§ 1395bb. Effect of accreditation

Legislative history

Reconstructed from this section’s Code source credit and amendment notes, resolved against the local Statutes at Large. Editorial notes are evidence, not the law that made the change.

1. 1935

   Health Insurance for the Aged Act

   Pub. L. 89–97 title I § 102(a) · 79 Stat. 288

   Enacted · 42 U.S.C. § 1395bb

   Aug. 14, 1935, ch. 531, title XVIII, § 1865, as added Pub. L. 89–97, title I, § 102(a), July 30, 1965, 79 Stat. 326

   Source evidence

   Code source credit
   Aug. 14, 1935, ch. 531, title XVIII, § 1865, as added Pub. L. 89–97, title I, § 102(a), July 30, 1965, 79 Stat. 326

   Enacted provision · exact public law section
   (a) The Social Security Act is amended by adding after title XVII the following new title: 42 USC 1305. “TITLE XVIII— HEALTH INSURANCE FOR THE AGED “Sec. 1801. “prohibition against any federal interference Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person. “Sec. 1802. “free choice by patient guaranteed Any individual entitled to insurance benefits under this title may obtain health services from any institution, agency, or person qualified to participate under this title if such institution, agency, or person undertakes to provide him such services. “Sec. 1803. “option to individuals to obtain other health insurance protection Nothing contained in this title shall be construed to preclude any State from providing, or any individual from purchasing or oilier wise securing, protection against the cost of any health services. “Part A— Hospital Insurance Benefits for the Aged “Sec. 1811. “description of program The insurance program for which entitlement is established by section 226 provides basic protection against the costs of hospital Ante, p. 290. and related post-hospital services in accordance with this part for individuals who are age 65 or over and are entitled to retirement 42 USC 401–425. benefits under title II of this Act or under the railroad retirement system. “Sec. 1812. “scope of benefits (a) The benefits provided to an individual by the insurance program under this part shall consist of entitlement to have payment made on his behalf (subject to the provisions of this part) for— “(1) inpatient hospital services for up to 90 days during any spell of illness; “(2) post-hospital extended care services for up to 100 days during any spell of illness; “(3) post-hospital home health services for up to 100 visits (during the one-year period described in section 1861(h)) after the beginning of one spell of illness and before the beginning of the next; and “(4) outpatient hospital diagnostic services. “(b) Payment under this part for services furnished an individual during a spell of illness may not (subject to subsection (c)) be made for— “(1) inpatient hospital services furnished to him during such spell after such services have been furnished to him for 90 days (luring such spell; “(2) post-hospital extended care services furnished to him during such spell after such services have been furnished to him for 100 days during such spell; or “(3) inpatient psychiatric hospital services furnished to him after such services have been furnished to him for a total of 190 days during his lifetime. “(c) If an individual is an inpatient of a psychiatric hospital or a tuberculosis hospital on the first day of the first month for which lie is entitled to benefits under this part, the days on which he was an inpatient of such a hospital in the 90-day period immediately before such first day shall be included in determining the 90-day limit under subsection (b)(1)(but not in determining the 190-day limit under subsection (b)(3)). “(d) Payment under this part may be made for post-hospital home health services furnished an individual only during the one-year period described in section 1861 (n) following his most recent hospital discharge which meets the requirements of such section, and only for the first 100 visits in such period. The number of visits to be charged for purposes of the limitation in the preceding sentence, in connection with items or services described in section 1861 (m), shall be determined in accordance with regulations. “(e) For purposes of subsections (b), (c), and (d), inpatient hospital services, inpatient psychiatric hospital services, post-hospital extended care services, and post-hospital home health services shall be taken into account only if payment is or would be, except for this section or the failure to comply with the request and certification requirements of or under section 1814(a), made with respect to such services under this part. “(f) For definition of ‘spell of illness’, and for definitions of other terms used in this part, see section 1861. “Sec. 1813. “deductibles and coinsurance (a) (1) The amount payable for inpatient hospital services furnished an individual during any spell of illness shall be reduced by a deduction equal to the inpatient hospital deductible or, if less, the charges imposed with respect to such individual for such services, except that, if the customary charges for such services are greater than the charges so imposed, such customary charges shall be considered to be the charges so imposed. Such amount shall be further reduced by a coinsurance amount equal to one-fourth of the inpatient hospital deductible for each day (before the 91st day) on which such individual is furnished such services during such spell of illness after such services have been furnished to him for 60 days during such spell. “(2) The amount payable for outpatient hospital diagnostic Outpatient hospital diagnostic services. services furnished an individual during a diagnostic study shall be reduced by a deduction equal to the sum of (A) one-half of the inpatient hospital deductible which is applicable to spells of illness beginning in the same calendar year as such diagnostic study and (B) 20 per centum of the remainder of such amount. For purposes of the preceding sentence, a diagnostic study for any individual consists of the outpatient hospital diagnostic services provided by (or under arrangements made by) the same hospital during the 20-day period beginning on the first day (not included in a previous diagnostic study) on which he is entitled to hospital insurance benefits under section 226 and on which outpatient hospital diagnostic services are Ante, p. 290. furnished him. “(3) The amount payable to any provider of services under this part, for services furnished an individual during any spell of illness shall be further reduced by an amount equal to the cost of the first three pints of whole blood furnished to him as part of such services during such spell of illness. “(4) The amount payable for post-hospital extended care services furnished an individual during any spell of illness shall lie reduced by a coinsurance amount equal to one-eighth of the inpatient hospital deductible for each day (before the 101st day) on which he is furnished such services after such services have been furnished to him for 20 days during such spell. “(b) (1) The inpatient hospital deductible which shall be applicable Inpatient hospital deductible. for the purposes of subsection (a) shall be $40 in the case of any spell of illness or diagnostic study beginning before 1969. “(2) The Secretary shall, between July 1 and October 1 of 1968, and of each year thereafter, determine and promulgate the inpatient hospital deductible which shall be applicable for the purposes of subsection (a) in the case of any spell of illness or diagnostic study beginning during the succeeding calendar year. Such inpatient hospital deductible shall be equal to $40 multiplied by the ratio of (A) the current average per diem rate for inpatient hospital services for the calendar year preceding the promulgation, to (B) the current average per diem rate for such services for 1966. Any amount determined under the preceding sentence which is not a multiple of $4 shall be rounded to the nearest multiple of $4 (or, if it is midway between two multiples of $4, to the next, higher multiple of $4). The current average per diem rate for any year shall be determined by the Secretary on the basis of the best information available to him (at the time the determination is made) as to the amounts paid under this part on account of inpatient hospital services furnished during such year, by hospitals which have agreements in effect under section 1866, to individuals who are entitled Post, p. 327. to hospital insurance benefits under section 226, plus the amount which would have been so paid but for subsection (a)(1) of this section. “Sec. 1814. “conditions of and limitations on payment for services “Requirement of Requests and Certifications (a) Except as provided in subsection (d), payment for services furnished an individual may be made only to providers of services which are eligible therefor under section 1866 and only Post, p. 327. 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, within such time, and by such person or persons as the Secretary may by regulation prescribe; “(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— “(A) in the case of inpatient hospital services (other than inpatient psychiatric hospital services and inpatient tuberculosis hospital services), such services are or were required to be given on an inpatient basis for such individual’s medical treatment, or that inpatient diagnostic study is or was medically required and such services are or were necessary for such purpose; “(B) in the case of inpatient psychiatric hospital services, such services are or were required to be given on an inpatient basis, by or under the supervision of a physician, tor the psychiatric treatment of an individual; and (i) such treatment can or could reasonably be expected to improve the condition for which such treatment is or was necessary or (ii) inpatient diagnostic study is or was medically required and such services are or were necessary for such purposes; “(C) in the case of inpatient tuberculosis hospital services, such services are or 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 such treatment can or could reasonably be expected to (i) improve the condition for which such treatment is or was necessary or (ii) render the condition noncommunicable; “(D) in the case of post-hospital extended care services, such services are or were required to be given on an inpatient basis because the individual needs or needed skilled nursing care on a continuing 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 Post, p. 314. (6) and (8) of section 1861(e)) prior to transfer to the extended care 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; “(E) 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 1861 (m)(7)) and Post, p. 319. 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 (8) of section 1861(e)) 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 “(F) in the case of outpatient hospital diagnostic services, such services are or were required for diagnostic study; “(3) in the case of inpatient psychiatric hospital services, the services are those which the records of the hospital indicate were furnished to the individual during periods when he was receiving (A) intensive treatment services, (B) admission and related services necessary for a diagnostic study, or (C) equivalent services; “(4) in the case of inpatient tuberculosis hospital services, the services are 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 (A) improve his condition or (B) render it noncommunicable; “(5) 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 sifter 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 extended care facility, as the case may be, a decision under section 1866(d)(based on a finding that utilization Post, p. 327. review of long-stay cases is not being made in such hospital or facility); and “(6) 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 1861(h)(4)) 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 extended care 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), (E), or (F) 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) “Reasonable Cost 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 Ante, p. 292. Post, p. 322. to the provisions of section 1813, be the reasonable cost of such services, as determined under section 1861 (v). “(c) “No Payments to Federal Providers of Services No payment may be made under this part (except under subsection (d)) to any Federal provider of services, except a provider of services which the Secretary determines is providing services to the public generally as a community institution or agency; and no such payment may be made to any provider of services for any item or service which such provider is obligated by a law of, or a contract with, the United States to render at public expense. “(d) “Payments for Emergency Hospital Services Payments shall also be made to any hospital for inpatient hospital services or outpatient hospital diagnostic services furnished, by the hospital or under arrangements (as defined in section 1861 (w)) with it, to an individual entitled to hospital insurance benefits under Ante, p. 290. section 226 even though such hospital does not have an agreement in effect under this title if (A) such services were emergency services and (B) the Secretary would be required to make such payment if the hospital had such an agreement in effect and otherwise met the conditions of payment hereunder. Such payments shall be made only in the amounts provided under subsection (b) and then only if such hospital agrees to comply, with respect to the emergency services provided, Post, p. 327. with the provisions of section 1866(a). “(e) “Payment for Inpatient Hospital Services Prior to Notification of Noneligibility Notwithstanding that an individual is not entitled to have payment made under this part for inpatient hospital services furnished by any hospital, payment shall be made to such hospital (unless it elects not to receive such payment or, if payment has already been made by or on behalf of such individual, fails to refund such payment within the time specified by the Secretary) for such services which are furnished to the individual prior to notification to such hospital from the Secretary of his lack of entitlement, if such payments are precluded Ante, p. 291. only by reason of section 1812 and if such hospital complies with the requirements of and regulations under this title with respect to such payments, has acted in good faith and without knowledge of such lack of entitlement, and has acted reasonably in assuming entitlement existed. Payment under the preceding sentence may not be made for services furnished an individual pursuant, to any admission after the 6th elapsed day (not including as an elapsed day Saturday, Sunday, or a legal holiday) after the day on which such admission occurred. “(f) “Payment for Certain Emergency Hospital Services Furnished Outside the United States The authority contained in subsection (d) shall be applicable to emergency inpatient hospital services furnished an individual by a hospital located outside the United States if— “(1) such individual was physically present in a place within the United States at the time the emergency which necessitated such inpatient hospital services occurred; and “(2) 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. “Sec. 1815. “payment to providers or services The Secretary shall periodically determine the amount which should be paid under this part to each provider of services with respect to the services furnished by it, and the provider of services shall be paid, at such time or times as the Secretary believes appropriate (but not less often than monthly) and prior to audit or settlement by the General Accounting Office, from the Federal Hospital Insurance Trust Fund, the amounts so determined, with necessary Post, p. 299. adjustments on account of previously made overpayments or underpayments; except that no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part, for the period with respect to which the amounts are being paid or any prior period. “Sec. 1816. “use of public agencies or private organizations to facilitate payment to providers of services (a) If any group or association of providers of services wishes to have payments under this part to such providers made through a national, State, or other public or private agency or organization and nominates such agency or organization for this purpose, the Secretary is authorized to enter into an agreement with such agency or organization providing for the determination by such agency or organization (subject to such review by the Secretary as may be provided for by the agreement.) of the amount of the payments required pursuant to this part, to be made to such providers, and for the making of such payments by such agency or organization to such providers. Such agreement may also include provision for the agency or organization to do all or any part of the following: (1) to provide consultative services to institutions or agencies to enable them to establish and maintain fiscal records necessary for purposes of this part and otherwise to qualify as hospitals, extended care facilities, or home health agencies, and (2) with respect to the providers of services which are to receive payments through it (A) to serve as a center for, and communicate to providers, any information or instructions furnished to it by the Secretary, and serve as a channel of communication from providers to the Secretary; (B) to make such audits of the records of providers as may be necessary to insure that proper payments are made under this part; and (C) to perform such other functions as are necessary to carry out this subsection. “(b) The Secretary shall not enter into an agreement with any agency or organization under this section unless (1) he finds (A) that to do so is consistent with the effective and efficient administration of this part, and (B) that such agency or organization is willing and able to assist the providers to which payments are made through it under this part in the application of safeguards against unnecessary utilization of services furnished by them to individuals entitled Ante, p. 290. to Hospital insurance benefits under section 226, and the agreement provides for such assistance, and (2) such agency or organization agrees to furnish to the Secretary such of the information acquired by it in carrying out its agreement under this section as the Secretary may find necessary in performing his functions under this part. “(c) An agreement with any agency or organization under this section may contain such terms and conditions as the Secretary finds necessary or appropriate, may provide for advances of funds to the agency or organization for the making of payments by it under subsection (a), and shall provide for payment of so much of the cost of administration of the agency or organization as is determined by the Secretary to be necessary and proper for carrying out the functions covered by the agreement. “(d) If the nomination of an agency or organization as provided in this section is made by a group or association of providers of services, it shall not be binding on members of the group or association which notify the Secretary of their election to that effect Any provider may, upon such notice as may be specified in the agreement under this section with an agency or organization, withdraw its nomination to receive payments through such agency or organization. Any provider which has withdrawn its nomination, and any provider which has not made a nomination, may elect to receive payments from any agency or organization which has entered into an agreement with the Secretary under this section if the Secretary and such agency or organization agree to it. “(e) An agreement with the Secretary under this section may be terminated— “(1) by the agency or organization which entered into such agreement at such time and upon such notice to the Secretary, to the public, and to the providers as may be provided in regulations, or “(2) by the Secretary at such time and upon such notice to the agency or organization, to the providers which have nominated it for purposes of this section, and to the public, as may be provided in regulations, but only if he finds, after reasonable notice and opportunity for hearing to the agency or organization, that (A) the agency or organization has failed substantially to carry out the agreement, or (B) the continuation of some or all of the functions provided for in the agreement with the agency or organization is disadvantageous or is inconsistent with the efficient administration of this part. “(f) An agreement with an agency or organization under this section may require any of its officers or employees certifying payments or disbursing funds pursuant to the agreement, or otherwise participating in carrying out the agreement, to give surety bond to the United States in such amount as the Secretary may deem appropriate. “(g) (1) No individual designated pursuant to an agreement, under this section as a certifying officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payments certified by him under this section. “(2) No disbursing officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect, to any payment by him under this section if it was based upon a voucher signed by a certifying officer designated as provided in paragraph (1) of this subsection. “(3) No such agency or organization shall be liable to the United States for any payments referred to in paragraph (1) or (2). “Sec. 1817. “federal hospital insurance trust fund (a) There is hereby created on the books of the Treasury of the United States a trust, fund to be known as the ‘Federal Hospital Insurance Trust Fund’ (hereinafter in this section referred to as the ‘Trust Fund’). The Trust Fund shall consist of such amounts as may be deposited in, or appropriated to, such fund as provided in this part. There are hereby appropriated to the Trust Fund for the fiscal year ending June 30, 1966, and for each fiscal year thereafter, out of any moneys in the Treasury not otherwise appropriated, amounts equivalent to 100 per centum of— “(1) the taxes imposed by sections 3101 (b) and 3111(b) of the Internal Revenue Code of 1954 with respect to wages reported Post, pp, 395, 396. to the Secretary of the Treasury or his delegate pursuant to subtitle F of such Code after December 31, 1965, as determined by 26 USC 6001 et seq. the Secretary of the Treasury by applying the applicable rates of tax under such sections to such wages, which wages shall be certified by the Secretary of Health, Education, and Welfare on the basis of records of wages established and maintained by the Secretary of Health, Education, and Welfare in accordance with such reports; and “(2) the taxes imposed by section 1401(b) of the Infernal Revenue Code of 1954 with respect to self-employment income Post, p. 394. reported to the Secretary of the Treasury or his delegate on tax returns under subtitle F of such Code, as determined by the Secretary of the Treasury by applying the applicable rate of tax under such section to such self-employment income, which self-employment income shall be certified by the Secretary of Health, Education, and Welfare on the basis of records of self-employment established and maintained by the Secretary of Health, Education, and Welfare in accordance with such returns. The amounts appropriated by the preceding sentence shall be transferred from time to time from the general fund in the Treasury to the Trust Fund, such amounts to be determined on the basis of estimates by the Secretary of the Treasury of the taxes, specified in the preceding sentence, paid to or deposited into the Treasury; and proper adjustments shall be made in amounts subsequently transferred to the extent prior estimates were in excess of or were less than the taxes specified in such sentence. “(b) With respect to the Trust Fund, there is hereby created a Board of Trustees. body to be known as the Board of Trustees of the Trust Fund (hereinafter in this section referred to as the ‘Board of Trustees’) composed of the Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health, Education, and Welfare, all ex officio. The Secretary of the Treasury shall be the Managing Trustee of the Board of Trustees (hereinafter in this section referred to as the ‘Managing Trustee’), The Commissioner of Social Security shall Reports to Congress. serve as the Secretary of the Board of Trustees. The Board of Trustees shall meet not less frequently than once each calendar year. It shall be the duty of the Board of Trustees to— “(1) Hold the Trust. Fund; “(2) Report to the Congress not later than the first day of March of each year on the operation and status of the Trust Fund during the preceding fiscal year and on its expected operation and status during the current fiscal year and the next 2 fiscal years; “(3) Report immediately to the Congress whenever the Board is of the opinion that the amount of the Trust Fund is unduly small; and “(4) Review the general policies followed in managing the Trust Fund, and recommend changes in such policies, including necessary changes in the provisions of law which govern the way in which the Trust Fund is to be managed. The report, provided for in paragraph (2) shall include a statement of the assets of, and the disbursements made from, the Trust Fund during the preceding fiscal year, an estimate of the expected income to, and disbursements to be made from, the Trust Fund during the current fiscal year and each of the next 2 fiscal years, and a statement of the actuarial status of the Trust Fund. Such report shall be printed as a House document of the session of the Congress to which the report is made. “(c) It shall be the duty of the Managing Trustee to invest such portion of the Trust. Fund as is not, in his judgment, required to meet current withdrawals. Such investments may be made only in interest-bearing obligations of the United States or in obligations guaranteed as to both principal and interest by the United States. For such purpose such obligations may be acquired (1) on original issue at the issue price, or (2) by purchase of outstanding obligations at the market price. The purposes for which obligations of the 40 Stat. 288. 