). Pub. L. 105–33, § 4201(c)(3)(B), amended heading and text of subsec. (l) generally. Prior to amendment, text read as follows:
“(1) The amount of payment under this part for inpatient rural primary care hospital services—
“(A) in the case of the first 12-month cost reporting period for which the facility operates as such a hospital, is the reasonable costs of the facility in providing inpatient rural primary care hospital services during such period, as such costs are determined on a per diem basis, and
“(B) in the case of a later reporting period, is the per diem payment amount established under this paragraph for the preceding 12-month cost reporting period, increased by the applicable percentage increase under section 1395ww(b)(3)(B)(i) of this title for that particular cost reporting period applicable to hospitals located in a rural area.
The payment amounts otherwise determined under this paragraph shall be reduced, to the extent necessary, to avoid duplication of any payment made under section 1395i–4(a)(2) of this title (or under section 4005(e) of the Omnibus Budget Reconciliation Act of 1987) to cover the provision of inpatient rural primary care hospital services.
“(2) The Secretary shall develop a prospective payment system for determining payment amounts for inpatient rural primary care hospital services under this part furnished on or after
1994—Subsec. (a)(5). Pub. L. 103–432, § 106(b)(1)(A), struck out “and with respect to post-hospital extended care services furnished after such day of a continuous period of such services as may be prescribed in or pursuant to regulations” after “continuous period of such services”, “or skilled nursing facility, as the case may be” after “such individual to the hospital”, and “or facility” after “made in such hospital”.
Subsec. (a)(8). Pub. L. 103–432, § 102(a)(3), substituted “the individual may reasonably be expected to be discharged or transferred to a hospital within 72 hours after admission to the rural primary care hospital.” for “such services were required to be immediately furnished on a temporary, inpatient basis.”
Subsec. (i)(1)(C)(i). Pub. L. 103–432, § 110(d)(1), substituted “
Subsec. (l)(2). Pub. L. 103–432, § 102(d), substituted “
1993—Subsec. (i)(1)(C)(ii). Pub. L. 103–66 substituted “increased by—” and subcls. (I) to (VI) for “increased by the market basket percentage increase (as defined in section 1395ww(b)(3)(B)(iii) of this title) otherwise applicable to discharges occurring in the fiscal year.”
1991—Subsec. (h). Pub. L. 102–54 substituted “Department of Veterans Affairs” for “Veterans’ Administration” in heading and par. (1) and “Secretary of Veterans Affairs” for “Veterans’ Administration” in par. (2).
1990—Subsec. (a)(7)(A)(iii). Pub. L. 101–508, § 4006(b), added cl. (iii).
Subsec. (b)(3). Pub. L. 101–508, § 4008(i)(3), substituted “
Subsec. (i)(1)(C)(i). Pub. L. 101–508, § 4008(m)(3)(A), substituted “on or after
1989—Subsec. (a). Pub. L. 101–239, § 6028(2), substituted “a physician, nurse practitioner, or clinical nurse specialist (as the case may be) makes” for “a physician makes” in first sentence of concluding provisions.
Subsec. (a)(2). Pub. L. 101–239, § 6028(1), substituted “a physician, or, in the case of services described in subparagraph (B), a physician, or a nurse practitioner or clinical nurse specialist who does not have a direct or indirect employment relationship with the facility but is working in collaboration with a physician,” for “a physician” after “(2)”.
Subsec. (a)(2)(B), (6). Pub. L. 101–234 repealed Pub. L. 100–360, § 104(d)(2)(A), (B), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment notes below.
Subsec. (a)(7)(A)(i). Pub. L. 101–239, § 6005(b), substituted “certify in writing, not later than 2 days after hospice care is initiated (or, if each certify verbally not later than 2 days after hospice care is initiated, not later than 8 days after such care is initiated),” for “certify, not later than two days after hospice care is initiated,” in concluding provisions.
Subsec. (a)(7)(A)(iii). Pub. L. 101–234 repealed Pub. L. 100–360, § 104(d)(2)(C), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (a)(8). Pub. L. 101–239, § 6003(g)(3)(B)(ii), added par. (8).
Subsec. (b). Pub. L. 101–239, § 6003(g)(3)(B)(iii)(I), inserted “, other than a rural primary care hospital providing inpatient rural primary care hospital services,” after “providing hospice care” in introductory provisions.
