United States Code

without adversely affecting the quality of such services;

(B) to determine whether payments for services other than those for which payment may be made under such programs (and which are incidental to services for which payment may be made under such programs) would, in the judgment of the Secretary, result in more economical provision and more effective utilization of services for which payment may be made under such program, where such services are furnished by organizations and institutions which have the capability of providing

(i) comprehensive health care services,

(ii) mental health care services (as defined by section 2691 (c) of this title,

(iii) ambulatory health care services (including surgical services provided on an outpatient basis), or

(iv) institutional services which may substitute, at lower cost, for hospital care;

(C) to determine whether the rates of payment or reimbursement for health care services, approved by a State for purposes of the administration of one or more of its laws, when utilized to determine the amount to be paid for services furnished in such State under the health programs establish by this chapter, would have the effect of reducing the costs of such programs without adversely affecting the quality of such services;

(D) to determine whether payments under such programs based on a single combined rate of reimbursement or charge for the teaching activities and patient care which residents, interns, and supervising physicians render in connection with a graduate medical education program in a patient facility would result in more equitable and economical patient care arrangements without adversely affecting the quality of such care;

(E) to determine whether coverage of intermediate care facility services and homemaker services would provide suitable afternatives to posthospital benefits presently provided under this subchapter; such experiment and demonstration projects may include:

(1) counting each day of care in an intermediate care facility as one day of care in a skilled nursing facility, if such care was for a condition for which the individual was hospitalized,

(ii) covering the services of homemakers for a maximum of 21 days, if institutional services are not medically appropriate,

(iii) determining whether such coverage would reduce long-range costs by reducing the lengths of stay in hospitals and skilled nursing facilities, and

(iv) establishing alternative eligibility requirements and determining the probable cost of applying each alternative, if the project suggests that such extension of coverage would be desirable;

(F) to determine whether, and if so which type of, fixed price or performance incentive contract would have the effect of inducing to the greatest

degree effective, efficient, and economical performance of agencies and organizations making payment under agreements or contracts with the Secretary for health care and services under health programs established by this subchapter; (G) to determine under what circumstances payment for services would be appropriate and the most appropriate, equitable, and noninflationary methods and amounts of reimbursement under health care programs established by this subchapter for services, which are performed independently by an assistant to a physician, including a nurse practitioner (whether or not performed in the office of or at a place at which such physician is physically present), and

(i) which such assistant is legally authorized to perform by the State or political subdivision wherein such services are performed, and

(ii) for which such physician assumes full legal and ethical responsibility as to the necessity, propriety, and quality thereof;

(H) to establish an experimental program to provide day-care services, which consist of such personal care, supervision, and services as the Secretary shall by regulation prescribe, for individuals eligible to enroll in the supplemental medical insurance program established under part B of this subchapter and subchapter XIX of this chapter, in day-care centers which meet such standards as the Secretary shall by regulation establish; and

(I) to determine whether the services of clinical psychologists may be made more generally available to persons eligible for services under this subchapter and subchapter XIX of this chapter in a manner consistent with quality of care and equitable and efficient administration.

For purposes of this subsection,"health programs established by this chapter" means the program established by this subchapter, a program established by a plan of a State approved under subchapter XIX of this subchapter, and a program established by a plan of a State approved under subchapter V of this chapter.

(2) Grants, payments under contracts, and other expenditures made for experiments and demonstration projects under paragraph (1) shall be made in appropriate part from the Federal Hospital Insurance Trust Fund (established by section 1395i of this title) and the Federal Supplementary Medical Insurance Trust Fund (established by section 1395t of this title) and from funds appropriated under subchapters V and XIX of this chapter. Grants and payments under contracts may be made either in advance or by way of reimbursement, as may be determined by the Secretary, and shall be made in such installments and on such conditions as the Secretary finds necessary to carry out the purpose of this section. With respect to any such grant, payment, or other expenditure, the amount to be paid from each of such trust funds (and from funds appropriated under such subchapters V and XIX of this chapter) shall be determined by the Secretary, giving due regard to the purposes of the experiment or project involved.

(b) Waiver of certain payment or reimbursement requirements; advice and recommendations of specialists preceding experiments and demonstration projects.