31 USC 774. United States may be issued under the Second Liberty Bond Act, as amended, are hereby extended to authorize the issuance at par of public-debt obligations for purchase by the Trust Fund. Such obligations issued for purchase by the Trust Fund shall have maturities fixed with due regard for the needs of the Trust. Fund and shall bear interest at a rate equal to the average market yield (computed by the Managing Trustee on the basis of market quotations as of the end of the calendar month next preceding the date of such issue) on all marketable interest-bearing obligations of the United States then forming a part of the public debt which are not due or callable until after the expiration of 4 years from the end of such calendar month; except that where such average market yield is not a multiple of one--eighth of 1 per centum, the rate of interest on such obligations shall be the multiple of one-eighth of 1 per centum nearest such market yield. The Managing Trustee may purchase other interest-bearing obligations of the United States or obligations guaranteed as to both principal and interest by the United States, on original issue or at the market, price, only where he determines that the purchase of such other obligations is in the public interest. “(d) Any obligations acquired by the Trust Fund (except public-debt obligations issued exclusively to the Trust Fund) may be sold by the Managing Trustee at the market price, and such public-debt obligations may be redeemed at par plus accrued interest. “(e) The interest on, and the proceeds from the sale or redemption of, any obligations held in the Trust Fund shall be credited to and form a part of the Trust Fund. _ “(f) (1) The Managing Trustee is directed to pay from time to time from the Trust Fund into the Treasury the amount estimated by him as taxes imposed under section 3101(b) which are subject to Post, p. 395. Post, p. 393. refund under section 6413(c) of the Internal Revenue Code of 1954 with respect to wages paid after December 31, 1965. Such taxes shall be determined on the basis of the records of wages established and maintained by the Secretary of Health, Education, and Welfare in accordance with the wages reported to the Secretary of the Treasury or his delegate pursuant to subtitle F of the Internal Revenue Code 26 USC 6001 et seq. of 1954, and the Secretary of Health, Education, and Welfare shall furnish the Managing Trustee such information as may be required by the Managing Trustee for such purpose. The payments by the Managing Trustee shall be covered into the Treasury as repayments to the account for refunding internal revenue collections. “(2) Repayments made under paragraph (1) shall not be available for expenditures but shall be carried to the surplus fund of the Treasury. If it subsequently appears that the estimates under such paragraph in any particular period were too high or too low, appropriate adjustments shall be made by the Managing Trustee in future payments. “(g) There shall be transferred periodically (but not less often than once each fiscal year) to the Trust Fund from the Federal Old-Age and Survivors Insurance Trust Fund and from the Federal Disability Insurance Trust Fund amounts equivalent to the amounts not previously so transferred which the Secretary of Health, Education, and Welfare shall have certified as overpayments (other than amounts so certified to the Railroad Retirement Board) pursuant to section 1870(b) of this Act. There shall be transferred periodically Post, p. 331. (but not less often than once each fiscal year) to the Trust Fund from the Railroad Retirement Account amounts equivalent to the amounts not previously so transferred which the Secretary of Health, Education, and Wei fare shall have certified as overpayments to the Railroad Retirement Board pursuant to section 1870(b) of this Act. “(h) The Managing Trustee shall also pay from time to time from the Trust Fund such amounts as the Secretary of Health, Education, and Welfare certifies are necessary to make the payments provided for by this part, and the payments with respect to administrative expenses in accordance with section 201 (g)(1). Post, p. 338. “Part B— Supplementary Medical Insurance Benefits for the Aged “Sec. 1831. “establishment of supplementary medical insurance program for the aged There is hereby established a voluntary insurance program to provide medical insurance benefits in accordance with the provisions of this part for individuals 65 years of age or over who elect to enroll under such program, to be financed from premium payments by enrollees together with contributions from funds appropriated by the Federal Government. “Sec. 1832. “scope of benefits (a) The benefits provided to an individual by the insurance program established by this part shall consist of— “(1) entitlement to have payment made to him or on his behalf (subject to the provisions of this part) for medical and other health services, except those described in paragraph (2)(B);and “(2) entitlement to have payment made on his behalf (subject to the provisions of this part) for— “(A) home health services for up to 100 visits during a calendar year; and “(B) medical and other health services (other than physicians services unless furnished by a resident or intern of a hospital) furnished by a provider of services or by others under arrangements with them made by a provider of services. “(b) For definitions of ‘spell of illness’, ‘medical and other health services’, and other terms used in this part, see section 1861. “Sec. 1833. “payment of benefits (a) Subject to the succeeding provisions of this section, there shall be paid from the Federal Supplementary Medical Post, p. 308. Insurance Trust Fund, in the case of each individual who is covered under the insurance program established by this part and incurs expenses for services with respect to which benefits are payable under this part, amounts equal to— “(1) in the case of services described in section 1832(a)(1)—80 percent of the reasonable charges for the services; except that an organization which provides medical and other health services (or arranges for their availability) on a prepayment basis may elect to be paid 80 percent of the reasonable cost of services for which payment may be made under this part on behalf of individuals enrolled in such organization in lieu of 80 percent of the reasonable charges for such services if the organization undertakes to charge such individuals no more than 20 percent of such reasonable cost plus any amounts payable by them as a result of subsection (b); and “(2) in the case of services described in section 1832(a)(2)—80 percent of the reasonable cost of the services (as determined Post, p. 322. under section 1861 (v)). “(b) Before applying subsection (a) with respect to expenses incurred by an individual during any calendar year, the total amount of the expenses incurred by such individual during such year (which would, except for this subsection, constitute incurred expenses from which benefits payable under subsection (a) are determinable) shall be reduced by a deductible of $50; except that (1) the amount of the deductible for such calendar year as so determined shall first be reduced by the amount of any expenses incurred by such individual in the last three months of the preceding calendar year (or regarded under clause (2) as incurred in such preceding year with respect to services furnished in such last three months) and applied toward such individual’s deductible under this section for such preceding year, and (2) the Ante, p. 292. amount of any deduction imposed under section 1813(a)(2)(A) with respect to outpatient hospital diagnostic services furnished in any calendar year shall be regarded as an incurred expense under this part for such year. “(c) Notwithstanding any other provision of this part, with respect Mental disorders. to expenses incurred in any calendar year in connection with the treatment of mental, psychoneurotic, and personality disorders of an individual who is not an inpatient of a hospital at the time such expenses are incurred, there shall be considered as incurred expenses for purposes of subsections (a) and (b) only whichever of the following amounts is the smaller: “(1) $312.50, or “(2) 62½ percent of such expenses. “(d) No payment may be made under this part with respect be any services furnished an individual to the extent that such individual is entitled (or would be entitled except for section 1813 other than Ante, p. 292. subsection (a)(2)(A) thereof) to have payment made with respect to such services under part A. “(e) No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period. “Sec. 1834. “limitation on home health services (a) Payment under this part may be made for home health services furnished an individual during any calendar year only for 100 visits during such year. The number of visits to be charged for purposes of the limitation in the preceding sentence, in connection with items and services described in section 1861 (m), shall be determined Post, p. 319. in accordance with regulations. “(b) For purposes of subsection (a), home health services shall be taken into account only if payment under this part is or would be, except for this section or the failure to comply with the request and certification requirements of or under section 1835(a), made with respect to such services. “Sec. 1835. “procedure for payment of claims of providers of services (a) Payment for services described in section 1832(a)(2) furnished an individual may be made only to providers of services which are eligible therefor under section 1866(a), and only if— Post, p. 327. “(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, within such time, and by such person or persons as the Secretary may by regulations prescribe; and “(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) that— “(A) in the case of home health services (i) 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 1861 (m)(7)) and needed skilled nursing care on an intermittent basis, or physical or speech therapy , (ii) a plan for furnishing such services to such individual has been established and is periodically reviewed by a physician, and (iii) such services are or were furnished while the individual is or was under the care of a physician; and “(B) in the case of medical and other health services, such services are or were medically required. 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 a certification of the kind provided in subparagraph (A) or (B) 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) No payment may be made under this part to any Federal provider of services or other Federal agency, except a provider of services which the Secretary determines is providing services to the public generally as a community institution or agency; and no such payment may be made to any provider of services or other person for any item or service which such provider or person is obligated by a law of, or a contract with, the United States to render at public expense. “Sec. 1836. “eligible individuals Every individual who— “(1) has attained the age of 65, and “(2) (A) is a resident of the United States, and is either (i) a citizen or (ii) an alien lawfully admitted for permanent residence who has resided in the United States continuously during the 5 years immediately preceding the month in which he applies for enrollment under this part, or (B) is entitled to hospital insurance benefits under part A, is eligible to enroll in the insurance program established by this part. “Sec. 1837. “enrollment periods (a) An individual may enroll in the insurance program established by this part only in such manner and form as may be prescribed by regulations, and only during an enrollment period prescribed in or under this section. “(b) (1) No individual may enroll for the first time under this part more than 3 years after the close of the first enrollment period during which he could have enrolled under this part. “(2) An individual whose enrollment under this part has terminated may not enroll for the second time under this part unless he does so in a general enrollment period (as provided in subsection (e)) which begins within 3 years after the effective date of such termination. No individual may enroll under this part more than twice. “(c) In the case of individuals who first, satisfy paragraphs (1) and (2) of section 1836 before January 1, 1966, the initial general enrollment period shall begin on the first day of the second month which begins after the date of enactment of this title and shall end on March 31, 1966. For purposes of this subsection and subsection (d), an individual who satisfies paragraph (2) of section 1836 solely by reason of subparagraph (B) thereof shall be treated as satisfying such paragraph (2) on the first day on which he is (or on filing application would be) entitled to hospital insurance benefits under part A. “(d) In the case of an individual who first satisfies paragraphs (1) and (2) of section 1836 on or after January 1, 1966, his initial enroll- ment period shall begin on the first day of the third month before the month in which he first satisfies such paragraphs and shall end seven months later. “(e) There shall be a general enrollment period, after the period described in subsection (c), during the period beginning on October 1 and ending on December 31 of each odd-numbered year beginning with 1967. “Sec. 1838. “coverage period (a) The period during which an individual is entitled to benefits under the insurance program established by this part (hereinafter referred to as his ‘coverage period’) shall begin on whichever of the following is the latest: “(1) July 1, 1966; or “(2) (A) in the case of an individual who enrolls pursuant to subsection (d) of section 1837 before the month in which he first satisfies paragraphs (1) and (2) of section 1836, the first day of such month, or “(B) in the case of an individual who enrolls pursuant to such subsection (d) in the month in which he first satisfies such paragraphs, the first day of the month following the month in which he so enrolls, Or “(C) in the case of an individual who enrolls pursuant to such subsection (d) in the month following the month in which he first satisfies such paragraphs, the first day of the second month following the month in which he so enrolls, or “(D) in the case of an individual who enrolls pursuant to such subsection (d) more than one month following the month in which he satisfies such paragraphs, the first day of the third month following the month in which he so enrolls, or “(E) in the case of an individual who enrolls pursuant to subsection (e) of section 1837, the July 1 following the month in which he so enrolls. “(b) An individual’s coverage period shall continue until his enrollment has been terminated— “(1) by the filing of notice, during a general enrollment period described in section 1837(e), that the individual no longer wishes to participate in the insurance program established by this part, or “(2) for nonpayment of premiums. The termination of a coverage period under paragraph (1) shall take effect at the close of December 31 of the year in which the notice is filed. The termination of a coverage period under paragraph (2) shall take effect on a date determined under regulations, which may be determined so as to provide a grace period (not in excess of 90 days) in which overdue premiums may be paid and coverage continued. “(c) No payments may be made under this part with respect to the expenses of an individual mi less such expenses were incurred by such individual during a period which, with respect to him, is a coverage period. “Sec. 1839. “amounts of premiums (a) The monthly premium of each individual enrolled under this part for each month before 1968 shall be $3. “(b) (1) The monthly premium of each individual enrolled under this part for each month after 1967 shall be the amount determined under paragraph (2), “(2) The Secretary shall, between July 1 and October 1 of 1967 and of each odd-numbered year thereafter, determine and promulgate the dollar amount which shall be applicable for premiums for months occurring in either of the two succeeding calendar years. Such dollar amount shall be such amount as the Secretary estimates to be necessary so that the aggregate premiums for such two succeeding calendar years will equal one-half of the total of the benefits and administrative costs which he estimates will be payable from the Federal Supplementary Post, p. 308. Medical Insurance Trust Fund for such two succeeding calendar years. In estimating aggregate benefits payable for any period, the Secretary shall include an appropriate amount for a contingency margin. “(c) In the case of an individual whose coverage period began pursuant to an enrollment after his initial enrollment period (determined pursuant to subsection (c) or (d) of section 1837), the monthly premium determined under subsection (b) shall be increased by 10 percent of the monthly premium so determined for each full 12 months in which he could have been but was not enrolled. For purposes of the preceding sentence, there shall be taken into account (1) the months which elapsed between the close of his initial enrollment period and the close of the enrollment period in which he enrolled, plus (in the case of an individual who enrolls for a second time)(2) the month which elapsed between the date of the termination of his first coverage period and the close of the enrollment period in which he enrolled for the second time. “(d) If any monthly premium determined under the foregoing provisions of this section is not a multiple of 10 cents, such premium shall be rounded to the nearest multiple of 10 cents. “Sec. 1840. “payment of premiums (a) (1) In the case of an individual who is entitled to monthly benefits under section 202, his monthly premiums under this part shall (except, as provided in subsection (d)) be collected by deducting the amount thereof from the amount of such monthly benefits. Such deduction shall be made in such manner and at such times as the Secretary shall by regulation prescribe. “(2) The Secretary of the Treasury shall, from time to time, transfer from the Federal Old-Age and Survivors Insurance Trust Fund or the Federal Disability Insurance Trust Fund to the Federal Supplementary Post, p. 308. Medical Insurance Trust Fund the aggregate amount deducted under paragraph (1) for the period to which such transfer relates from benefits under section 202 which are payable from such Trust Fund. Such transfer shall be made on the basis of a certification by the Secretary of Health, Education, and Welfare and shall be appropriately adjusted to the extent that prior transfers were too great or too small. “(b) (1) In the case of an individual who is entitled to receive for a month an annuity or pension under the Railroad Retirement Act of 1937, Ids monthly premiums under this part shall (except as provided in subsection (d)) be collected by deducting the amount thereof from such annuity or pension. Such deduction shall be made in such manner and at such times as the Secretary shall by regulations prescribe. Such regulations shall be prescribed only after consultation with the Railroad Retirement Board. “(2) The Secretary of the Treasury shall, from time to time, transfer from the Railroad Retirement Account to the Federal Supplementary Medical Insurance Trust Fund the aggregate amount deducted under paragraph (1) for the period to which such transfer relates. Such transfers shall be made on the basis of a certification by the Railroad Retirement Board and shall be appropriately adjusted to the extent that prior transfers were too great or too small. “(c) In the case of an individual who is entitled both to monthly benefits under section 202 and to an annuity or pension under the Railroad Retirement Act of 1937 at the time he enrolls under this part, subsection (a) shall apply so long as lie continues to be entitled both to such benefits and such annuity or pension. In the case of an individual who becomes entitled both to such benefits and such an annuity or pension after 42 USC 402. Post, pp. 335, 340, 400. he enrolls under this part-, subsection (a) shall apply if the first month for which he was entitled to such benefits was the same as or earlier than the first month for which he was entitled to such annuity or pension, and otherwise subsection (b) shall apply. “(d) If an individual to whom subsection (a) or (b) applies estimates that the amount which will be available for deduction under such subsection for any premium payment period will be less than the amount of the monthly premiums for such period, he may (under regulations) pay to the Secretary such portion of the monthly premiums for such period as he desires. “(e) (1) In the case of an individual receiving an annuity under the Civil Service Retirement Act annuitants. 70 Stat. 743. 5 USC 2251 note. Civil Service Retirement Act, or other Act. administered by the Civil Service Commission providing retirement or survivorship protection, to whom neither subsection (a) nor subsection (b) applies, his monthly premiums under this part (and the monthly premiums of the spouse of such individual under this part if neither subsection (a) nor subsection (b) applies to such spouse and if such individual agrees) shall, upon notice from the Secretary of Health, Education, and Welfare to the Civil Service Commission, be collected by deducting the amount thereof from each installment of such annuity. Such deduction shall be made in such manner and at such times as the Civil Service Commission may determine. The Civil Service Commission shall furnish such information as the Secretary of Health, Education, and Welfare may reasonably request in order to carry out his functions under this part with respect to individuals to whom this subsection applies. “(2) The Secretary of the Treasury shall, from time to time, but not less often than quarterly, transfer from the Civil Service Retirement and Disability Fund, or the account (if any) applicable in the case of such other Act administered by the Civil Service Commission, to the Federal Supplementary Medical Insurance Trust Fund the aggregate amount deducted under paragraph (1) for the period to which such transfer relates. Such transfer shall be made on the basis of a certification by the Civil Service Commission and shall be appropriately adjusted to the extent that prior transfers were too great or too small. “(f) In the case of an individual who participates in the insurance program established by this part, but with respect to whom none of the preceding provisions of this section applies, or with respect to whom subsection (d) applies, the premiums shall be paid to the Secretary at such times, and in such manner, as the Secretary shall by regulations prescribe. “(g) Amounts paid to the Secretary under subsection (d) or (f) shall be deposited in the Treasury to the credit of the Federal Supplementary Medical Insurance Trust Fund. “(h) In the case of an individual who participates in the insurance program established by this part, premiums shall be payable for the period commencing with the first month of his coverage period and ending with the month in which he dies or, if earlier, in which his coverage under such program terminates. “Sec. 1841. “federal supplementary medical insurance trust fund (a) There is hereby created on the books of the Treasury of the United States a trust fund to be known as the ‘Federal Supplementary Medical Insurance Trust Fund’ (hereinafter in this section referred to as the ‘Trust Fund’). The Trust Fund shall consist of such amounts as may be deposited in, or appropriated to, such fund as provided in this part. “(b) With respect to the Trust. Fund, there is hereby created a body to lie known as the Board of Trustees of the Trust Fund (hereinafter in this section referred to as the ‘Board of Trustees’) composed of the Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health, Education, and Welfare, all ex officio. The Secretary of the Treasury shall be the Managing Trustee of the Board of Trustees (hereinafter in this section referred to as the ‘Managing Trustee’). The Commissioner of Social Security shall serve as the Secretary of the Board of Trustees. The Board of Trustees shall meet not less Reports to Congress. frequently than once each calendar year. It shall be the duty of the Board of Trustees to— “(1) Hold the Trust Fund; “(2) Report, to the Congress not later than the first day of March of each year on the operation and status of the Trust Fund during the preceding fiscal year and on its expected operation and status during the current fiscal year and the next 2 fiscal years; “(3) Report immediately to the Congress whenever the Board is of the opinion that the amount of the Trust Fund is unduly small; and “(4) Review the general policies followed in managing the Trust Fund, and recommend changes in such polities, including necessary changes in the provisions of law which govern the way in which the Trust Fund is to be managed. The report provided for in paragraph (2) shall include a statement of the assets of, and the disbursements made from, the Trust Fund during the preceding fiscal year, an estimate of the expected income to, and disbursements to be made from, the Trust Fund during the current fiscal year and each of the next 2 fiscal years, and a statement, of the actuarial status of the Trust Fund. Such report shall be printed as a House document of the session of the Congress to which the report is made. “(c) It shall be the duty of the Managing Trustee to invest such portion of the Trust Fund as is not, in his judgment, required to meet current withdrawals. Such investments may be made only in interest-bearing obligations of the United States or in obligations guaranteed as to both principal and interest by the United States. For such purpose such obligations may be acquired (1) on original issue at the issue price, or (2) by purchase of outstanding obligations at the market price. The purposes for which obligations of the 40 Stat. 288. 