Subsec. (d)(3). Pub. L. 101–234 repealed Pub. L. 100–360, § 104(d)(2)(D), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (i)(1)(A). Pub. L. 101–239, § 6005(a)(1), inserted “and except as otherwise provided in this paragraph” after “section 1395e(a)(4) of this title”.
Subsec. (i)(1)(C). Pub. L. 101–239, § 6005(a)(2), added subpar. (C) and struck out former subpar. (C) which read as follows: “With respect to care and services furnished on or after
Subsec. (l). Pub. L. 101–239, § 6003(g)(3)(B)(iii)(II), added subsec. (l).
1988—Subsec. (a)(2)(B). Pub. L. 100–360, § 104(d)(2)(A), (B), struck out “post-hospital” after “in the case of” and “, for any of the conditions with respect to which he was receiving inpatient hospital services (or services which would constitute inpatient hospital services if the institution met the requirements of paragraphs (6) and (9) of section 1395x(e) of this title) prior to transfer to the skilled nursing facility or for a condition requiring such extended care services which arose after such transfer and while he was still in the facility for treatment of the condition or conditions for which he was receiving such inpatient hospital services” before semicolon at end.
Subsec. (a)(6). Pub. L. 100–360, § 104(d)(2)(A), struck out “post-hospital” before “extended care services” in two places.
Subsec. (a)(7)(A)(iii). Pub. L. 100–360, § 104(d)(2)(C), added cl. (iii) which read as follows: “in a subsequent extension period, the medical director or physician described in clause (i)(II) recertifies at the beginning of the period that the individual is terminally ill;”.
Subsec. (d)(3). Pub. L. 100–360, § 104(d)(2)(D), substituted “equal to 100 percent” for “equal to 60 percent” and “plus 100 percent” for “plus 80 percent” and struck out “two-thirds of” after “based on”.
1987—Subsec. (a). Pub. L. 100–203, § 4024(a), inserted two sentences at end clarifying “confined to his home” for purposes of par. (2)(C).
Subsec. (b)(3)(B). Pub. L. 100–203, § 4008(b)(1), substituted “aggregate rate of increase from
Subsec. (j)(2)(B). Pub. L. 100–203, § 4062(d)(1)(A), substituted “Section 1395m(a)(1)(B) of this title” for “Subsection (k)(1)(B) of this section”.
Subsec. (k). Pub. L. 100–203, § 4062(d)(1)(B), substituted “the amount described in section 1395m(a)(1) of this title.” for a dash and former pars. (1) and (2) which read as follows:
“(1) the lesser of—
“(A) the reasonable cost of such equipment, as determined under section 1395x(v) of this title, or
“(B) the customary charges with respect to such equipment,
less the amount the home health agency may charge as described in section 1395cc(a)(2)(A)(ii) of this title, but in no case may the payment for such equipment exceed 80 percent of such reasonable cost, or
“(2) if such equipment is furnished by a public home health agency, or by another home health agency which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this paragraph), free of charge or at nominal charge to the public, 80 percent of the amount which the Secretary finds will provide fair compensation to the home health agency.”
1986—Subsec. (i)(1)(B). Pub. L. 99–272, § 9123(b)(1), amended subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: “Notwithstanding subparagraph (A), the rate of payment per day for routine home care furnished during fiscal year 1985 shall be $53.17.”
Subsec. (i)(1)(C). Pub. L. 99–272, § 9123(b)(2), substituted “1986” for “1985”.
1984—Subsec. (a). Pub. L. 98–369, § 2354(b)(1), as amended by Pub. L. 98–617, § 3(a)(3), in concluding provisions, substituted “contractual” for “contractural”.
Pub. L. 98–369, § 2336(b), inserted before period at end of third sentence “, except that such prohibition shall not apply with respect to a home health agency which is a sole community home health agency (as determined by the Secretary)”.
Pub. L. 98–369, § 2336(a), inserted sentence at end that for purposes of the preceding sentence, service by a physician as an uncompensated officer or director of a home health agency shall not constitute having a significant ownership interest in, or a significant financial or contractual relationship with, such agency.
Pub. L. 98–369, § 2335(a)(4), in concluding provisions, substituted “or (D)” for “(D), or (E)”.