In the case of any experiment or demonstration project under subsection (a) of this section, the Secretary may waive compliance with the requirements of this subchapter and subchapters V and XIX of this chapter insofar as such requirements relate to reimbursement or payment on the basis of reasonable cost, or (in the case of physicians) on the basis of reasonable charge, or to reimbursement or payment only for such services or items as may be specified in the experiment; and costs incurred in such experiment or demonstration project in excess of the costs which would otherwise be reimbursed or paid under such subchapters may be reimbursed or paid to the extent that such waiver applies to them (with such excess being borne by the Secretary). No experiment or demonstration project shall be engaged in or developed under subsection (a) of this section until the Secretary obtains the advice and recommendations of specialists who are competent to evaluate the proposed experiment or demonstration project as to the soundness of its objectives, the possibilities of securing productive results, the adequacy of resources to conduct the proposed experiment or demonstration project, and its relationship to other similar experiments and projects already completed or in process. (As amended Oct. 30, 1972, Pub. L. 92-603, title II, §§ 222(b), 278(b) (2), 86 Stat. 1391, 1453.)

REFERENCES IN TEXT

Section 222 (a) of the Social Security Amendments of 1972, referred to in subsec. (a) (1) (A), is section 222(a) of Pub. L. 92-603, which is set out as a note under section 1395f of this title.

AMENDMENTS

1972 Subsec. (a). Pub. L. 92-603, § 222(b) (1), 278(b) (2), substituted provisions spelling out in detail the purposes for which experiments and demonstration projects may be carried out for a general statement setting out the increase in efficiency and economy of health services as the purpose of experiments selected by the Secretary, added references to demonstration projects, and inserted references to the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund.

Subsec. (b). Pub. L. 92-603, § 222(b)(2), added references to demonstration projects and inserted ", or to reimbursement or payment only for such services or items as may be specified in the experiment".

PART A-HOSPITAL INSURANCE BENEFITS FOR THE AGED AND DISABLED

PART REFERRED TO IN OTHER SECTIONS

This part is referred to in sections 13950, 1395mm, 1395pp of this title; title 45 section 228s-3.

§ 1395c. Description of program.

The insurance program for which entitlement is established by section 426 of this title provides basic protection against the costs of hospital and related posthospital services in accordance with this part for (1) individuals who are age 65 or over and are entitled to retirement benefits under subchapter II of this chapter or under the railroad retirement system and (2) individuals under age 65 who have been entitled for not less than 24 consecutive months to benefits under subchapter II of this chapter or under the railroad retirement system on the basis of a

disability. (As amended Oct. 30, 1972, Pub. L. 92-603, title II, § 201(a) (2), 86 Stat. 1371.) AMENDMENTS

1972-Pub. L. 92-603 designated existing provisions as cl. (1) and added cl. (2).

§ 1395d. Scope of benefits.

SECTION REFERRED TO IN OTHER SECTIONS This section is referred to in sections 1395mm, 1396b of this title.

§ 1395e. Deductibles and coinsurance.

SECTION REFERRED TO IN OTHER SECTIONS This section is referred to in section 13951-2 of this title.

§ 1395f. Conditions of and limitations on payment for services.

(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 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;

(2) a physician certifies (and recertifies, where such services are furnished over a period of time, in such cases, with such frequency, and accompanied by such supporting material, appropriate to the case involved, as may be provided by regulations, except that the first of such recertifications shall be required in each case of inpatient hospital services not later than the 20th day of such period) that

(C) in the case of post-hospital extended care services, such services are or were required to be given 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 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;

(D) in the case of post-hospital home health services, such services are or were required because the individual is or was confined to his home (except when receiving items and services referred to in section 1395x(m) (7), of this title) and needed skilled nursing care on an intermittent basis, or physical or speech therapy, 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; a plan for furnishing such services to such individual has been established and is periodically reviewed by a physician; and such services are or were furnished while the individual was under the care of a physician; or (E) in the case of inpatient hospital services in connection with 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;