31 USC 774. United States may be issued under the Second Liberty Bond Act, as amended, are hereby extended to authorize the issuance at par of public-debt obligations for purchase by the Trust Fund. Such obligations issued for purchase by the Trust Fund shall have matu-rities fixed with due regard for the needs of the Trust Fund and shall bear interest at a rate equal to the average market yield (computed by the Managing Trustee on the basis of market quotations as of the end of the calendar month next preceding the date of such issue) on all marketable interest-bearing obligations of the United States then forming a part of the public debt which are not due or callable until after the expiration of 4 years from the end of such calendar month; except that where such average market yield is not a multiple of one-eighth of 1 per centum, the rate of interest on such obligations shall be the multiple of one-eighth of 1 per centum nearest such market yield. The Managing Trustee may purchase other interest-bearing obligations of the United States or obligations guaranteed as to both principal and interest by the United States, on original issue or at the market price, only where he determines that the purchase of such other obligations is in the public interest. “(d) Any obligations acquired by the Trust Fund (except public-debt obligations issued exclusively to the Trust Fund) may be sold by the Managing Trustee at the market price, and such public-debt obligations may be redeemed at par plus accrued interest. “(e) The interest on, and the proceeds from the sale or redemption of, any obligations held in the Trust Fund shall be credited to and form a part of the Trust Fund. “(f) There shall be transferred periodically (but not less often than once each fiscal year) to the Trust Fund from the Federal Old-Age and Survivors Insurance Trust Fund and from the Federal Disability Insurance Trust Fund amounts equivalent to the amounts not previously so transferred which the Secretary of Health, Education, and Welfare shall have certified as overpayments (other than amounts so certified to the Railroad Retirement Board) pursuant to section 1870(b) of this Act. There shall be transferred periodically (but Post, p. 331. not less often than once each fiscal year) to the Trust Fund from the Railroad Retirement Account amounts equivalent to the amounts not previously so transferred which the Secretary of Health, Education, and Welfare shall have certified as overpayments to the Railroad Retirement Board pursuant to section 1870(b) of this Act. “(g) The Managing Trustee shall pay from time to time from the Trust Fund such amounts as the Secretary of Health, Education, and Welfare certifies are necessary to make the payments provided for by this part, and the payments with respect to administrative expenses in accordance with section 201(g)(1). Post, p. 338. “(h) The Managing Trustee shall pay from time to time from the Trust Fund such amounts as the Secretary of Health, Education, and Welfare certifies are necessary to pay the costs incurred by the. Civil Service Commission in making deductions pursuant to section 1840(e). During each fiscal year, or after the close of such fiscal year, the Civil Service Commission shall certify to the Secretary the amount of the costs it incurred in making such deductions, and such certified amount shall be the basis for the amount of such costs certified by the Secretary to the Managing Trustee. “Sec. 1842. “use of carriers for administration of benefits (a) In order to provide for the administration of the benefits under this part with maximum efficiency and convenience for individuals entitled to benefits under this part and for providers of services and other persons furnishing services to such individuals, and with a view to furthering coordination of the administration of the benefits under part A and under this part, the Secretary is authorized to enter into contracts with carriers, including carriers with which Ante, p. 297. agreements under section 1816 are in effect, which will perform some or all of the following functions (or, to the extent provided in such Contracts, will secure performance thereof by other organizations); and, with respect to any of the following functions which involve payments for physicians’ services, the Secretary shall to the extent possible enter into such contracts: “(1) (A) make determinations of the rates and amounts of payments required pursuant to this part to be made to providers of services and other persons on a reasonable cost or reasonable charge basis (as maybe applicable); “(B) receive, disburse, and account for funds in making such payments; and “(C) make such audits of the records of providers of services as may be necessary to assure that proper payments are made under this part; “(2) (A) determine compliance with the requirements of section 1861 (k) as to utilization review; and “(B) assist providers of services and other persons who furnish services for which payment may be made under this part in the development of procedures relating to utilization practices, make studies of the effectiveness of such procedures and methods for their improvement, assist in the application of safeguards against unnecessary utilization of services furnished by providers of services and other persons to individuals entitled to benefits under this part, and provide procedures for and assist in arranging, where necessary, the establishment of groups outside hospitals Post, p. 318. (meeting the requirements of section 1861(k)(2)) to make reviews of utilization; “(3) serve as a channel of communication of information relating to the administration of this part; and “(4) otherwise assist, in such manner as the contract may provide, in discharging administrative duties necessary to carry out the purposes of this part. “(b) (1) Contracts with carriers under subsection (a) may be entered into without regard to section 3769 of the Revised Statutes or any other provision of law requiring competitive bidding. “(2) No such contract shall be entered into with any carrier unless the Secretary finds that such carrier will perform its obligations under the contract efficiently and effectively and will meet such requirements as to financial responsibility, legal authority, and other matters as he finds pertinent. “(3) Each such contract shall provide that the carrier— “(A) will take such action as may be necessary to assure that, where payment under this part for a service is on a cost, basis, the cost is reasonable cost (as determined under section 1861 (v)); “(B) will take such action as may be necessary to assure that, where payment under this part for a service is on a charge basis, (i) such charge will be reasonable and not higher than the charge applicable, for a comparable service and under comparable circumstances, to the policyholders and subscribers of the carrier, and (ii) such payment will be made on the basis of a receipted bill, or on the basis of an assignment, under the terms of which the reasonable charge is the full charge for the service; “(C) will establish and maintain procedures pursuant to which an individual enrolled under this part will be granted an oppor-tunity for a fair hearing by the carrier when requests for payment under this part with respect to services furnished him are denied or are not acted upon with reasonable promptness or when the amount of such payment is in controversy; “(D) will furnish to the Secretary such timely information and reports as he may find necessary in performing his functions under this part; and “(E) will maintain such records and afford such access thereto as the Secretary finds necessary to assure the correctness and verification of the information and reports under subparagraph (D) and otherwise to carry out the purposes of this part; and shall contain such other terms and conditions not inconsistent with this section as the Secretary may find necessary or appropriate. In determining the reasonable charge for services for purposes of this paragraph, there shall be taken into consideration the customary charges for similar services generally made by the physician or other person furnishing such services, as well as the prevailing charges in the locality for similar services. “(4) Each contract under this section shall be for a term of at least one year, and may be made automatically renewable from term to term in the absence of notice by either party of intention to terminate at the end of the current term; except that the Secretary may terminate any such contract at any time (after such reasonable notice and opportunity for hearing to the carrier involved as he may provide in regulations) if he finds that the carrier has failed substantially to carry out the contract or is carrying out the contract in a manner inconsistent with the efficient and effective administration of the insurance program established by this part. “(c) Any contract entered into with a carrier under this section shall provide for advances of funds to the carrier for the making of payments by it under this part, and shall provide for payment of the cost of administration of the carrier, as determined by the Secretary to be necessary and proper for carrying out the functions covered by the contract. “(d) Any contract with a carrier under this section may require such carrier or any of its officers or employees certifying payments or disbursing funds pursuant to the contract, or otherwise participating in carrying out the contract, to give surety bond to the United States in such amount as the Secretary may deem appropriate. “(e) (1) No individual designated pursuant to a contract under this section as a certifying officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payments certified by him under this section. “(2) No disbursing officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payment by him under this section if it was based upon a voucher signed by a certifying officer designated as provided in paragraph (1) of this subsection. “(3) No such carrier shall be liable to the United States for any payments referred to in paragraph (1) or (2). “(f) For purposes of this part, the term ‘carrier’ means— “Carrier.” “(1) with respect to providers of services and other persons, a voluntary association, corporation, partnership, or other non-governmental organization which is lawfully engaged in providing, paying for, or reimbursing the cost of, health services under group insurance policies or contracts, medical or hospital service agreements, membership or subscription contracts, or similar group arrangements, in consideration of premiums or other periodic charges payable to the carrier, including a health benefits plan duly sponsored or underwritten by an employee organization; and “(2) with respect to provider’s of services only, any agency or organization (not described in paragraph (1)) with which an Ante, p. 297. agreement is in effect under section 1816. “Sec. 1843. “state agreements for coverage of eligible individuals who are receiving money payments under public assistance programs (a) The Secretary shall, at the request of a State made before January 1, 1968, enter into an agreement with such State pursuant to which all eligible individuals in either of the coverage groups described in subsection (b)(as specified in the agreement) will be enrolled under the program established by this part. “(b) An agreement entered into with any State pursuant to subsection (a) may be applicable to either of the following coverage groups: “(1) individuals receiving money payments under the plan of such State approved under title I or title XVI; or “(2) individuals receiving money payments under all of the plans of such State approved under titles I, IV, X, XIV, and 42 USC 301, 601, 1201, 1351, 1381. XVI; except that there shall be excluded from any coverage group any 42 USC 401. individual who is entitled to monthly insurance benefits under title II or who is entitled to receive an annuity or pension under the Railroad Post, pp. 335, 340, 400. Retirement Act of 1937. “(c) For purposes of this section, an individual shall be treated as an eligible individual only if he is an eligible individual (within Ante, p. 304. the meaning of section 1836) on the date an agreement covering him is entered into under subsection (a) or he becomes an eligible individual (within the meaning of such section) at any time after such date and before January 1, 1968; and he shall be treated as receiving money payments described in subsection (b) if he receives such payments for the month in which the agreement is entered into or any month thereafter before January 1968. “(d) In the case of any individual enrolled pursuant to this section— “(1) the monthly premium to be paid by the State shall be determined under section 1839 (without any increase under subsection (c) thereof); “(2) his coverage period shall begin on whichever of the following is the latest: “(A) July 1, 1966; “(B) the first day of the third month following the month in which the State agreement, is entered into; “(C) the first day of the first month in which he is both an eligible individual and a member of a coverage group specified in the agreement under this section; or “(D) such date (not later than January 1, 1968) as may be specified in the agreement; and “(3) his coverage period attributable to the agreement with the State under this section shall end on the last day of whichever of the following first occurs: “(A) the month in which he is determined by the State agency to have become ineligible for money payments of a kind specified in the agreement, or “(B) the month preceding the first month for which lie becomes entitled to monthly benefits under title II or to an 42 USC 401. annuity or pension under the Railroad Retirement Act of 1937. Post, pp. 335, 340, 400. “(e) Any individual whose coverage period attributable to the State agreement is terminated pursuant to subsection (d)(3) shall be deemed for purposes of this part (including the continuation of his coverage period under this part) to have enrolled under section 1837 in the initial general enrollment period provided by section Ante, p. 304. 1837(c). “(f) With respect to eligible individuals receiving money payments under the plan of a State approved under title I, IV, X, XlV, 42 USC 301, 601, 1201, 1351, 1381. or XVI, if the agreement entered into under this section so provides, the term ‘carrier’ as defined in section 18–12 (f) also includes the State agency, specified in such agreement, which administers or supervises the administration of the plan of such State approved under title I, XVI, or XIX. The agreement shall also contain such provisions as will facilitate the financial transactions of the State and the carrier with respect to deductions, coinsurance, and otherwise, and as will lead to economy and efficiency of operation, with respect to individuals receiving money payments under plans of the State approved under titles I, IV, X, XIV, and XVI. “Sec. 1844. “appropriations to cover government contributions and contingency reserve (a) There are authorized to be appropriated from time to time, out of any moneys in the Treasury not otherwise appropriated, to the Federal Supplementary Medical Insurance Trust Fund, a Government. contribution equal to the aggregate premiums payable under this part. “(b) In order to assure prompt payment of benefits provided under this part and the administrative expenses thereunder during the early months of the program established by this part, and to provide a contingency reserve, there is also authorized to be appropriated, out of any moneys in the Treasury not otherwise appropriated, to remain available through the calendar year 1967 for repayable advances (without interest) to the Trust Fund, an amount equal to $18 multiplied by the number of individuals (as estimated by the Secretary) who could be covered in July 1966 by the insurance program established by this part if they had theretofore enrolled under this part. “Part C— Miscellaneous Provisions “Sec. 1861. “definitions of services, institutions, etc. For purposes of this title— “(a) “Spell of Illness The term ‘spell of illness’ with respect to any individual means a period of consecutive days— “(1) beginning with the first day (not included in a previous spell of illness)(A) on which such individual is furnished inpatient hospital services or extended care services, and (B) which occurs in a month for which he is entitled to benefits under part A, and Ante, p. 291. “(2) ending with the close of the first period of 60 consecutive days thereafter on each of which he is neither an inpatient of a hospital nor an inpatient of an extended care facility. “(b) “Inpatient Hospital Services The term ‘inpatient hospital services’ means the following items and services furnished to an inpatient of a hospital and (except as provided in paragraph (3)) by the hospital— “(1) bed and board; “(2) such nursing services and other related services, such use of hospital facilities, and such medical social services as are ordinarily furnished by the hospital for the care and treatment of inpatients, and such drugs, biologicals, supplies, appliances, and equipment, for use in the hospital, as are ordinarily furnished by such hospital for the care and treatment of inpatients; and “(3) such other diagnostic or therapeutic items or services, furnished by the hospital or by others under arrangements with them made by the hospital, as are ordinarily furnished to inpatients either by such hospital or by others under such arrangements; excluding, however— “(4) medical or surgical services provided by a physician, resident, or intern: and “(5) the services of a private-duty nurse or other private-duty attendant. Paragraph (4) shall not apply to services provided in the hospital by an intern or a resident-in-training under a teaching program approved by the Council on Medical Education of the American Medical Association or, in the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association, or, in the case of services in a hospital or osteopathic hospital by an intern or resident-in-training in the field of dentistry, approved by the Council on Dental Education of the American Dental Association. “(c) “Inpatient Psychiatric Hospital Services The term ‘inpatient psychiatric hospital services’ means inpatient hospital services furnished to an inpatient of a psychiatric hospital. “(d) “Inpatient Tuberculosis Hospital Services The term ‘inpatient tuberculosis hospital services’ means inpatient hospital services furnished to an inpatient of a tuberculosis hospital “(e) “Hospital The term ‘hospital’ (except for purposes of section 1814(d), subsection (a)(2) of this section, paragraph (7) of this subsection, and subsections (i) and (n) of this section) means an institution which— “(1) is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons; “(2) maintains clinical records on all patients; “(3) has bylaws in effect with respect to its staff of physicians; “(4) has a requirement that every patient must be under the care of a physician; “(5) provides 24-hour nursing service rendered or supervised by a registered professional nurse, and has a licensed practical nurse or registered professional nurse on duty at all times; “(6) has in effect a hospital utilization review plan which meets the requirements of subsection (k); “(7) in the case of an institution in any State in which State or applicable local law provides for the licensing of hospitals, (A) is licensed pursuant to such law or (B) is approved, by the agency of such State or locality responsible for licensing hospitals, as meeting the standards established for such licensing; and “(8) meets such other requirements as the Secretary finds necessary in the interest of the health and safety of individuals who are furnished services in the institution, except that such other requirements may not be higher than the comparable requirements prescribed for the accreditation of hospitals by the Joint Commission on Accreditation of Hospitals (subject to the second sentence of section 1863). Post, p. 326. For purposes of subsection (a)(2), such term includes any institution which meets the requirements of paragraph (1) of this subsection. For purposes of sections 1814(d)(including determination of whether Ante, p. 296. an individual received inpatient hospital services for purposes of such section and subsections (i) and (n) of this section, such term includes any institution which meets the requirements of paragraphs (1), (2), (3), (4), (5), and (7) of this subsection. Notwithstanding the preceding provisions of this subsection, such term shall not, except for purposes of subsection (a)(2), include any institution which is primarily for the care and treatment of mental diseases or tuberculosis unless it is a tuberculosis hospital (as defined in subsection (g)) or unless it is a psychiatric hospital (as defined in subsection (f)). The term ‘hospital’ also includes a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts, but only with respect to items and services ordinarily furnished by such institution to inpatients, and payment may be made with respect to services provided by or in such an institution only to such extent and under such conditions, limitations, and requirements (in addition to or in lieu of the conditions, limitations, and requirements otherwise applicable) as may be provided in regulations. For provisions deeming certain requirements of this subsection to be met in the case of accredited institutions, see section 1865. “(f) “Psychiatric Hospital The term ‘psychiatric hospital’ means an institution which— “(1) is primarily engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill persons; “(2) satisfies the requirements of paragraphs (3) through (8) of subsection (e); “(3) maintains clinical records on all patients and maintains such records as the Secretary finds to be necessary to determine the degree and intensity of the treatment provided to individuals entitled to hospital insurance benefits under part A; “(4) meets such staffing requirements as the Secretary finds necessary for the institution to carry out an active program of treatment for individuals who are furnished services in the institution; and “(5) is accredited by the Joint Commission on Accreditation of Hospitals. In the case of an institution which satisfies paragraphs (1) and (2) of the preceding sentence and which contains a distinct part which also satisfies paragraphs (3) and (4) of such sentence, such distinct part shall be considered to be a ‘psychiatric hospital’ if the institution is accredited by the Joint Commission on Accreditation of Hospitals or if such distinct part meets requirements equivalent to such accreditation requirements as determined by the Secretary. “(g) “Tuberculosis Hospital The term ‘tuberculosis hospital’ means an institution which— “(1) is primarily engaged in providing, by or under the supervision of a physician, medical services for the diagnosis and treatment of tuberculosis; “(2) satisfies the requirements of paragraphs (3) through (8) of subsection (e); “(3) maintains clinical records on all patients and maintains such records as the Secretary finds to be necessary to determine the degree and intensity of the treatment provided to individuals covered by the insurance program established by part A; “(4) meets such staffing requirements as the Secretary finds necessary for the institution to carry out an active program of treatment for individuals who are furnished services in the institution; and “(5) is accredited by the Joint Commission on Accreditation of Hospitals. In the case of an institution which satisfies paragraphs (1) and (2) of the preceding sentence and which contains a distinct part which also satisfies paragraphs (3) and (4) of such sentence, such distinct part, shall be considered to be a. ‘tuberculosis hospital’ if the institution is accredited by the Joint Commission on Accreditation of Hospitals or if such distinct part meets requirements equivalent to such accreditation requirements as determined by the Secretary. “(h) “Extended Care Services The term ‘extended care services’ means the following items and services furnished