Subsec. (a)(2)(B) to (E). Pub. L. 98–369, § 2335(a)(1), redesignated subpars. (C) to (E) as (B) to (D), respectively, and struck out former subpar. (B) which provided that payment could be made only if a physician certified, in the case of inpatient tuberculosis hospital services, that such services were required to be given on an inpatient basis, by or under the supervision of a physician, for the treatment of an individual for tuberculosis; and that such treatment could reasonably be expected to improve the condition for which such treatment was necessary or render the condition noncommunicable.
Subsec. (a)(3). Pub. L. 98–369, § 2335(a)(2), struck out “and inpatient tuberculosis hospital services” after “psychiatric hospital services”.
Subsec. (a)(5) to (8). Pub. L. 98–369, § 2335(a)(3), redesignated pars. (6) to (8) as (5) to (7), respectively, and struck out former par. (5) which had provided that payment would be made only if, in the case of inpatient tuberculosis hospital services, the services were those which the records of the hospital indicate were furnished to the individual during periods when he was receiving treatment which could reasonably be expected to improve his condition or render it noncommunicable.
Subsec. (b). Pub. L. 98–369, § 2321(a)(1), inserted in provisions preceding par. (1) “and other than a home health agency with respect to durable medical equipment” after “hospice care”.
Subsec. (b)(2). Pub. L. 98–369, § 2308(b)(2)(A), inserted “, or by another provider which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this paragraph),”.
Subsec. (b)(3). Pub. L. 98–369, § 2354(c)(1)(A), amended directory language of Pub. L. 96–449, § 903(a)(4), resulting in no change in text. See 1980 Amendment note below.
Subsec. (i)(1). Pub. L. 98–617, § 1(a), designated existing provisions as subpar. (A) and added subpars. (B) and (C).
Subsec. (j)(2)(B) to (D). Pub. L. 98–369, § 2321(f), added subpar. (B) and redesignated former subpars. (B) and (C) as (C) and (D), respectively.
Subsec. (k). Pub. L. 98–369, § 2321(a)(2), added subsec. (k).
Subsec. (k)(2). Pub. L. 98–617, § 3(b)(1), inserted “, or by another home health agency which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low-income (and requests that payment be made under this paragraph),” after “public home health agency” and “80 percent of” before “the amount”.
1983—Subsec. (g). Pub. L. 98–21, § 602(b), inserted “(or would be if section 1395ww of this title did not apply)” after “section 1395x(v)(1)(D) of this title”.
Subsec. (h)(2). Pub. L. 98–21, § 602(c), substituted “the amount that would be payable for such services under subsection (b) of this section and section 1395ww of this title” for “the reasonable costs for such services”.
Subsec. (i)(1). Pub. L. 97–448 inserted “made” before “for bereavement counseling”.
Subsec. (i)(2)(A). Pub. L. 98–90, § 1(1), struck out “located in a region (as defined by the Secretary)” after “a hospice program” and “for the region” after “ ‘the cap amount’ ”.
Subsec. (i)(2)(B). Pub. L. 98–90, § 1(2), amended subpar. (B) generally, substituting provisions establishing a hospice reimbursement cap amount of $6,500, indexed by the medical care component of the Consumer Price Index, for provisions which had established a cap of 40% of the estimated regional average medicare expenditure per beneficiary in the regular medicare program during the six months of life for persons dying of cancer.
Subsec. (j). Pub. L. 98–21, § 601(d)(2), added subsec. (j) by transferring and redesignating provisions formerly classified to subsec. (d) of section 1395ww of this title.
Subsec. (j)(2)(A). Pub. L. 98–21, § 601(d)(1), substituted “subsection (b) of this section” for “section 1395f(b) of this title”.
1982—Subsec. (a)(8). Pub. L. 97–248, § 122(c)(1), added par. (8).
Subsec. (b). Pub. L. 97–248, § 101(c)(1), substituted “sections 1395e and 1395ww” for “section 1395e” in provisions preceding par. (1), and substituted “until the first day of the seventh month beginning after the date the Secretary determines and notifies the Governor of the State” for “until the Secretary determines” in provisions following par. (3).
Pub. L. 97–248, § 122(c)(2)(A), inserted “(other than a hospice program providing hospice care)” after “The amount paid to any provider of services”.
Subsec. (i). Pub. L. 97–248, § 122(c)(2)(B), added subsec. (i).