(6) with respect to inpatient hospital services furnished such individual after the 20th day of a continuous period of such services 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, there was not in effect, at the time of admission of such individual to the hospital or skilled nursing facility, as the case may be, a decision under section 1395cc (d) of this title (based on a finding that utilization review of longstay cases is not being made in such hospital or facility); and

(7) with respect to inpatient hospital services or post-hospital extended care services furnished such individual during a continuous period, a finding has not been made (by the physician members of the committee or group, as described in section 1395x(k) (4) of this title, including any finding made in the course of a sample or other review of admissions to the institution) pursuant to the system of utilization review that further inpatient hospital services or further post-hospital extended care services, as the case may be, are not medically necessary; except that, if such a finding has been made, payment may be made for such services furnished before the 4th day after the day on which the hospital or skilled nursing facility, as the case may be, received notice of such finding. To the extent provided by regulations, the certification and recertification requirements of paragraph (2) shall be deemed satisfied where, at a later date, a physician makes certification of the kind provided in subparagraph (A), (B), (C), (D), or (E) of paragraph (2) (whichever would have applied), but only where such certification is accompanied by such medical and other evidence as may be required by such regulations.

(b) Amount paid to provider of services.

The amount paid to any provider of services with respect to services for which payment may be made under this part shall, subject to the provisions of section 1395e of this title, be

(1) the lesser of (A) the reasonable cost of such services, as determined under section 1395x (v) of this title, or (B) the customary charges with respect to such services; or

(2) if such services are furnished by a public provider of services free of charge or at nominal charges to the public, the amount determined on the basis of those items (specified in regulations prescribed by the Secretary) included in the determination of such reasonable cost which the Secretary finds will provide fair compensation to such provider for such services.

(f) Payment for certain inpatient hospital services furnished outside the United States.

(1) Payment shall be made for inpatient hospital services furnished to an individual entitled to hospital insurance benefits under section 426 of this title by a hospital located outside the United States, or under arrangements (as defined in section 1395x(w) of this title) with it, if—

(A) such individual is a resident of the United States, and

(B) such hospital was closer to, or substantially more accessible from, the residence of such individual than the nearest hospital within the United States which was adequately equipped to deal with, and was available for the treatment of, such individual's illness or injury.

(2) Payment may also be made for emergency inpatient hospital services furnished to an individual entitled to hospital insurance benefits under section 426 of this title by a hospital located outside the United States if

(A) such individual was physically present

(i) in a place within the United States; or (ii) at a place within Canada while traveling without unreasonable delay by the most direct route (as determined by the Secretary) between Alaska and another State;

at the time the emergency which necessitated such inpatient hospital services occurred, and

(B) such hospital was closer to, or substantially more accessible from, such place than the nearest hospital within the United States which was adequately equipped to deal with, and was available for the treatment of, such individual's illness or injury.

(3) Payment shall be made in the amount provided under subsection (b) of this section to any hospital for the inpatient hospital services described in paragraph (1) or (2) furnished to an individual by the hospital or under arrangements (as defined in section 1395x (w) of this title) with it if (A) the Secretary would be required to make such payment if the hospital had an agreement in effect under this subchapter and otherwise met the conditions of payment hereunder, (B) such hospital elects to claim such payment, and (C) such hospital agrees to comply, with respect to such services, with the provisions of section 1395cc (a) of this title.

(4) Payment for the inpatient hospital services described in paragraph (1) or (2) furnished to an individual entitled to hospital insurance benefits under section 426 of this title may be made on the basis of an itemized bill to such individual if (A) payment for such services cannot be made under paragraph (3) solely because the hospital does not elect to claim such payment, and (B) such individual files application (submitted within such time and in such form and manner and by such person, and continuing and supported by such information as the Secretary shall by regulations prescribe) for reimbursement. The amount payable with respect to such services shall, subject to the provisions of section 1395e of this title, be equal to the amount which would be payable under subsection (d)(3) of this section.

(g) Payments to physicians for services rendered in teaching hospitals.