to an inpatient of an extended care facility and (except as provided in paragraphs (3) and (6)) by such extended care facility— “(1) nursing care provided by or under the supervision of a registered professional nurse; “(2) bed and board in connection with the furnishing of such nursing care; “(3) physical, occupational, or speech therapy furnished by the extended care facility or by others under arrangements with them made by the facility; “(4) medical social services; “(5) such drugs, biologicals, supplies, appliances, and equipment, furnished for use in the extended care facility, as are ordinarily furnished by such facility for the care and treatment of inpatients; “(6) medical services provided by an intern or resident-in-training or a hospital with which the facility has in effect a transfer agreement (meeting the requirements of subsection (1)), under a teaching program of such hospital approved as provided in the last sentence of subsection (b), and other diagnostic or therapeutic services provided by a hospital with which the facility has such an agreement in effect; and “(7) such other services necessary to the health of the patients as are generally provided by extended care facilities; excluding, however, any item or service if it. would not be included under subsection (b) if furnished to an inpatient of a hospital. “(i) “Post-Hospital Extended Care Services The term ‘post-hospital extended care services’ means extended care services furnished an individual after transfer from a hospital hi which he was an inpatient for not less than 3 consecutive days before his discharge from the hospital in connection with such transfer. For purposes of the preceding sentence, items and services shall be deemed to have been furnished to an individual after transfer from a hospital, and he shall be deemed to have been an inpatient in the hospital immediately before transfer therefrom, if he is admitted to the extended care facility within 14 days after discharge from such hospital; and an individual shall be deemed not to have been discharged from an extended care facility if, within 14 days after discharge therefrom, he is admitted to such facility or any other extended care facility. “(j) “Extended Care Facility The term ‘extended care facility’ means (except for purposes of subsection (a)(2)) an institution (or a distinct part of an institution) which has in effect a transfer agreement (meeting the requirements of subsection (1)) with one or more hospitals having agreements in effect under section 1866 and which— Post, p. 327. “(1) is primarily engaged in providing to inpatients (A) skilled nursing care and related services for patients who require medical or nursing care, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons; “(2) has policies, which are developed with the advice of (and with provision of review of such policies from time to time by) a group of professional personnel, including one or more physicians and one or more registered professional nurses, to govern the skilled nursing care and related medical or other services it provides; “(3) has a physician, a registered professional nurse, or a medical staff responsible for the execution of such policies; “(4) (A) has a requirement that the health care of every patient must be under the supervision of a physician, and (B) provides for having a physician available to furnish necessary medical care in case of emergency; “(5) maintains clinical records on all patients; “(6) provides 24-hour nursing service which is sufficient to meet nursing needs in accordance with the policies developed as provided in paragraph (2), and has at least one registered professional nurse employed full time; “(7) provides appropriate methods and procedures for the dispensing and administering of drugs and biologicals; “(8) has in effect a utilization review plan which meets the requirements of subsection (k); “(9) in the case of an institution in any State in which State or applicable local law provides for the licensing of institutions of this nature, (A) is licensed pursuant to such law, or (B) is approved, by the agency of such State or locality responsible for licensing institutions of this nature, as meeting the standards established for such licensing; and “(10) meets such other conditions relating to the health and safety of individuals who are furnished services in such institution or relating to the physical facilities thereof as the Secretary may find necessary (subject to the second sentence of section 1863); except that such term shall not (other than for purposes of subsection (a)(2)) include any institution which is primarily for the care and treatment of mental diseases or tuberculosis. For purposes of subsection (a)(2), such term includes any institution which meets the requirements of paragraph (1) of this subsection. The term ‘extended care facility’ also includes an institution described in paragraph (1) of subsection (y), to the extent and subject to the limitations provided in such subsection. “(k) “Utilization Review A utilization review plan of a hospital or extended care facility shall be considered sufficient if it is applicable to services furnished by the institution to individuals entitled to insurance benefits under this title and if it provides— “(1) for the review, on a sample or other basis, of admissions to the institution, the duration of stays therein, and the professional services (including drugs and biologicals) furnished, (A) with respect to the medical necessity of the services, and (B) for the purpose of promoting the most efficient use of available health facilities and services; “(2) for such review to be made by either (A) a staff committee of the institution composed of two or more physicians, with or without participation of other professional personnel, or (B) a group outside the institution which is similarly composed and (i) which is established by the local medical society and some or all of the hospitals and extended care facilities in the locality, or (ii) if (and for as long as) there has not been established such a group which serves such institution, which is established in such other manner as may be approved by the Secretary; “(3) for such review, in each case of inpatient hospital services or extended care services furnished to such an individual during a continuous period of extended duration, as of such days of such period (which may differ for different classes of cases) as may be specified in regulations, with such review to be made as promptly as possible, after each day so specified, and in no event later than one week following such day; and “(4) for prompt notification to the institution, the individual, and his attending physician of any finding (made after opportunity for consultation to such attending physician) by the physician members of such committee or group that any further stay in the institution is not medically necessary. The review committee must be composed as provided in clause (B) of paragraph (2) rather than as provided in clause (A) of such paragraph in the case of any hospital or extended care facility where, because of the small size of the institution, or (in the case of an extended care facility) because of lack of an organized medical staff, or for such other reason or reasons as may be included in regulations, it is impracticable for the institution to nave a properly functioning staff committee for the purposes of this subsection. “(l) “Agreements for Transfer Between Extended Care Facilities and Hospitals A hospital and an extended care facility shall be considered to have a transfer agreement in effect if, by reason of a written agreement between them or (in case, the two institutions are under common control) by reason of a written undertaking by the person or body which controls them, there is reasonable assurance that— “(1) transfer of patients will be effected between the hospital and the extended care facility whenever such transfer is medically appropriate as determined by the attending physician; and “(2) there will be interchange of medical and other information necessary or useful in the care and treatment of individuals transferred between the institutions, or in determining whether such individuals can be adequately cared for otherwise than in either of such institutions. Any extended care facility which does not have such an agreement in effect, but which is found by a State agency (of the State in which such facility is situated) with which an agreement under section 1864 Post, p. 326. is in effect (or, in the case of a State in which no such agency has an agreement under section 1864, by the Secretary) to have attempted in good faith to enter into such an agreement with a hospital sufficiently close to the facility to make feasible the transfer between them of patients and the information referred to in paragraph (2), shall be considered to have such an agreement in effect if and for so long as such agency (or the Secretary, as the case may be) finds that to do so is in the public interest and essential to assuring extended care services for persons in the community who are eligible for payments with respect to such services under this title. “(m) “Home Health Services The term ‘home health services’ means the following items and services furnished to an individual, who is under the care of a physician, by a home health agency or by others under arrangements with them made by such agency, under a plan (for furnishing such items and services to such individual) established and periodically reviewed by a physician, which items and services are, except as provided in paragraph (7), provided on a visiting basis in a place of residence used as such individual’s home— “(1) part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse; “(2) physical, occupational, or speech therapy; “(3) medical social services under the direction of a physician; “(4) to the extent permitted in regulations, part-time or intermittent services of a home health aide; “(5) medical supplies (other than drugs and biologicals), and the use of medical appliances, while under such a plan; “(6) in the ease of a home health agency which is affiliated or under common control with a hospital, medical services provided by an intern or resident-in-training of such hospital, under a teaching program of such hospital approved as provided in the last sentence or subsection (b); and “(7) any of the foregoing items and services which are provided on an outpatient basis, under arrangements made by the home health agency, at a hospital or extended care facility, or at a rehabilitation center which meets such standards as may be prescribed in regulations, and— “(A) the furnishing of which involves the use of equipment of such a nature that the items and services cannot readily be made available to the individual in such place of residence, or “(B) which are furnished at such facility while he is there to receive any such item or service described in clause (A), but not including transportation of the individual in connection with any such item or service; excluding, however, any item or service if it would not be included under subsection (b) if furnished to an inpatient of a hospital. “(n) “Post-Hospital Home Health Services The term ‘post-hospital home health services’ means home health services furnished an individual within one year after his most recent discharge from a hospital of which he was an inpatient for not less than 3 consecutive days or (if later) within one year after his most recent discharge from an extended care facility of which he was an inpatient, entitled to payment under part A for post-hospital extended care services, but only if the plan covering the home health services (as described in subsection (m)) is established within 14 days after his discharge from such hospital or extended care facility. “(o) “Home Health Agency The term ‘home health agency’ means a public agency or private organization, or a subdivision of such an agency or organization. which— “(1) is primarily engaged in providing skilled nursing services and other therapeutic services; “(2) has policies, established by a group of professional personnel (associated with the agency or organization), including one or more physicians and one or more registered professional nurses, to govern the services (referred to in paragraph (1)) which it provides, and provides for supervision of such services by a physician or registered professional nurse; “(3) maintains clinical records on all patients; “(4) in the case of an agency or organization in any State in which State or applicable local law provides for the licensing of agencies or organizations of this nature, (A) is licensed pursuant to such law, or (B) is approved, by the agency of such State or locality responsible for licensing agencies or organizations of this nature, as meeting the standards established for such licensing; and “(5) meets such other conditions of participation as the Secretary may find necessary in the interest of the health and safety of individuals who are furnished services by such agency or organization; except that such term shall not include a private organization which is not a nonprofit organization exempt from Federal income taxation 68A Stat. 163. 26 USC 501. under section 501 of the Internal Revenue Code of 1954 (or a subdivision of such organization) unless it is licensed pursuant to State law and it meets such additional standards and requirements as may be prescribed in regulations; and except that for purposes of part A such term shall not include any agency or organization which is primarily for the care and treatment or mental diseases. “(p) “Outpatient Hospital Diagnostic Services The term ‘outpatient hospital diagnostic services’ means diagnostic services— “(1) which are furnished to an individual as an outpatient by a hospital or by others under arrangements with them made by a hospital; and “(2) which are ordinarily furnished by such hospital (or by others under such arrangements) to its outpatients for the purpose of diagnostic study; excluding, however— “(3) any item or service if it would not be included under subsection (b) if furnished to an inpatient of a hospital; and “(4) any services furnished under such arrangements unless furnished m the hospital or in other facilities operated by or under the supervision of the hospital or its organized medical staff. “(q) “Physicians’ Services The term ‘physicians’ services’ means professional services performed by physicians, including surgery, consultation, anti home, office, and institutional calls (but not. including services described in the last sentence of subsection (b)). “(r) “Physician The term ‘physician’, when used in connection with the performance of any function or action, means (1) a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action (including a physician within the meaning of section 1101(a)(7)), or (2) a doctor of 64 Stat. 559. 42 USC 1301. dentistry or of dental or oral surgery who is legally authorized to practice dentistry by the State in which he performs such function but only with respect to (A) surgery related to the jaw or any structure contiguous to the jaw or (B) the reduction of any fracture of the jaw or any facial bone, “(s) “Medical and Other Health Services The term ‘medical and other health services’ means any of the following items pr services (unless they would otherwise constitute inpatient hospital services, extended care services, or home health services) : “(1) physicians’ services; “(2) services and supplies (including drugs and biologicals which cannot, as determined in accordance with regulations, be self-administered) furnished as an incident, to a physician’s professional service, of kinds which are commonly furnished in physicians’ offices and are commonly either rendered without charge or included in the physicians’ bills, and hospital services (including drugs and biologicals which cannot, as determined in accordance with regulations, be self-administered) incident to physicians’ services rendered to outpatients; “(3) diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests; “(4) X-ray, radium, and radioactive isotope therapy, including materials and services of technicians; “(5) surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations; “(6) rental of durable medical equipment, including iron lungs, oxygen tents, hospital beds, and wheelchairs used in the patient’s home (including an institution used as his home) : “(7) ambulance service where the use of other methods of transportation is contraindicated by the individual’s condition, but only to the extent provided in regulations; “(8) prosthetic devices (other than dental) which replace all or part of an internal body organ, including replacement of such devices; and “(9) leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements if required because of a change in the patient’s physical condition. No diagnostic tests performed in any laboratory which is independent of a physician’s office or a hospital shall lie included within paragraph (3) unless such laboratory— “(10) if situated in any State in which State or applicable local law provides for licensing of establishments of this nature, (A) is licensed pursuant to such law, or (B) is approved, by the agency of such State or locality responsible for licensing establishments of this nature, as meeting the standards established for such licensing; and “(11) meets such other conditions relating to the health and safety of individuals with respect to whom such tests are performed as the Secretary may find necessary. “(t) “Drugs and Biologicals The term ‘drugs’ and the term ‘biologicals’, except for purposes of subsection (m)(5) of this section, include only such drugs and biologicals, respectively, as are included (or approved for inclusion) in the United States Pharmacopoeia, the National Formulary, or the United States Homeopathic Pharmacopoeia, or in New Drugs or Accepted Dental Remedies (except for any drugs and biologicals unfavorably evaluated therein), or as are approved by the pharmacy and drug therapeutics committee (or equivalent committee) of the medical staff of the hospital furnishing such drugs and biologicals for use in such hospital. “(u) “Provider of Services The term ‘provider of services’ means a hospital, extended care facility, or home health agency. “(v) “Reasonable Cost (1) The reasonable cost of any services shall be determined in accordance with regulations establishing the method or methods to be used, and the items to be included, in determining such costs for various types or classes of institutions, agencies, and services; except that in any case to which paragraph (2) or (3) applies, the amount of the payment determined under such paragraph with respect to the services involved shall be considered the reasonable cost of such services. In prescribing the regulations referred to in the preceding sentence, the Secretary shall consider, among other things, the principles generally applied by national organizations or established prepayment organizations (which have developed such principles) in computing the amount of payment, to be made by persons other than the recipients of services, to providers of services on account of services furnished to such recipients by such providers. Such regulations may provide for determination of the costs of services on a per diem, per unit, per capita, or other basis, may provide for using different methods in different circumstances, may provide for the use of estimates of costs of particular items or services, and may provide for the use of charges or a percentage of charges where this method reasonably reflects the costs. Such regulations shall (A) take into account both direct and indirect costs of providers of services in order that, under the methods of determining costs, the costs with respect to individuals covered by the insurance programs established by this title will not be borne by individuals not so covered, and the costs with respect to individuals not so covered will not be borne by such insurance programs, and (B) provide for the making of suitable retroactive corrective adjustments where, for a provider of services for any fiscal period, the aggregate reimbursement produced by the methods of determining costs proves to be either inadequate or excessive. “(2) (A) If the bed and board furnished as part of inpatient hospital services (including inpatient tuberculosis hospital services and inpatient psychiatric hospital services) or post-hospital extended care services is in accommodations more expensive than semiprivate accommodations, the amount taken into account for purposes of payment under this title with respect to such services may not exceed an amount equal to the reasonable cost of such services if furnished in such semiprivate accommodations unless the more expensive accommodations were required for medical reasons. “(B) Where a provider of services which has an agreement in effect under this title furnishes to an individual items or services which are in excess of or more expensive than the items or services with respect to which payment may be made under part A or part B, as the case may Ante, pp. 291, 301. be, the Secretary shall take into account for purposes of payment to such provider of services only the equivalent of the reasonable cost of the items or services with respect to which such payment may be made. “(3) If the bed and board furnished as part of inpatient hospital services (including inpatient tuberculosis hospital services and inpatient psychiatric hospital services) or post-hospital extended care services is in accommodations other than, but not more expensive than, semiprivate accommodations and the use of such other accommodations rather than semiprivate accommodations was neither at the request of the patient nor for a reason which the Secretary determines is consistent with the purposes of this title, the amount of the payment with respect to such bed and board under part A shall be the reasonable cost of such bed and board furnished in semiprivate accommodations (determined pursuant to paragraph (1)) minus the difference between the charge customarily made by the hospital or extended care facility for bed and board in semiprivate accommodations and the charge customarily made by it for bed and board in the accommodations furnished. “(4) For purposes of this subsection, the term ‘semiprivate accommodations’ “Semi-private accommodations.” means two-bed, three-bed, or four-bed accommodations. “(w) “Arrangements for Certain Services The term ‘arrangements’ is limited to arrangements under which receipt of payment by the hospital, extended care facility, or home health agency (whether in its own right or as agent), with respect to services for which an individual is entitled to have payment made under this title, discharges the liability of such individual or any other person to pay for the services. “(x) “State and United States The terms ‘State’ and ‘United States’ have the meaning given to them by subsections (h) and (i), respectively, of section 210. “(y) “Post-Hospital Extended Care in Christian Science Extended Care Facilities (1) The term ‘extended care facility’ also includes a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts, but only (except for purposes of subsection (a)(2)) with respect to items and services ordinarily furnished by such an institution to inpatients, and payment may be made with respect to services provided by or in such an institution only to such extent and under such conditions, limitations, and requirements (in addition to or in lieu of the conditions, limitations, and requirements otherwise applicable) as may be provided in regulations. “(2) Notwithstanding any other provision of this title., payment under part A may not be made for services furnished an individual in an extended care facility to which paragraph (1) applies unless such individual elects, in accordance with regulations, for a spell of illness to have such services treated as post-hospital extended care services for purposes of such part; and payment under part-A may not be made for post-hospital extended care services— “(A) furnished an individual during such spell of illness in an extended care facility to which paragraph (1) applies after— “(i) such services have been furnished to him in such a facility for 30 days during such spell, or “(ii) such services have been furnished to him during such spell in an extended care facility to which such paragraph does not apply; or “(B) furnished an individual during such spell of illness in an extended care facility to which paragraph (1) does not apply after such services have been furnished to him during such spell in an extended care facility to which such paragraph applies. “(3) The amount payable under part A for post-hospital extended care services furnished an individual during any spell of illness in an extended care facility to which paragraph (1) applies shall be reduced by a coinsurance amount equal to one-eighth of the inpatient hospital deductible for each day before the 31st day on which he is furnished such services in such a facility during such spell (and the reduction under this paragraph shall be in lieu of any reduction under section Ante, p. 292. 