1981—Subsec. (a)(2)(D). Pub. L. 97–35, § 2122(a)(1), substituted “needs or needed skilled nursing care on an intermittent basis or physical or speech therapy or, in the case of an individual who has been furnished home health services based on such a need and who no longer has such a need for such care or therapy, continues or continued to need occupational therapy” for “needed skilled nursing care on an intermittent basis, or physical, occupational, or speech therapy”.
Subsec. (a)(2)(F). Pub. L. 97–35, § 2121(b), struck out subpar. (F) which provided that in the case of alcohol detoxification facility services, such services were required on an inpatient basis (based upon an examination by such certifying physician made prior to initiation of alcohol detoxification).
1980—Subsec. (a). Pub. L. 96–499, § 930(e), inserted provision at end of subsec. (a) authorizing the Secretary to prescribe regulations to prohibit significantly interested physicians from performing the physician certification required by par. (2) for home health services.
Subsec. (a)(2)(D). Pub. L. 96–499, § 930(f), substituted “home health services” for “post-hospital home health services” and “physical, occupational, or speech” for “physical or speech” and deleted “, for any of the conditions with respect to which he was receiving inpatient hospital services (or services which would constitute inpatient hospital services if the institution met the requirements of paragraphs (6) and (9) of section 1395x(e) of this title) or post-hospital extended care services” after “therapy”.
Subsec. (a)(2)(E). Pub. L. 96–499, § 936(b), inserted “or because of the severity of the dental procedure” and substituted “such services” for “such dental services”.
Subsec. (a)(2)(F). Pub. L. 96–499, § 931(b), added subpar. (F).
Subsec. (b)(1). Pub. L. 96–499, § 903(a)(1), inserted “except as provided in paragraph (3),”.
Subsec. (b)(3). Pub. L. 96–499, § 903(a)(4), as amended by Pub. L. 98–369, § 2354(c)(1)(A), added par. (3).
Subsec. (c). Pub. L. 96–499, § 941(b), substituted “subsection (h)” for “subsection (j)”.
Subsecs. (h) to (j). Pub. L. 96–499, § 941(a), struck out subsecs. (h) and (i) and redesignated subsec. (j) as (h).
1978—Subsec. (b)(1). Pub. L. 95–292 inserted “and as further limited by section 1395rr(b)(2)(B) of this title” after “section 1395x(v) of this title”.
1977—Subsec. (c). Pub. L. 95–142, § 23(a), inserted reference to subsec. (j) of this section.
Subsec. (j). Pub. L. 95–142, § 23(b), added subsec. (j).
1976—Subsec. (c). Pub. L. 94–437 substituted “Subject to section 1395qq of this title, no payment” for “No payment”.
1973—Subsec. (a)(2)(E). Pub. L. 93–233, § 18(k)(1), substituted “the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, the individual, because of his underlying medical condition and clinical status, requires hospitalization in connection with the provision of such dental services” for “a dental procedure, the individual suffers from impairments of such severity as to require hospitalization”.
Subsec. (a), last sentence. Pub. L. 93–233, § 18(k)(2), inserted reference to subpar. (E) of par. (2).
1972—Subsec. (a). Pub. L. 92–603, §§ 226(c)(1), 227(b)(1), inserted reference to subsec. (g) of this section and section 1395mm of this title in provisions preceding par. (1).
Subsec. (a)(1). Pub. L. 92–603, § 281(e), placed a 3-year time limitation on the time within which a written request for payment is filed, with provision for reduction of the limit to 1 year.
Subsec. (a)(2)(C). Pub. L. 92–603, §§ 234(g)(1), 247(a), 278(a)(1), substituted “because the individual needs or needed on a daily basis skilled nursing care (provided directly by or requiring the supervision of skilled nursing personnel) or other skilled rehabilitation services, which as a practical matter can only be provided in a skilled nursing facility on an inpatient basis,” for “on an inpatient basis because the individual needs or needed skilled nursing care on a continuing basis”, “skilled nursing facility” for “extended care facility”, and “paragraphs (6) and (9) of section 1395x(e) of this title” for “paragraphs (6) and (8) of section 1395x(e) of this title”.
Subsec. (a)(2)(D). Pub. L. 92–603, § 234(g)(1), substituted reference to par. (9) of section 1395x(e) of this title for reference to par. (8) of section 1395x(e) of this title.