For purposes of services for which the reasonable cost thereof is determined under section 1395x(v) (1) (D) of this title, payment under this part shall be made to such fund as may be designated by the organized medical staff of the hospital in which such services were furnished or, if such services were furnished in such hospital by the faculty of a medical school, to such fund as may be designated by such faculty, but only if—

(1) such hospital has an agreement with the Secretary under section 1395cc of this title, and (2) the Secretary has received written assurances that (A) such payment will be used by such fund solely for the improvement of care of hospital patients or for educational or charitable purposes and (B) the individuals who were furnished such services or any other persons will not be charged for such services (or if charged, provision will be made for return of any moneys incorrectly collected).

(h) Payment for posthospital extended care services.

(1) An individual shall be presumed to require the care specified in subsection (a) (2) (C) of this section for purposes of making payment to a skilled nursing facility (subject to the provisions of section 1395d of this title) for posthospital extended care services which are furnished by such facility to such individual if

(A) the certification referred to in subsection (a) (2) (C) of this section is submitted prior to or at the time of admission of such individual to such skilled nursing facility.

(B) such certification states that the medical condition of the individual is a condition designated in regulations.

(D) there is compliance with such other requirements and procedures as may be specified in regulations,

but only for services furnished during such limited periods of time with respect to such conditions of the individual as may be prescribed in regulations by the Secretary, taking into account the medical severity of such conditions, the degree of incapacity, and the minimum length of stay in an institution generally needed for such conditions, and such other

factors affecting the type of care to be provided as the Secretary deems pertinent.

(i) Payment for posthospital home health services.

(1) An individual shall be presumed to require the services specified in subsection (a)(2) (D) of this section for purposes of making payment to a home health agency (subject to the provisions of section 1395d of this title) for posthospital home health services furnished by such agency to such individual if

(A) the certification and plan referred to in subsection (a) (2) (D) of this section are submitted in timely fashion prior to the first visit by such agency,

(B) such certification states that the medical condition of the individual is a condition designated in regulations, and

but only for services furnished during such limited number of visits with respect to such conditions of the individual as may be prescribed in regulations by the Secretary, taking into account the medical severity of such conditions, the degree of incapacity, and the minimum period of home confinement generally needed for such conditions, and such other factors affecting the type of care to be provided as the Secretary deems pertinent.

(2) If the Secretary determines with respect to a physician that such physician is submitting with some frequency (A) erroneous certifications that individuals have conditions designated in regulations as provided in this subsection or (B) plans for providing services which are inappropriate, the provisions of paragraph (1) shall not apply, after the effective date of such determination, in any case in which such physician submits a certification or plan referred to in subparagraph (A) or (B) of paragraph (1). (As amended Oct. 30, 1972, Pub. L. 92-603, title II, §§ 211(a), 226 (c) (1), 227(b), 228(a), 233(a), 234 (g) (1), 238(a), 247(a), 256(a), 278(a)(1)–(3), (b) (4), (17), 281 (e), 86 Stat. 1382, 1404, 1405, 1407, 1411, 1413, 1416, 1425, 1447, 1453, 1454, 1456; Dec. 31, 1973, Pub. L. 93-233, § 18(k) (1), (2), 87 Stat. 970.)

AMENDMENTS

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), added 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 subsec. (a) (2) (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" following "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) and 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 in subsec. (h) as added, substituted "skilled nursing facility" for "extended care faciliity."

Subsec. (1). Pub.. L. 92-603, § 228(a), added subsec. (1). EFFECTIVE DATE OF 1973 AMENDMENT

Section 18(z-3) (2) of Pub. L. 93-233 provided that: "The amendments made by subsection (k) [amending subsec. (a) (2) (E) and last sentence of subsec. (a) of this section and section 1395y (a) (12) of this title] shall be effective with respect to admissions subject to the provisions of section 1814(a) (2) of the Social Security Act [subsec. (a) (2) of this section] which occur after December 31, 1972."

EFFECTIVE DATE OF 1972 AMENDMENT Section 211(d) of Pub. L. 92-603 provided that: "The amendments made by this section [amending subsec. (f) of this section and sections 1395x (e) and (r), 1395y (a) (4), 1395u (b) (3) (B) (ii) and 13951(a)(1) of this title] shall apply to services furnished with respect to admissions occuring after December 31, 1972."

Amendment of section by section 226(c) (1) of Pub. L. 92-603 effective with respect to services provided on or after July 1, 1973, see section 226 (f) of Pub. L. 92-603, set out as a note under section 1395mm of this title.