1813(a)(4)). “(4) For purposes of subsection (i), the determination of whether services furnished by or in an institution described in paragraph (1) constitute post-hospital extended care services shall be made in accordance with and subject to such conditions, limitations, and requirements as may be provided in regulations. “Sec. 1862. “exclusions from coverage (a) Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses Ante, pp, 291, 301. incurred for items or services— “(1) which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member; “(2) for which the individual furnished such items or services has no legal obligation to pay, and which no other person (by reason of such individual’s membership in a prepayment plan or otherwise) has a legal obligation to provide or pay for; “(3) which are paid for directly or indirectly by a governmental entity (other than under this Act and other than under a health benefits or insurance plan established for employees of such an entity), except in such cases as the Secretary may specify; “(4) which are not provided within the United States (except for emergency inpatient hospital services furnished outside the United States under the conditions described in section 1814 (f)); Ante, p. 294. “(5) which are required as a result of war, or of an act of w, occurring after the effective date of such individual’s current coverage under such part; “(6) which constitute personal comfort items; “(7) where such expenses are for routine physical checkups, eyeglasses or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, hearing aids or examinations therefor, or immunizations; “(8) where such expenses are for orthopedic shoes or other supportive devices for the feet; “(9) where such expenses are for custodial care; “(10) where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member; “(11) where such expenses constitute charges imposed by immediate relatives of such individual or members of his household; or “(12) where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth. “(b) Payment under this title may not be made with respect to any item or service to the extent that payment has been made, or can reasonably be expected to be made (as determined in accordance with regulations), with respect to such item or service, under a workmen’s compensation law or plan of the United States or a State. Any payment under this title with respect to any item or service shall be conditioned on reimbursement to the appropriate Trust Fund established by this title when notice or other information is received that payment for such item or service has been made under such a law or plan. “Sec. 1863. “consultation with state agencies and other organizations to develop conditions of participation for providers of services In carrying out his functions, relating to determination of conditions of participation by providers of services, under subsections (e)(8), (f)(4), (g)(4), (j)(10), and (o)(5) of section 1861, the Secretary shall consult with the Health Insurance Benefits Advisory Council established by section 1867, appropriate State agencies, and recognized national listing or accrediting bodies, and may consult with appropriate local agencies. Such conditions prescribed under any of such subsections may be varied for different areas or different classes of institutions or agencies and may, at the request-of a State, provide higher requirements for such State than for other States; except that, in the case of any State or political subdivision of a State which imposes higher requirements on institutions as a condition to the purchase of services (or of certain specified services) in such institutions 42 USC 301, Post, p. 343. under a State plan approved under title I, XVI, or XIX, the Secretary shall impose like requirements as a condition to the payment for services (or for the services specified by the State or subdivision) in such institutions in such State or subdivision. “Sec. 1864. “use of state agencies to determine compliance by providers of services with conditions of participation (a) The Secretary shall make an agreement with any State which is able and willing to do so under which the services of the State health agency or other appropriate State agency (or the appropriate local agencies) will be utilized by him for the purpose of determining whether an institution therein is a hospital or extended care facility, or whether an agency therein is a home health agency, or whether a laboratory meets the requirements of paragraphs (10) Ante, p. 321. and (11) of section 1861 (s). To the extent that the Secretary finds it appropriate, an institution or agency which such a State (or local) agency certifies is a hospital, extended care facility, or home health agency (as those terms are defined in section 1861) may be treated as such by the Secretary. The Secretary may also, pursuant to agreement, utilize the services of State health agencies and other appropriate State agencies (and the appropriate local agencies) to do any one or more of the following: (1) to provide consultative services to institutions or agencies to assist them (A) to establish and maintain fiscal records necessary for purposes of this title, or otherwise to qualify as hospitals, extended care facilities, or home health agencies, or (B) to provide information which may be necessary to permit determination under this title as to whether payments are due and the amounts thereof, and (2) to provide consultative services to institutions, agencies, or organizations to assist in the establishment of utilization review procedures meeting the requirements of section 1861 (k) and in evaluating their effectiveness. “(b) The Secretary shall pay any such Stale, in advance or by way of reimbursement, as may be provided in the agreement with it (and may make adjustments in such payments on account-of overpayments or underpayments previously made), for the reasonable cost of performing the functions specified in subsection (a), and for the Federal Ante, p. 299. Hospital Insurance Trust Fund’s fair share of the costs attributable to the planning and other efforts directed toward coordination of activities in carrying out its agreement and other activities related to the provision of services similar to those for which payment may be made under part A, or related to the facilities and personnel required for the provision of such services, or related to improving the quality of such services. “Sec. 1865, “effect of accreditation Except as provided in the second sentence of section 1863, an institution shall be deemed to meet the requirements of the numbered paragraphs of section 1861(e)(except paragraph (6) thereof) if such institution is accredited as a hospital by the Joint Commission on Accreditation of Hospitals. If such Commission, as a condition for accreditation of a hospital, requires a utilization review plan or imposes another requirement which serves substantially the same purpose, the Secretary is authorized to find that all institutions so accredited by the Commission comply also with section 1861 (e)(6), In addition, if the Secretary finds that accreditation of an institution or agency by the American Osteopathic Association or any other national accreditation body provides reasonable assurance that, any or all of the conditions of section 1861 (e), (]), or (o), as the case may be, are met, he may, to the extent he deems it appropriate, treat such institution or agency as meeting the condition or conditions with respect to which he made such finding. “Sec. 1866. “agreements with providers of services (a) (1) Any provider of services shall be qualified to participate under this title and shall be eligible for payments under this title if it files with the Secretary an agreement— “(A) not to charge, except as provided in paragraph (2), any individual or any other person for items or services for which such individual is entitled to have payment made under this title (or for which he would be so entitled if such provider of services had complied with the procedural and other requirements under or pursuant to this title or for which such provider is paid pursuant to the provisions of section 1814(e)), and Ante, p. 296. “(B) to make adequate provision for return (or other disposition, in accordance with regulations) of any moneys incorrectly collected from such individual or other person. “(2) (A) A provider of services may charge such individual or other person (i) the amount of any deduction or coinsurance amount imposed pursuant to section 1813 (a)(1), (a)(2), or (a)(4), section 1833 (b),or section 1861 (y)(3) with respect to such items and services (not in excess of the amount customarily charged for such items and services by such provider), and (ii) an amount equal to 20 per centum of the reasonable charges for such items and services (not in excess of 20 per centum of the amount customarily charged for such items and services by such provider) for which payment is made under part B or, in the case of outpatient hospital diagnostic services, for which payment is made under part A. In the case of items and services described in section 1833(c), clause (ii) of the preceding sentence shall be applied by substituting for 20 percent the proportion which is appropriate under such section. “(B) Where a provider of services has furnished, at the request of such individual, items or services which are in excess of or more expensive than the items or services with respect to which payment may be made under this title, such provider of services may also charge such individual or other person for such more expensive items or services to the extent that the amount customarily charged by it for the items or services furnished at such request exceeds the amount customarily charged by it for the items or services with respect to which payment may be made under this title. “(C) A provider of services may also charge any such individual for any whole blood furnished him with respect to which a deductible is imposed under section 1813(a)(3), except that (i) any excess of such charge over the cost to such provider for the blood shall be deducted from any payment to such provider under this title, (ii) no such charge may be imposed for the cost of administration of such blood, and (iii) such charge may not be made to the extent such blood has been replaced on behalf of such individual or arrangements have been made for its replacement on his behalf. “(b) An agreement with the Secretary under this section may be terminated— “(1) by the provider of services at such time and upon such notice to the Secretary and the public as may be provided in regulations, except that notice of more than 6 months shall not be required, or “(2) by the Secretary at such time and upon such reasonable notice to the provider of services and the public as may be specified in regulations, but only after the Secretary has determined (A) that such provider of services is not complying substantially with the provisions of such agreement, or with the provisions of this title and regulations thereunder, or (B) that such provider of services no longer substantially meets the applicable provisions of section 1861, or (C) that such provider of services has failed to provide such information as the Secretary finds necessary to determine whether payments are or were due under this title and the amounts thereof, or has refused to permit such examination of its fiscal and other records by or on behalf of the Secretary as may be necessary to verify such information. Any termination shall be applicable— “(3) in the case of inpatient hospital services (including inpatient tuberculosis hospital services and inpatient psychiatric hospital services) or post-hospital extended care services, with respect to such services furnished to any individual who is admitted to the hospital or extended care facility furnishing such services on or after the effective date of such termination, “(4) (A) with respect to home health services furnished to an individual under a plan therefor established on or after the effective date of such termination, or (B) if a plan is established before such effective date, with respect to such services furnished to such individual after the calendar year in which such termination is effective, and “(5) with respect, to any other items and services furnished on or after the effective date of such termination. “(c) Where an agreement, filed under this title by a provider of services has been terminated by the Secretary, such provider may not file another agreement under this title unless the Secretary finds that the reason for the termination has been removed and that there is reasonable assurance that it will not recur. “(d) If the Secretary finds that there is a substantial failure to make timely review in accordance with section 1861(k) of long-stay cases in a hospital or extended care facility, he may, in lieu of terminating his agreement with such hospital or facility, decide that, with respect to any individual admitted to such hospital or facility after a subsequent date specified by him, no payment shall be made under this title for inpatient hospital services (including inpatient tuberculosis hospital services and inpatient psychiatric hospital services) after the 20th day of a continuous period of such services or for post-hospital extended care services after such day of a continuous period of such care as is prescribed in or pursuant to regulations, as the case may be. Such decision may lie made effective only after such notice to the hospital, or (in the case of an extended care facility) to the facility and the hospital or hospitals with which it has a transfer agreement, and to the public, as may be prescribed by regulations, and its effectiveness shall terminate when the Secretary finds that the reason therefor has been removed and that there is reasonable assurance that it will not recur. The Secretary shall not make any such decision except after reasonable notice and opportunity for hearing to the institution or agency affected thereby. “Sec. 1867. “health insurance benefits advisory council For the purpose of advising the Secretary on matters of general policy in the administration of this title and in the formulation of regulations under this title, there is hereby created a Health Insurance Benefits Advisory Council which shall consist, of 16 persons, not otherwise in the employ of the United States, appointed by the Secretary without, regard to the civil service laws. The Secretary shall from time to time appoint one of the members to serve as Chairman. The members shall include persons who are outstanding in fields related to hospital, medical, and other health activities, and at least one person who is representative of the general public. Each member shall hold office for a term of 4 years, except that any member appointed to fill a vacancy occurring prior to the expiration of the term for which his predecessor was appointed shall be appointed for the remainder of such term, and except that the terms of office of the members first, taking office shall expire, as designated by the Secretary at. the time of appointment, four at the end of the first year, four at the end of the second year, four at the end of the third year, and four at the end of the fourth year after the date of appointment. A member shall not be eligible to serve continuously for more than 2 terms. The Secretary may, at the request of the Council or otherwise, appoint such special advisory professional or technical committees as may be useful in carrying out this title. Members of the Advisory Council and members of any such advisory or technical committee, while attending meetings or conferences thereof or otherwise serving on business of the Advisory Council or of such committee, shall be entitled to receive compensation at rates fixed by the Secretary, but not exceeding $100 per day, including travel time, and while so serving away from their homes or regular places of business they may be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5 of the Administrative Expenses Act of 1946 (5 U.S.C. 73b–2) for persons in the 60 Stat. 808; 75 Stat. 339, 340. Government service employed intermittently. The Advisory Council shall meet as frequently as the Secretary deems necessary. Upon request of 4 or more members, it shall be the duty of the Secretary to call a meeting of the Advisory’ Council. “Sec. 1868. “national medical review committee (a) There is hereby created a National Medical Review Committee (hereinafter in this section referred to as the ‘Committee’) which shall consist of nine persons, not otherwise in the employ of the United States, appointed by the Secretary without regard to the civil service laws. The Secretary shall from time to time appoint one of the members to serve as chairman. The members shall be selected from among individuals who are representative of organizations and associations of professional personnel in the field of medicine and other individuals who are outstanding in the field of medicine or in related fields; except that at least one member shall be representative of the general public, and at least a majority of the members shall be physicians. Each member shall hold office for a term of three years, except that any member appointed to fill a vacancy occurring prior to the expiration of the term for which his predecessor was appointed shall be appointed for the remainder of such term, and except that the terms of office of the members first taking office shall expire, as designated by the Secretary at the time of appointment, three at the end of the first year, three at the end of the second year, and three at the end of the third year after the date of appointment. A member shall not be eligible to serve continuously for more than two terms. “(b) Members of the Committee, while attending meetings or conferences thereof or otherwise serving on business of the Committee, shall be entitled to receive compensation at rates fixed by the Secretary, but not exceeding $100 per day, including travel time, and while so serving away from their homes or regular places of business they may be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5 of the Administrative Expenses Act 60 Stat. 808; 75 Stat. 339, 340. of 1946 (5 U.S.C. 73b–2) for persons in the Government service employed intermittently. “(c) It shall be the function of the Committee to study the utilization of hospital and other medical care and services for which payment may be made under this title with a view to recommending any changes which may seem desirable in the way in which such care and services are utilized or in the administration of the programs established by this title, or in the provisions of this title. The Committee Report to Congress. shall make an annual report to the Secretary of the results of its study, including any recommendations it may have with respect thereto, and such report shall be transmitted promptly by the Secretary to the Congress. “(d) The Committee is authorized to engage such technical assistance as may be required to carry out its functions, and the Secretary shall, in addition, make available to the Committee such secretarial, clerical, and other assistance and such pertinent data obtained and prepared by the Department of Health, Education, and Welfare as the Committee may require to carry out its functions. “Sec. 1869. “determinations; appeals (a) The determination of whether an individual is entitled to benefits under part. A or part B, and the determination of the amount of benefits under part A, shall be made by the Secretary in accordance with regulations prescribed by him. “(b) Any individual dissatisfied with any determination under subsection (a) as to entitlement under part A or part B, or as to amount of benefits under part A where the matter in controversy is $100 or more, shall be entitled to a hearing thereon by the Secretary 42 USC 405. to the same extent as is provided in section 205(b), and, in the case of a determination as to entitlement or as to amount of benefits where the amount in controversy is $1,000 or more, to judicial review of the Secretary’s final decision after such hearing as is provided in section 205(g). “(c) Any institution or agency dissatisfied with any determination by the Secretary that it is not a provider of services, or with any determination described in section 1866(b)(2), shall be entitled to a hearing thereon by the Secretary (after reasonable notice and opportunity for hearing) to the same extent as is provided in section 205(b), and to judicial review of the Secretary’s final decision after such hearing as is provided in section 205(g). “Sec. 1870. “overpayments on behalf of individuals (a) Any payment under this title to any provider of services or other person with respect to any items or services furnished any individual shall be regarded as a payment to such individual. “(b) Where— “(1) more than the correct amount is paid under this title to a provider of services or other person for items or services furnished an individual end the Secretary determines that, within such period as he may specify, the excess over the correct amount cannot be recouped from such provider of services or other person, or “(2) any payment has been made under section 1814(e) to a Ante, p. 294. provider of services or other person for items or services furnished on individual, proper adjustments shall be made, under regulations prescribed (after consultation with the Railroad Retirement Board) by the Secretary, by decreasing subsequent payments— “(3) to which such individual is entitled under title II of this Act or under the Railroad Retirement Act of 1937, as the case 42 USC 401. Post, pp. 335, 340, 400. may be, or “(4) if such individual dies before such adjustment has been completed, to which any other individual is entitled under title II of this Act or under the Railroad Retirement Act of 1937, as the case may be, with respect to the wages and self-employment income or the compensation constituting the basis of the benefits of such deceased individual under title II of such Act. As soon as practicable after any adjustment under paragraph (3) or (4) is determined to be necessary, the Secretary, for purposes of this section, section 1817(g), and section 1841(f), shall certify (to the Railroad Retirement Board if the adjustment, is to be made by decreasing subsequent payments under the Railroad Retirement Act of 1937) the amount of the overpayment as to which the adjustment is to be made. “(c) There shall be no adjustment as provided in subsection (b)(nor shall there be recovery) in any case where the incorrect payment has been made (including payments under section 1814(e)) with respect to an individual who is without fault and where such adjustment (or recovery) would defeat the purposes of title II or would be against equity and good conscience. “(d) No certifying or disbursing officer shall be held liable for any amount certified or paid by him to any provider of services or other person where the adjustment or recovery of such amount is waived under subsection (c) or where adjustment under subsection (b) is not completed prior to the death of all persons against whose benefits such adjustment is authorized. “Sec. 1871. “regulations The Secretary shall prescribe such regulations as may be necessary to carry out the administration of the insurance programs under this title. When used in this title, the term ‘regulations’ means, unless the context otherwise requires, regulations prescribed by the Secretary. “Sec. 1872. “application of certain provisions of title ii The provisions of sections 206, 208, and 216(j), and of subsections (a), (d), (e), (f), (h), (i), (j), (k), and (l) of section 205, shall also apply with respect to this title to the same extent as they are applicable with respect to title II. “Sec. 1873. “designation of organization or publication by name Designation in this title, by name, of any nongovernmental organization or publication shall not be affected by change of name or such organization or publication, and shall apply to any successor organization or publication which the Secretary finds serves the purpose for which such designation is made. “Sec. 1874. “administration (a) Except as otherwise provided in this title, the insurance programs established by this title shall be administered by the Secretary. The Secretary may perform any of his functions under this title directly, or by contract providing for payment in .advance or by way of reimbursement, and in such installments, as the Secretary may deem necessary. “(b) The Secretary may contract with any person, agency, or institution to secure on a reimbursable basis such special data, actuarial information, and other information as may be necessary in the carrying out of his functions under this title. “Sec. 1875. “studies and recommendations (a) The Secretary shall carry on studies and develop recommendations to be submitted from time to time to the Congress relating to health care of the aged, including studies and recommendations concerning (1) the adequacy of existing personnel and facilities for health care for purposes of the programs under parts A and B; Ante, pp. 291, 301. (2) methods for encouraging the further development of efficient and economical forms of health care which are a constructive alternative to inpatient hospital care; and (3) the effects of the deductibles and coinsurance provisions upon beneficiaries, persons who provide health services, and the financing, of the program. “(b) The Secretary shall make a continuing study of the operation and administration of the insurance programs under parts A and B, and shall transmit to the Congress annually a report concerning the operation of such programs.”