Subsec. (a)(2)(E). Pub. L. 92–603, § 256(a), added subpar. (E).
Subsec. (a)(6). Pub. L. 92–603, § 278(a)(2), substituted “skilled nursing facility” for “extended care facility”.
Subsec. (a)(7). Pub. L. 92–603, §§ 238(a), 278(a)(3), inserted “, including any finding made in the course of a sample or other review of admissions to the institution” after “as described in section 1395x(k)(4) of this title” in the parenthetical provisions covering the finding not made by the committee or group, and substituted “skilled nursing facility” for “extended care facility”.
Subsec. (b). Pub. L. 92–603, § 233(a), substituted pars. (1) and (2) for provisions describing the amount payable as the reasonable cost determined under section 1395x(v) of this title.
Subsec. (f). Pub. L. 92–603, § 211(a), designated existing provisions as par. (2), added pars. (1) and (3), and in par. (2) as so redesignated inserted provisions covering individuals physically present at a place within Canada while traveling without unreasonable delay by the most direct route between Alaska and another State.
Subsec. (g). Pub. L. 92–603, § 227(b)(2), added subsec. (g).
Subsec. (h). Pub. L. 92–603, §§ 228(a), 278(b)(4), (17), added subsec. (h) and substituted “skilled nursing facility” for “extended care facility”.
Subsec. (i). Pub. L. 92–603, § 228(a), added subsec. (i).
1968—Subsec. (a). Pub. L. 90–248, §§ 126(a)(5), 129(c)(5)(B), struck out references to former subpars. (E) and (F) in last sentence.
Subsec. (a)(2)(A) to (E). Pub. L. 90–248, § 126(a)(1), (2), struck out subpar. (A) which provided that there be a physician’s certification of medical necessity for admissions to hospitals other than psychiatric or tuberculosis institutions, and redesignated subpars. (B) to (E) as (A) to (D), respectively.
Subsec. (a)(2)(F). Pub. L. 90–248, § 129(c)(5)(A), struck out subpar. (F) which provided that there be a physician’s certification for services furnished to outpatients.
Subsec. (a)(3) to (7). Pub. L. 90–248, § 126(a)(3), (4), added par. (3) and redesignated former pars. (3) to (6) as (4) to (7), respectively.
Subsec. (d). Pub. L. 90–248, § 129(c)(6)(A), struck out reference to outpatient hospital diagnostic services from provisions requiring payment for emergency hospital services.
Subsec. (d)(1) to (3). Pub. L. 90–248, § 143(c), designated existing provisions as par. (1), inserted “in a calendar year” after “furnished” in first sentence of par. (1), added subpar. (C) to par. (1), and added pars. (2) and (3).
Effective Date Of Amendment
Pub. L. 111–148, title III, § 3108(b),
Pub. L. 111–148, title VI, § 6404(b),
Pub. L. 111–148, title VI, § 6405(d),
Pub. L. 108–173, title IV, § 405(a)(2),
Pub. L. 108–173, title IV, § 405(g)(3),
Amendment by section 512(b) of Pub. L. 108–173 applicable to services provided by a hospice program on or after
Pub. L. 108–173, title IX, § 946(c),
Pub. L. 106–554, § 1(a)(6) [title III, § 321(b)],
Pub. L. 106–554, § 1(a)(6) [title III, § 322(a)(2)],
Pub. L. 106–554, § 1(a)(6) [title V, § 507(a)(2)],
Pub. L. 105–33, title IV, § 4201(d),
Pub. L. 105–33, title IV, § 4442(b),
Amendment by sections 4441, 4443(b)(2), and 4448 of Pub. L. 105–33 applicable to benefits provided on or after
Amendment by section 4603(c)(1) of Pub. L. 105–33 applicable to cost reporting periods beginning on or after
Pub. L. 105–33, title IV, § 4615(b),
Amendment by section 106(b)(1)(A) of Pub. L. 103–432 effective as if included in the enactment of Pub. L. 100–203, see section 106(b)(2) of Pub. L. 103–432, set out as a note under section 1395cc of this title.