Amendment of section by section 227(b) of Pub. L. 92603 applicable with respect to accounting periods beginning after June 30, 1973, see section 227(g) of Pub. L. 92603, set out as a note under section 1395x of this title. Section 228(b) of Pub. L. 92-603 provided that: "The amendment made by subsection (a) [adding subsecs. (h) and (1) to this section] and any regulations adopted

pursuant to such amendment shall apply with respect to plans of care initiated on or after January 1, 1973, and with respect to admission to skilled nursing facilities and home health plans initiated on or after such date." Section 233 (f) of Pub. L. 92-603 provided that: "The amendments made by subsections (a) and (b) [amending this section and section 13951 of this title] shall apply to services furnished by hospitals, extended care facilities, and home health agencies in accounting periods beginning after December 31, 1972. The amendments made by subsections (c), (d), and (e) [amending sections 706, 709 and 1396b of this title] shall apply with respect to services furnished by hospitals in accounting periods beginning after December 31, 1972." See, also, section 16 of Pub. L. 93-233, set out as a note hereunder.

Amendment of subsec. (a) (2) (C), (D), of this section by section 234(g) (1) of Pub. L. 92-603 applicable with respect to providers of services for fiscal years beginning after the fifth month following October 1972, see section 234(1) of Pub. L. 92-603, set out as a note under section 1395x of this title.

Section 238(b) of Pub. L. 92-603 provided that: "The amendment made by subsection (a) [amending subsec. (a) (7) of this section] shall apply with respect to services furnished after the second month following the month in which this Act is enacted. [Oct. 1972]."

Section 247 (c) of Pub. L. 92-603 provided that: "The amendments made by this section [enacting section 1396d (f) of this title and amending subsec. (a) (2) (C) of this section] shall be effective with respect to services furnished after December 31, 1972."

Section 256 (d) of Pub. L. 92-603 provided that: "The amendments made by this section [amending subsec. (a) (2) of this section and sections 1395x(r) and 1395y (a) (12) of this title] shall apply with respect to admissions occurring after the second month following the month in which this Act is enacted [Oct. 1972]."

Amendment of subsec. (a) (1) of this section by section 281 (e) of Pub. L. 92-603 to apply 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.

MEDICARE PAYMENT BASIS FOR SERVICES PROVIDED BY AGENCIES AND PROVIDERS; EFFECTIVE DATE Section 16 of Pub. L. 93-233 provided that: "In the administration of titles [subchapters] V, XVIII, and XIX of the Social Security Act [this chapter], the amount payable under such title [subchapter] to any provider of services on account of services provided by such hospital, skilled nursing facility, or home health agency shall be determined (for any period with respect to which the amendments made by section 233 of Public Law 92-603 [to this section and sections 706, 709, 13957 and 1396b of this title] would, except for the provisions of this section, be applicable) in like manner as if the date contained in the first and second sentences of subsection (f) of such section 233 [set out as 1972 Effective Date note hereunder] were December 31, 1973, rather than December 31, 1972."

EXPERIMENTS and DemonSTRATION PROJECTS TO DETERMINE METHODS FOR PROSPECTIVE PAYMENTS TO HOSPITALS, SKILLED NURSING FACILITIES, AND OTHER PROVIDERS OF SERVICES FOR CARE AND SERVICES FURNISHED; SCOPE; WAIVER OF PAYMENT REQUIREMENTS; Source and MANNER OF PAYMENTS FOR GRANTS, ETC.; REPORTS TO CONGRESS Section 222(a) of Pub. L. 92-603 provided that: "(1) The Secretary of Health, Education, and Welfare, directly or through contracts with, or grants to, public or private agencies or organizations, shall develop and carry out experiments and demonstration projects designed to determine the relative advantages and disadvantages of various alternative methods of making payment on a prospective basis to hospitals, skilled nursing facilities, and other providers of services for care and services provided by them under title XVIII of the Social Security Act [this subchapter] and under State plans approved under titles XIX and V of such Act [subchapters XIX and V of this chapter], including alternative methods for classifying providers, for establishing prospective rates

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