2. 1972

   Social Security Amendments of 1972

   Pub. L. 92–603 title II · 86 Stat. 1329

   1. Amended · 42 U.S.C. § 1395bb

      Pub. L. 92–603 designated existing provisions as subsec. (a)

   2. Inserted · 42 U.S.C. § 1395bb

      Pub. L. 92–603 inserted reference to subsec. (b) of this section in opening provisions

   3. Redesignated · 42 U.S.C. § 1395bb

      Pub. L. 92–603 redesignated existing provisions as pars. (1) and (3)

   4. Inserted · 42 U.S.C. § 1395bb

      Pub. L. 92–603 added pars. (2) and (4) and in provisions following par. (4) inserted provisions for the imposition of a standard which the Secretary determines is at least equivalent to the standard promulgated by the Secretary as described in par. (4)

   5. Added · 42 U.S.C. § 1395bb

      Pub. L. 92–603 added subsec. (b)

   Source evidence

   Code amendment note
   Pub. L. 92–603 designated existing provisions as subsec. (a), inserted reference to subsec. (b) of this section in opening provisions, redesignated existing provisions as pars. (1) and (3) and added pars. (2) and (4) and in provisions following par. (4) inserted provisions for the imposition of a standard which the Secretary determines is at least equivalent to the standard promulgated by the Secretary as described in par. (4), and added subsec. (b).