Amendment by section 4006(b) of Pub. L. 101–508 applicable with respect to care and services furnished on or after
Pub. L. 101–239, title VI, § 6005(c),
Amendment by Pub. L. 101–234 effective
Amendment by Pub. L. 100–360 effective
Pub. L. 100–203, title IV, § 4008(b)(2),
Pub. L. 100–203, title IV, § 4024(c),
Pub. L. 100–203, title IV, § 4062(e),
[Pub. L. 101–508, title IV, § 4152(h),
Pub. L. 98–617, § 1(b),
Pub. L. 98–617, § 3(c),
Pub. L. 98–369, div. B, title III, § 2321(g),
Pub. L. 98–369, div. B, title III, § 2335(g),
Pub. L. 98–369, div. B, title III, § 2336(c)(1),
Amendment by section 2354(b)(1) of Pub. L. 98–369 effective
Amendment by section 2354(c)(1)(A) of Pub. L. 98–369 effective as if originally included in Pub. L. 96–499, see section 2354(e)(2) of Pub. L. 98–369, set out as a note under section 1320a–1 of this title.
Amendment by Pub. L. 98–21 applicable to items and services furnished by or under arrangement with a hospital beginning with its first cost reporting period that begins on or after
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 122(c)(1), (2) of Pub. L. 97–248 applicable to hospice care provided on or after
Amendment by section 2121(b) of Pub. L. 97–35 applicable to services furnished in detoxification facilities for inpatient stays beginning on or after the tenth day after
Pub. L. 97–35, title XXI, § 2122(b),
Amendment by section 930(e), (f) of Pub. L. 96–499 effective with respect to services furnished on or after
Amendment by section 931(b) of Pub. L. 96–499 effective
Pub. L. 96–499, title IX, § 936(d),
Pub. L. 96–499, title IX, § 941(c),
Amendment by Pub. L. 95–292 effective with respect to services, supplies, and equipment furnished after the third calendar month beginning after
Pub. L. 95–142, § 23(c),
Pub. L. 93–233, § 18(z–3)(2),
Pub. L. 92–603, title II, § 211(d),
Amendment by section 226(c)(1) of Pub. L. 92–603 effective with respect to services provided on or after
Amendment by section 227(b) of Pub. L. 92–603 applicable with respect to accounting periods beginning after
Pub. L. 92–603, title II, § 228(b),
Pub. L. 92–603, title II, § 233(f),
Amendment by section 234(g)(1) of Pub. L. 92–603 applicable with respect to providers of services for fiscal years beginning after fifth month following October 1972, see section 234(i) of Pub. L. 92–603, set out as a note under section 1395x of this title.
Pub. L. 92–603, title II, § 238(b),
Pub. L. 92–603, title II, § 247(c),
Pub. L. 92–603, title II, § 256(d),
Amendment by section 281(e) of Pub. L. 92–603 applicable in the case of services furnished (or deemed to have been furnished) after 1970, see section 281(g) of Pub. L. 92–603, set out as a note under section 1395gg of this title.
Pub. L. 90–248, title I, § 126(c),
Amendment by section 129(c)(5), (6)(A) of Pub. L. 90–248 applicable with respect to services furnished after
Amendment by section 143(c) of Pub. L. 90–248 applicable with respect to services furnished with respect to admissions occurring after
Miscellaneous
Pub. L. 98–369, div. B, title III, § 2336(c)(2),
Section 122(h)(2) of Pub. L. 97–248 provided that:
Pub. L. 111–148, title VI, § 6405(c),
Pub. L. 111–148, title VI, § 6407(c),
Pub. L. 111–148, title VI, § 6407(d),
Pub. L. 106–554, § 1(a)(6) [title V, § 507(b)],
Pub. L. 106–554, § 1(a)(6) [title III, § 322(b)],
Pub. L. 106–554, § 1(a)(6) [title III, § 321(c)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title I, § 131],
Pub. L. 106–113, div. B, § 1000(a)(6) [title I, § 132],
Pub. L. 101–239, title VI, § 6016,
Pub. L. 100–203, title IV, § 4008(c),
[Pub. L. 101–239, title VI, § 6023(b),
[Pub. L. 100–647, title VIII, § 8402,
Pub. L. 98–369, div. B, title III, § 2308(a),
Pub. L. 98–369, div. B, title III, § 2308(b)(1),
Pub. L. 97–248, title I, § 122(j), formerly § 122(i),
Pub. L. 97–248, title I, § 122(k), formerly § 122(j),
Effective Date
Pub. L. 93–233, § 16,