   Enacted provision · exact public law
   TITLE II— PROVISIONS RELATING TO MEDICARE, MEDICAID, AND MATERNAL AND CHILD HEALTH Sec. 201. coverage for disability beneficiaries under medicare (a) (1) (A) The heading of title XVIII of the Social Security Act is amended to read as follows: “TITLE XVIII— HEALTH INSURANCE FOR THE AGED AND DISABLED”. (B) The heading of part A of such title is amended to read as follows: “Part A— Hospital Insurance Benefits for the Aged and Disabled”. (C) The heading of part B of such title is amended to read as follows: “Part B— Supplementary Medical Insurance Benefits for the Aged and Disabled”. (2) The text of section 1811 of such Act is amended to read as 79 Stat. 291. 42 USC 1395c. follows: “Sec. 1811. The insurance program for which entitlement is established by section 226 provides basic protection against the costs of hospital Infra. 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 title II of this Act or under the railroad retirement system 42 USC 401. and (2) individuals under age 65 who have been entitled for not less than 24 consecutive months to benefits under title II of this Act or under the railroad retirement system on the basis of a disability.” (3) Section 1831 of such Act is amended— 79 Stat. 301. 42 USC 1395j. (A) by inserting “and the disabled” after “aged” in the heading, and (B) by striking out “individuals 65 years of age or over” and inserting in lieu thereof “aged and disabled individuals”. (b) (1) Section 226(a) of such Act is amended to read as follows: 79 Stat. 290. 42 USC 426. “(a) (1) Every individual who— “(A) has attained age 65, and “(B) is entitled to monthly insurance benefits under section 202 or is a qualified railroad retirement beneficiary, Ante, pp. 1335–1350. shall be entitled to hospital insurance benefits under part A of title XVIII for each month for which he meets the condition specified in 42 USC 1395. subparagraph (B), beginning with the first month after June 1966 for which he meets the conditions specified in subparagraphs (A) and (B). “(b) Every individual who— “(1) has not attained age 65, and “(2) (A) is entitled to, and has for 24 consecutive calendar months been entitled to, (i) disability insurance benefits under section 223 or (ii) child’s insurance benefits under section 202(d) 42 USC 423. Ante, p. 1347. by reason of a disability (as defined in section 223(d)) or (iii) widow’s insurance benefits under section 202(e) or widower’s insurance benefits under section 202(f) by reason of a disability (as defined in section 223(d)), or (B) is, and has been for not less than 24 consecutive months a disabled qualified railroad retirement beneficiary, within the meaning of section 22 of the Railroad Retirement Act of 1937, Post, p. 1373. shall be entitled to hospital insurance benefits under part (A) of title XVIII for each month beginning with the later of (I) July 1973 or (II) the twenty-fifth consecutive month of his entitlement or status as a qualified railroad retirement beneficiary described in paragraph (2), and ending with the month following the month in which notice of termination of such entitlement to benefits or status as a qualified railroad retirement beneficiary described in paragraph (2) is mailed to him, or if earlier, with the month before the month in which he attains age 65.” (2) Section 226(b) of such Act is amended by striking out 42 USC 426. “occurred after June 30, 1966, or on or after the first day of the month in which he attains age 65, whichever is later” and inserting in lieu thereof “occurred (i) after June 30, 1966, or on or after the first day of the month in which he attains age 65, whichever is later, or (ii) if he was entitled to hospital insurance benefits pursuant to subsection (b), at a time when he was so entitled”. (3) Section 226(b) (2) of such Act is amended by striking out “an individual shall be deemed entitled to monthly insurance benefits under section 202,” and inserting in lieu thereof “an individual shall be deemed entitled to monthly insurance benefits under section 202 or 42 USC 402, 423. 42 USC 426. section 223,”. (4) Section 226(c) of such Act is amended by inserting “or section 22” after “section 21” wherever it appeal’s. (5) Section 226 of such Act is further amended by redesignating subsection (b) as subsection (c), subsection (c) as subsection (d), and subsection (d) as subsection (f), and by inserting after subsection (d) the following new subsection: “(e) (1) For purposes of determining entitlement to hospital insurance benefits under subsection (b) in the, case of widows and widowers described in paragraph (2) (A) (iii) thereof— “(A) the term ‘age 60’ in sections 202(e) (1) (B) (ii) and 202(e) (5), and the term ‘age 62’ in sections 202(f) (1) (B) (ii), and 202 (f) (6) shall be deemed to read ‘age 65’; and “(B) the phrase ‘before she attained age 60’ in the matter following subparagraph (F) of section 202 (e) (1) shall be deemed to read ‘based on a disability’. “(2) For purposes of determining entitlement to hospital insurance benefits under subsection (a) (2) in the case of an individual under age 65 who is entitled to benefits under section 202, and who was entitled to widow’s insurance benefits or widower’s insurance benefits based on disability for the month before the first month in which such individual was so entitled to old-age insurance benefits (but ceased to be entitled to such widow’s or widower’s insurance benefits upon becoming entitled to such old-age insurance benefits), such individual shall be deemed to have continued to be entitled to such widow’s insurance benefits or widower’s insurance benefits for and after such first month. “(3) For purposes of determining entitlement to hospital insurance benefits under subsection (a)(2) any disabled widow age 50 or older who is entitled to mother’s insurance benefits (and who would have been entitled to widow’s insurance benefits by reason of disability if she had filed for such widow’s benefits) shall, upon application, for such hospital insurance benefits be deemed to have filed for such widow’s benefits and shall, upon furnishing proof of such disability prior to July 1, 1974, under such procedures as the Secretary may prescribe, be deemed to have been entitled to such widow’s benefits as of the time she would have been entitled to such widow’s benefits if she bad filed a timely application therefor.” (c) (1) Section 1836 of such Act is amended to read as follows: “Sec. 1836. “eligible individuate Every individual who— “(1) is entitled to hospital insurance benefits under part A, or “(2) has attained age 65 and is a resident of the United States, and is either (A) a citizen or (B) an alien lawfully admitted for permanent residence who has resided in the United States continuously during the 5 years immediately preceding the month in which he applies for enrollment under this part, is eligible to enroll in the insurance program established by this part.” (2) (A) The first sentence of section 1837 (c) of such Act is amended by striking out “paragraphs (1) and (2)” and inserting in lieu thereof “paragraph (1) or (2)”. (B) The second sentence of section 1837(c) of such Act is amended to read as follows: “For purposes of this subsection and subsection (d), an individual who has attained age 65 and who satisfies paragraph Supra. (1) of section 1836 but not paragraph (2) of such section shall be treated as satisfying such paragraph (1) on the first day on which he is (or on filing application would have been) entitled to hospital insurance benefits under part A.” (C) The first sentence of 1837(d) of such Act is amended by striking 42 USC 1395p. out “paragraphs (1) and (2)” and inserting in lieu thereof “paragraph (1) or (2)”. (3) (A) Section 1838(a) of such Act is amended by striking out 42 USC 1395q. “July 1, 1966” in paragraph (1) and inserting in lieu thereof “July 1, 1966 or (in the case of a disabled individual who has not attained age 65) July 1, 1973”. (B) Section 1838(a) of such Act is further amended— (i) by striking out “paragraphs (1) and (2)” in paragraph (2) (A) and inserting in lieu thereof “paragraph (1) or (2)”; and (ii) by striking out “such paragraphs” in subparagraphs (B), (C), and (D) and inserting in lieu thereof “such paragraph”. (C) Section 1838 of such Act is further amended by redesignating subsection (c) as subsection (d), and by inserting after subsection (b) the following new subsection: “(c) In the case of an individual satisfying paragraph (1) of section 1836 whose entitlement to hospital insurance benefits under Ante, p. 1372. part A is based on a disability rather than on his having attained the age of 65, his coverage period (and his enrollment under this part) shall be terminated as of the close of the last month for which he is entitled to hospital insurance benefits.” (4) Section 1839(c) of such Act is amended— 42 USC 1395r. (A) by inserting “(in the same continuous period of eligibility)” after “for each full 12 months”; and (B) by adding at the end thereof the following new sentence: “Any increase in an individual’s monthly premium under the first sentence of this subsection with respect to a particular continuous period of eligibility shall not be applicable with respect to any other continuous period of eligibility which such individual may have.” (5) Section 1839 of such Act is further amended by adding at Post, p. 1376. the end thereof the following new subsection: “(e) For purposes of subsection (c) (and section 1837(g) (1)), an “Continuous period of eligibility.” Post, p. 1378. individual’s ‘continuous period of eligibility’ is the period beginning with the first day on which he is eligible to enroll under section 1836 and Ante, p. 1372. ending with his death; except that any period during all of which an individual satisfied paragraph (i) of section 1836 and which terminated in or before the month preceding the month in which he attained age 65 shall be a separate ‘continuous period of eligibility’ with respect to such individual (and each such period which terminates shall he deemed not to have existed for purposes of subsequently applying this section).” (6) (A) Section 1840(a) (1) of such Act is amended by striking out 42 USC 1395s. “section 202” and inserting in lieu thereof “section 202 or 223”. (B) Section 1840(a)(2) of such Act is amended by striking out “section 202” and inserting in lieu thereof “section 202 or 223”. (7) Section 1875(a) of such Act is amended by striking out “aged” 42 USC 1395ll. and inserting in lieu thereof “aged and the disabled”. (d) The Railroad Retirement Act of 1937 is amended by adding after section 21 the following new section: 45 USC 228s–2. “Sec. 22. “hospital insurance benefits for the disabled “(1) who have been entitled to annuities for not less than 24 consecutive months during each of which the first proviso of section 3(e) could have applied on the basis of an application which 45 USC 228c. has been filed under paragraph 4 or 5 of section 2(a), and are 45 USC 228b. currently entitled to such annuities, or who are entitled to annui- 45 USC 228b. ties under paragraph 2 or 3 of section 2 (a) and could have been paid annuities for not less than 24 consecutive months under section 42 USC 423. 223 of the Social Security Act if their service as employees were included in the term ‘employment’ as defined in that Act, or “(2) who have been entitled to annuities under section 5(a) on the basis of disability, or could have been so entitled had they not been entitled on the basis of age or had they not been entitled under section 5(b) on the basis of having the custody of children, for not less than 24 consecutive months during each of which the first proviso of section 3(e) could have been applied on the basis of disability if an application for disability benefits had been filed, or “(3) who have been entitled to annuities for not less than 24 consecutive months under section 5(c) on the basis of a disability (within the meaning of section 5(1) (1) (ii)) or who could have been includible as disabled children for not less than 24 consecutive months in the computation of an annuity under the first proviso in section 3(e) and could currently be includible in such a computation, shall be certified by the Board in the same manner, for the same purposes, and subject to the same conditions, restrictions, and other 45 USC 228s–2 provisions as individuals specifically described in section 21, and also subject to the same conditions, restrictions, and other provisions as 42 USC 401. are disability beneficiaries under title II of the Social Security Act in connection with their eligibility for hospital insurance benefits Ante, p. 1370. 42 USC 1395. under part A of title XVIII of such Act and their eligibility to enroll under part B of such title XVIII: and for the purposes of this Act and title XVIII of the Social Security Act, individuals certified as provided in this section shall be considered individuals described in and certified under such section 21. Notwithstanding the other provisions of this section it shall not apply to any individual who could not be taken into account on the basis of disability in calculating the annuity under the first proviso of section 3(e) without regard to’ the second paragraph of such section.” Sec. 202. hospital insurance benefits for uninsured individuals not eligible under transitional provision Title XVIII of the Social Security Act is amended by 79 Stat. 299. 42 USC 1305i. adding after section 1817 the following new section: “Sec. 1818. “hospital insurance benefits for uninsured individuals not otherwise eligible (a) Every individual who— “(1) has attained the age of 65, “(2) is enrolled under part B of this title, “(3) is a resident of the United States, and is either (A) a citizen or (B) an alien lawfully admitted for permanent residence who has resided in the United States continuously during the 5 years immediately preceding the month in which he applies for enrollment under this section, and “(4) is not otherwise entitled to benefits under this part. shall be eligible to enroll in the insurance program established by this part, “(b) An individual may enroll under this section only in such manner and form as may be prescribed in regulations, and only during an enrollment period prescribed in or under this section. “(c) The provisions of section 1837 (except subsection (f) thereof), Ante, p. 1372. section 1838, subsection (c) of section 1839, and subsections (f) Ante, p. 1373. and (h) of section 1840 shall apply to persons authorized to enroll under this section except that— “(1) individuals who meet the conditions of subsection (a) (1), (3), and (4) on or before the last day of the seventh month after the month in which this section is enacted may enroll under this part and (if not already so enrolled) may also enroll under part B during an initial general enrollment period which shall begin on the first day of the second month which begins after the date on which this section is enacted and shall end on the last day of the tenth month after the month in which this Act is enacted; “(2) in the case, of an individual who first meets the conditions of eligibility under this section on or after the first day of the eighth month after the month in which this section is enacted, the initial enrollment period shall begin on the first day of the third month before the month in which he first becomes eligible and shall end 7 months later; “(3) in the case of an individual who enrolls pursuant to paragraph (1) of this subsection, entitlement to benefits shall begin on— “(A) the first day of the second month after the month in which he enrolls, “(B) July 1, 1973, or “(C) the first day of the first month in which he meets the requirements of subsection (a), whichever is the latest; “(4) termination of coverage under this section by the filing of notice that the individual no longer wishes to participate in the hospital insurance program shall take effect at the close of the month following the month in which such notice is filed; “(5) an individual’s entitlement under this section shall terminate with the month before the first month in which he becomes eligible for hospital insurance benefits under section 226 of this Act or section 103 of the Social Security Amendments of 1965; and Ante, p. 1371; Post, p. 1463. 42 USC 426a. upon such termination, such individual shall be deemed, solely for purposes of hospital insurance entitlement, to have filed in such first month the application required to establish such entitlement; and ‘(6) termination of coverage for supplementary medical insurance shall result in simultaneous termination of hospital insurance benefits for uninsured individuals who are not otherwise entitled to benefits under this Act. “(d) (1) The monthly premium of each individual for each month Monthly premiums. in his coverage period before July 1974 shall be $33. “(2) The Secretary shall, during the last calendar quarter of each year, beginning in 1973, determine and promulgate the dollar amount (whether or not such dollar amount was applicable for premiums for any prior month) which shall be applicable for premiums for months occurring in the 12-month period commencing July 1 of the next year. Such amount shall be equal to $33, multiplied by the ratio of (A) the inpatient hospital deductible for such next year, as promulgated under section 1813(b)(2), to (B) such deductible promulgated for 42 USC 1395e. 1973. Any amount determined under the preceding sentence which is not a multiple of $1 shall be rounded to the nearest multiple of $1, or if midway between multiples of $1 to the next higher multiple of $1. “(e) Payment of the monthly premiums on behalf of any individual who meets the conditions of subsection (a) may be made by any public or private agency or organization under a contract or other arrangement entered into between it and the Secretary if the Secretary determines that payment of such premiums under such contract or arrangement is administratively feasible. “(f) Amounts paid to the Secretary for coverage under this section shall be deposited in the Treasury to the credit of the Federal Hospital Insurance Trust Fund.” Sec. 203. amount of supplementary medical insurance premium (a) Section 1839(b)(1) of the Social Security Act is amended by inserting “and before July 1, 1973,” after “1967”. (b) Section 1839(b)(2) of such Act is amended by striking out “thereafter” and inserting in lieu thereof “ending on or before December 31, 1971”. (c) Section 1839 of such Act (as amended by section 201 (c) (4) and Ante, p. 1373. (5) of this Act) is further amended by redesignating subsections (c), (d), and (e) as subsections (d), (e), and (f), respectively, and by inserting after subsection (b) the following new subsection: “(c) (1) The Secretary shall, during December of 1972 and of each year thereafter, determine the monthly actuarial rate for enrollees age 65 and over which shall be applicable for the 12-month period commencing July 1 in the succeeding year. Such actuarial rate shall be the amount the Secretary estimates to be necessary so that the aggregate amount for such 12-month period with respect to those enrollees age 65 and over will equal one-half of the total of the benefits and administrative costs which he estimates will be payable from the Federal Supplementary Medical Insurance Trust Fund for services performed and related administrative costs incurred in such 12-month period. In calculating the monthly actuarial rate, the Secretary shall include an appropriate amount for a contingency margin. “(2) The monthly premium of each individual enrolled under this part for each month after June 1973 shall, except as provided in subsection (d), be the amount determined under paragraph (3). “(3) The Secretary shall, during December of 1972 and of each year thereafter, determine and promulgate the monthly premium applicable for the individuals enrolled under this part for the 12-month period commencing July 1 in the succeeding year. The monthly premium shall be equal to the smaller of— “(A) the monthly actuarial rate for enrollees age 65 and over, determined according to paragraph (1) of this subsection, for that 12-month period, or “(B) the monthly premium rate most recently promulgated by the Secretary under this paragraph or, in the case of the determination made in December 1971, such rate promulgated under subsection (b)(2) multiplied by the ratio of (i) the amount in column IV of the table which, by reason of the law in effect at the time the promulgation is made, will be in effect as of June 1 next following such determination appears (or is deemed to Ante, pp. 1333, 1334, 1369. appear) in section 215(a) on the line which includes the figure ‘750’ in column III of such table to (ii) the amount in column IV of the table which appeared (or was deemed to appear) in section 215(a) on the line which included the figure ‘750’ in column III as of June 1 of the year in which such determination is made. Whenever the Secretary promulgates the dollar amount which shall be applicable as the monthly premium for any period, he shall, at the time such promulgation is announced, issue a public statement setting forth the actuarial assumptions and bases employed by him in arriving at the amount of an adequate actuarial rate for enrollees age 65 and over as provided in paragraph (1) and the derivation of the dollar amounts specified in this paragraph. “(4) The Secretary shall also, during December of 1372 and of each year thereafter, determine the monthly actuarial rate for disabled enrollees under age 65 which shall be applicable for the 12-month period commencing July 1 in the succeeding year. Such actuarial rate shall be the amount the Secretary estimates to be necessary so that the aggregate amount for such 12-month period with respect to disabled enrollees under age 65 will equal one-half of the total of the benefits and administrative costs which he estimates will be incurred in the Federal Supplementary Medical Insurance Trust Fund for such 12-month period with respect to such enrollees. In calculating the monthly actuarial rate under this paragraph, the Secretary shall include an appropriate amount for a contingency margin.” (d) (1) Section 1839(d) of such Act, as redesignated by subsection (c) of this section, is amended by inserting “or (c)” after “subsection (b)” (2) Section 1839(f) of such Act, as redesignated by subsection (c) of this section, is amended by striking out “subsection (c)” and inserting in lieu thereof “subsection (d)”. (e) Effective with respect to enrollee premiums payable for months Effective date. after June 1973, section 1844(a) (1) of such Act is amended to read as 81 Stat. 874. 42 USC 1395w. follows: “(1) (A) a Government contribution equal to the aggregate premiums payable for a month for enrollees age 65 and over under this part and deposited in the Trust Fund, multiplied by the ratio of— “(i) twice the dollar amount of the actuarially adequate rate per enrollee age 65 and over as determined under section 1839(c) (1) for such month minus the dollar amount of the Ante, p. 1376. premium per enrollee for such month, as determined under section 1839(c) (3), to “(ii) the dollar amount of the premium per enrollee for such month, plus “(B) a Government contribution equal to the aggregate premiums payable for n month for enrollees under age 65 under this part and deposited in the Trust Fund, multiplied by the ratio of— “(i) twice the dollar amount of the actuarially adequate rate per enrollee under age 65 as determined under section 1839(c) (4) for such month minus the dollar amount of the premium per enrollee for such month, as determined under section 1839(c) (3), to “(ii) the dollar amount of the premium per enrollee for such month.” Sec. 204. change in supplementary medical insurance deductible (a) Section 1833 (b) of the Social Security Act is amended 79 Stat. 302. 42 USC 1395l. by striking out “shall be reduced by a deductible of $50” and inserting in lieu thereof “shall be reduced by a deductible of $60”. (b) Section 1835(c) of such Act is amended by striking out “but 81 Stat. 849. 42 USC 1395n. only if such charges for such services do not exceed $50” and inserting in lieu thereof “but only if such charges for such services do not exceed the applicable supplementary medical insurance deductible”. (c) The amendments made by this section shall be effective with Effective date. respect to calendar years after 1972 (except that, for purposes of applying clause (1)’of the first sentence of section 1833(b) of the Social Security Act, such amendments shall be deemed to have taken Supra. effect on January 1, 1972). Sec. 206. automatic enrollment for supplementary medical insurance (a) Section 1837 of the Social Security Act is amended by adding at the end thereof the following new subsections: “(f) Any individual— “(1) who is eligible under section 1836 to enroll in the medical insurance program by reason of entitlement to hospital insurance benefits as described in paragraph (1) of such section, and “(2) whose initial enrollment period under subsection (d) begins after March 31, 1973, and “(3) who is residing in the United States, exclusive of Puerto Rico, shall be deemed to have enrolled in the medical insurance program established by this part. “(g) All of the provisions of this section shall apply to individuals satisfying subsection (f), except that— “(1) in the case of an individual who satisfies subsection (f) by reason of entitlement to disability insurance benefits described Ante, p. 1371. in section 226(a)(2)(B), his initial enrollment period shall begin on the first day of the later of (A) April 1973 or (B) the third month before the 25th consecutive month of such entitlement, and shall reoccur with each continuous period of eligibility Ante, p. 1376. (as defined in section 1839(e)) and upon attainment of age 65; “(2) (A) in the case of an individual who is entitled to monthly 42 USC 402, 423. benefits under section 202 or 223 on the first day of his initial enrollment period or becomes entitled to monthly benefits under section 202 during the first 3 months of such period, his enrollment shall be deemed to have occurred in the third month of his initial enrollment period, and “(B) in the case of an individual who is not entitled to benefits under section 202 on the first day of his initial enrollment period and does not become so entitled during the first 3 months of such period, his enrollment shall be deemed to have occurred in the month in which he files the application establishing his entitlement to hospital insurance benefits provided such filing occurs during the last 4 months of his initial enrollment period: and “(3) in the case of an individual who would otherwise satisfy subsection (f) but does not establish his entitlement to hospital insurance benefits until after the last day of his initial enrollment period (as defined in subsection (d) of this section), his enrollment shall be deemed to have occurred on the first day of the earlier of the then current or immediately succeeding general enrollment period (as defined in subsection (e) of this section).” (b) Section 1838(a) of such Act is amended— (1) by striking out the period at the end of subsection (a) and by inserting in lieu thereof “; or”; and (2) by adding at the end of subsection (a) the following new paragraph: “(3) (A) in the case of an individual who is deemed to have enrolled on or before the last day of the third month of his initial enrollment period, the first day of the month in which he first meets the applicable requirements of section 1836 or July 1, 1973, whichever is later, or “(B) in the case of an individual who is deemed to have enrolled on or after the first day of the fourth month of his initial enrollment period, as prescribed under subparagraphs (B), (C), (D), and (E) of paragraph (2) of this subsection.” (c) Section 1838(b) of such Act (as amended by section 257(a) of Post, p. 1447. 42 USC 1395q. this Act) is further amended by adding at the end thereof the following new paragraph: “Where an individual who is deemed to have enrolled for medical insurance pursuant to section 1837(f) files a notice before the first day Ante, p. 1378. of the month in which his coverage period begins advising that he does not wish to be so enrolled, the termination of the coverage period resulting from such deemed enrollment shall take effect with the first day of the month the coverage would have been effective and such notice shall not be considered a disenrollment for the purposes of section 1837(b). Where an individual who is deemed enrolled for medical Post, p. 1448. insurance benefits pursuant to section 1837 (f) files a notice requesting termination of his deemed coverage in or after the month in which such coverage becomes effective, the termination of such coverage shall take effect at the close of the calendar quarter following the calendar quarter in which the notice is filed.” Sec. 207. incentives for states to establish effective utilization review procedures under medicaid (a) (1) Section 1903 of the Social Security Act is amended 79 Stat. 349; 81 Stat. 898. 42 USC 1396b. by adding at the end thereof the following new subsections: “(g) (1) With respect to amounts paid for the following services furnished under the State plan after June 30, 1973 (other than services furnished pursuant to a contract with a health maintenance organization as defined in section 1876), the Federal medical assistance percentage Post, pp. 1396, 1453. shall be decreased as follows: After an individual has received care as an inpatient in a hospital (including an institution for tuberculosis), skilled nursing home or intermediate care facility on 60 days, or in a hospital for mental diseases on 90 days (whether or not such days are consecutive), during any fiscal year, which for purposes of this section means the four calendar quarters ending with June 30, the Federal medical assistance percentage with respect to amounts paid for any such care furnished thereafter to such individual in the same fiscal year shall be decreased by 33⅓ per centum thereof unless the State agency responsible for the administration of the plan makes a showing satisfactory to the Secretary that, with respect to each calendar quarter for which the State submits a request for payment at the full Federal medical assistance percentage for amounts paid for inpatient hospital services (including tuberculosis hospitals), skilled nursing home services, or intermediate care facility services furnished beyond 60 days (or inpatient mental hospital services furnished beyond 90 days), there is in operation in the State an effective program of control over utilization of such services; such a showing must include evidence that— “(A) in each case for which payment is made under the State plan, a physician certifies at the time of admission, or, if later, the time the individual applies for medical assistance under the State plan (and recertifies, where such services are furnished over a period of time, in such cases, at least every 60 days, and accompanied by such supporting material, appropriate to the case involved, as may be provided in regulations of the Secretary), that such services are or were required to be given on an inpatient basis because the individual needs or needed such services; and “(B) in each such case, such services were furnished under a plan established and periodically reviewed and evaluated by a physician; “(C) such State has in effect a continuous program of review of utilization pursuant to section 1902(a) (30) whereby the necessity Post, p. 1416. for admission and the continued stay of each patient in such institution is periodically reviewed and evaluated (with such frequency as may be prescribed in regulations of the Secretary) by medical and other professional personnel who are not themselves directly responsible for the care of the patient and who are not employed by or financially interested in any such institution; and “(D) such State has an effective program of medical review of the care of patients in mental hospitals, skilled nursing homes, and intermediate care facilities pursuant to section 1902(a) (26) and 81 Stat. 906; 85 Stat. 809. 42 USC 1396a. (31) whereby the professional management of each case is reviewed and evaluated at least annually by independent professional review teams. In determining the number of days on which an individual has received services described in this subsection, there shall not be counted any days with respect to which such individual is entitled to have payments 42 USC 1395d. made (in whole or in part) on his behalf under section 1812. “(2) The Secretary shall, as part of his validation procedures under this subsection, conduct sample onsite surveys of private and public institutions in which recipients of medical assistance may receive care and services under a State plan approved under this title, and his findings with respect to such surveys (as well as the showings of the State agency required under this subsection) shall be made available for public inspection. “(h) (1) If the Secretary determines for any calendar quarter beginning after June 30, 1973, with respect to any State that there does not exist a reasonable cost differential between the statewide average cost of skilled nursing home services and the statewide average cost of intermediate care facility services in such State, the Secretary may reduce the amount which would otherwise be considered as expenditures under the State plan by any amount which in his judgment is a reasonable equivalent of the difference between the amount of the expenditures by such State for intermediate care facility services and the amount that would have been expended by such State for such services if there had been a reasonable cost differential between the cost of skilled nursing home services and the cost of intermediate care facility services. “(2) In determining whether any such cost differential in any State is reasonable the Secretary shall take into consideration the range of such cost differentials in all States. “(3) For the purposes of this subsection, the term ‘cost differential’ for any State for any quarter means, as determined by the Secretary on the basis of the data for the most recent calendar quarter for which satisfactory data are available, the excess of— “(A) the average amount paid in such State (regardless of the source of payment) per inpatient day for skilled nursing home services, over “(B) the average amount paid in such State (regardless of the source of payment) per inpatient day for intermediate care facility services. “(4) For purposes of this subsection, the term ‘cost’ shall mean amounts reimbursable by the State under a State plan approved under this title.” (2) Section 1903(a) (1) of such Act is amended by inserting “, subject to subsections (g) and (h) of this section” after “section 1905(b)”. (b) The amendments made by subsection (a) shall, except as otherwise provided therein, be effective July 1, 1973. Sec. 208. cost-sharing under medicaid (a) Section 1902(a) (14) of the Social Security Act is 42 USC 1396a. amended to read as follows: “(14) effective January 1, 1973, provide that— “(A) in the case of individuals receiving aid or assistance under a State plan approved under title I, X, XIV, or XVI, or part A of title IV, or who meet the income and resources 42 USC 301, 1201, 1351, 1381, 601. requirements of the one of such State plans which is appropriate— “(i) no enrollment fee, premium, or similar charge, and no deduction, cost sharing, or similar charge with respect to the care and services listed in clauses (1) through (5) and (7) of section 1905(a), will be imposed 42 USC 1396d. under the plan, and “(ii) any deduction, cost sharing, or similar charge imposed under the plan with respect to other care and services will be nominal in amount (as determined in accordance with standards approved by the Secretary and included in the plan), and “(B) with respect to individuals who are not receiving aid or assistance under any such State plan and who do not meet the income and resources requirements of the one of such State plans which is appropriate or who, after December 31, 1973, are included under the State plan for medical assistance pursuant to section 1902(a) (10) (B) approved under title XIX— “(i) there shall be imposed an enrollment fee, premium, or similar charge which (as determined in accordance with standards prescribed by the Secretary) is related to the individual’s income, and “(ii) any deductible, cost-sharing, or similar charge imposed under the plan will be nominal;”. (b) The amendment made by subsection (a) shall be effective January Effective date. 1, 1973 (or earlier if the State plan so provided). Sec. 209. medicaid conditions of eligibility for certain employed families (a) Section 1902 of the Social Security Act is amended by adding at the end thereof the following new subsection: “(e) Notwithstanding any other provision of this title, effective January 1, 1974, each State plan approved under this title must provide that, each family which was eligible for assistance pursuant to part A of title IV in at least 3 of the 6 months immediately preceding the month in which such family became ineligible for such assistance because of increased income from employment, shall, while a member of such family is employed, remain eligible for such assistance for 4 calendar months following the month in which such family would otherwise be determined to be ineligible for such assistance because of the income and resources limitations contained in such plan.” (b) (1) Section 1902 of the Social Security Act, as amended by this section, is further amended by adding at the end thereof the following new subsection: “(f) Notwithstanding any other provision of this title, except as provided in subsection (e), no State shall be required to provide medical assistance to any aged, blind, or disabled individual (within the meaning of title XVI) for any month unless such State would be (or would have been) required to provide medical assistance to such individual for such month had its plan for medical assistance approved under this title and in effect on January 1, 1972, been in effect in such month, except that for this purpose any such individual shall be deemed eligible for medical assistance under such State plan if (in addition to meeting such other requirements as are or may be imposed under the State plan) the income of any such individual as determined 42 USC 1396b. in accordance with section 1903(f) (after deducting such individual’s 42 USC 1381. payment under title XVI, and incurred expenses for medical care as 26 USC 213. defined in section 213 of the Internal Revenue Code of 1954) is not in excess of the standard for medical assistance established under the State plan as in effect on January 1, 1972.” (2) The amendment made by this subsection shall become effective on January 1, 1974. Sec. 210. payment under medicare to individuals covered by federal employees health benefits program Section 1862 of the Social Security Act is amended by adding at the end thereof the following new subsection: “(c) No payment may be made under this title with respect to any item or service furnished to or on behalf of any individual on or after January 1, 1975, if such item or service is covered under a health benefits plan in which such individual is enrolled under chapter 89 5 USC 8901. of title 5, United States Code, unless prior to the date on which such item or service is so furnished the Secretary shall have determined and certified that such plan or the Federal employees health benefits program under chapter 89 of such title 5 has been modified so as to assure that— “(1) there is available to each Federal employee or annuitant enrolled in such plan, upon becoming entitled to benefits under part. A or B, or both parts A and B of this title, in addition to the health benefits plans available before he becomes so entitled, one or more health benefits plans which offer protection supplementing the protection he has under this title, and “(2) the Government or such plan will make available to such Federal employee or annuitant a contribution in an amount at least equal to the contribution which the Government makes toward the health insurance of any employee or annuitant enrolled for high option coverage under the Government-wide plans established under chapter 89 of such title 5, with such contribution being in the form of (A) a contribution toward the supplementary protection referred to in paragraph (1), (B) a payment, to or on behalf of such employee or annuitant to offset the cost to him of his coverage under this title, or (C) a combination of such contribution and such payment.” Sec. 211. payment under medicare for certain inpatient hospital and related physicians’ services furnished outside the united states (a) Section 1814(f) of the Social Security Act is amended to read as follows: “(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 Ante, p. 1371. 42 USC 1395x. section 226 by a hospital located outside the United States, or under arrangements (as defined in section 1861 (w)) with it, if— “(A) such individual is a resident of the United States, and “(B) such hospital was closer to or substantially more acces-sible 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 226 by a hospital located outside the United States Ante, p. 1371. 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) 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 1861 (w)) with 42 USC 1395x. it if (A) the Secretary would be required to make such payment if the hospital had an agreement in effect under this title 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 1866 (a). 42 USC 1395cc. “(4) Payment for the inpatient hospital services described in paragraph (1) or (2) furnished to an individual entitled to hospital insurance benefits under section 226 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 1813, be equal to the amount which would be payable 42 USC 1395e. under subsection (d)(3).” (b) Section 1861(e) of such Act is amended— 42 USC 1395x. (1) by striking out “except for purposes of sections 1814(d) and 1835 (b)” and inserting in lieu thereof “except for purposes of sections 1814(d), 1814(f), and 1835(b)”; 42 USC 1395f. Ante, p. 1382. 42 USC 1395n. (2) by inserting “section 1814(f) (2),” immediately after “For purposes of sections 1814(d) and 1835(b) (including determination of whether an individual received inpatient hospital services or diagnostic services for purposes of such sections),”; and (3) by inserting immediately after the, third sentence the following new sentence: “For purposes of section 1814(f) (1), such term includes an institution winch (i) is a hospital for purposes of sections 1814(d), 1814(f) (2), and 1835(b) and (ii) is accredited by the Joint Commission on Accreditation of Hospitals, or is accredited by or approved by a program of the country in which such institution is located if the Secretary finds the accreditation or comparable approval standards of such program to be essentially equivalent to those of the Joint Commission on Accreditation of Hospitals.” (c) (1) Section 1862(a) (4) of such Act is amended— (A) by striking out “emergency”; and (B) by inserting after “1814(f)” the following: “and, subject to such conditions, limitations, and requirements as are provided under or pursuant to this title, physicians’ services and ambulance services furnished an individual in conjunction with such inpatient hospital services but only for the period during which such inpatient hospital services were furnished”. (2) Section 1861 (r) of such Act (as amended by sections 256(b) 42 USC 1395x. Post, pp. 1447, 1449, 1451. and 264 of this Act) is further amended by adding at the end thereof the following new sentence: “For the purposes of section 1862(a) (4) and subject to the limitations and conditions provided in the previous sentence, such term includes a doctor of one of the arts, specified in such previous sentence, legally authorized to practice such art in the country in which the inpatient hospital services (referred to in such section 1862(a) (4)) are furnished.” (3) Section 1842(b) (3) (B) (ii) of such Act is amended by striking out “service;” and inserting in lieu thereof the following: “service (except in the case of physicians’ services and ambulance service furnished as described in section 1862(a) (4), other than for purposes 42 USC 1395gg. of section 1870(f));”. (4) Section 1833(a)(1) of such Act is amended by striking out “and” before “(B)”, and by inserting before the semicolon at the end thereof the following: “, and (C) with respect to expenses incurred for those physicians’ services for which payment may be made under this part that are described in section 1862(a) (4), the amounts paid shall be subject to such limitations as may be prescribed by regulations”. (d) The amendments made by this section shall apply to services furnished with respect to admissions occurring after December 31, 1972. Sec. 212. optometrists’ services under medicaid (a) Section 1905 of the Social Security Act is amended by inserting at the end thereof the following new subsection: “(e) In the case of any State the State plan of which (as approved under this title)— “(1) does not provide for the payment of services (other than 42 USC 1396a. services covered under section 1902(a) (12)) provided by an optometrist; but “(2) at a prior period did provide for the payment of services referred to in paragraph (1); “Physicians’ services.” the term ‘physicians’ services’ (as used in subsection (a)(5)) shall include services of the type which an optometrist is legally authorized to perform where the State plan specifically provides that the term ‘physicians’ services’, as employed in such plan, includes services of the type which an optometrist is legally authorized to perform, and shall be reimbursed whether furnished by a physician or an optometrist.” (b) The provisions of subsection (e) of section 1905 of the Social Security Act (as added by subsection (a) of this section) shall be applicable in the case of services performed on or after the date of enactment of this Act. Sec. 213. limitation on liability of beneficiary where medicare claims are disallowed (a) Title XVIII of the Social Security Act, as amended Post, pp. 1396, 1419, 1420. by sections 226, 242, and 243 of this Act, is further amended by adding at the end thereof the following new section: “Sec. 1879. “limitation on liability of beneficiary where medicare claims are disallowed (a) Where— “(1) a determination is made that, by reason of section 1862(a) (1) or (9), payment may not be made under part A or part B 42 USC 1395y. of this title for any expenses incurred for items or services furnished 42 USC 1395c, 1395j. an individual by a provider of services or by another person pursuant to an assignment under section 1842(b) (3) (B) (ii), Ante, p. 1384. and “(2) both such individual and such provider of services or such other person, as the case may be, did not know, and could not reasonably have been expected to know, that payment would not be made for such items or services under such part. A or part B, then to the extent permitted by this title, payment shall, notwithstanding such determination, be made for such items or services (and for such period of time as the Secretary finds will carry out the objectives of this title), as though section 1862(a)(1) and section 1862(a)(9) did not apply. In each such ease the Secretary shall notify both such individual and such provider of services or such other person, as the case may be, of the conditions under which payment, for such items or services was made and in the case of comparable situations arising thereafter with respect to such individual or such provider or such other person, each shall, by reason of such notice (or similar notices provided before the enactment of this section), be deemed to have knowledge that payment cannot be made for such items or services or reasonably comparable, items or services. “(b) In any ease in which the provisions of paragraphs (1) and (2) of subsection (a) are met. except that, such provider or such other person, as the case may be, knew, or could be expected to know, that payment for such services or items could not be made under such part A or part B, then the Secretary shall, upon proper application filed within such time as may be prescribed in regulations, indemnify the individual (referred to in such paragraphs), subject to the deductible and coinsurance provisions of this title, for any payments received from such individual by such provider or such other person, as the case may be, for such, items or services. Any payments made by the Secretary as indemnification shall be deemed to have been made to such provider or such other person, as the case may be, and shall be treated as overpayments, recoverable from such provider or such other person, as the case may be, under applicable provisions of law. In each such case the Secretary shall notify such individual of the conditions under which indemnification is made and in the case of comparable situations arising thereafter with respect to such individual, be shall, by reason of such notice (or similar notices provided before the enactment, of this section), be deemed to have knowledge that payment cannot be made for such items or services. “(c) No payments shall be made under this title in any cases in which the provisions of paragraph (1) of subsection (a) are met, but both the individual to whom the items or services were furnished and the provider of service or other person, as the case may be who furnished the items or services knew, or could reasonably have been expected to know, that payment could not be made for items or services under part A or part. B by reason of section 1862 (a) (1) or (a) (9). “(d) In any case arising under subsection (b) (but without regard to whether payments have been made by the individual to the provider or other person) or subsection c, the provider or other person shall have the same rights that an individual has under section 1869(b) Post, p. 1464. (when the determination is under part A) or section 1842(b) (3)(C) Post, p. 1448. 42 USC 1395j. (when the determination is under part B) when the amount of benefit or payments is in controversy, except that such rights may, under prescribed regulations, be exercised by such provider or other person only after the Secretary determines that the individual will not exercise such rights under such sections.” (b) The amendments made by this section shall be effective with respect to claims under part A or part B of title XVIII of the Social 42 USC 1395c, 1395j. Security Act, filed with respect to items or services furnished after the date of the enactment of this Act. Sec. 221. limitation on federal participation for capital expenditures (a) Title XI of the Social Security Act is amended by adding at the end thereof the following new section: “Sec. 1122. “limitation on federal participation for capital expenditures (a) The purpose of this section is to assure that Federal 42 USC 701, 1395, 1396. funds appropriated under titles V, XVIII, and XIX are not used to support unnecessary capital expenditures made by or on behalf of health care, facilities or health maintenance organizations which are reimbursed under any of such titles and that, to the extent possible, reimbursement under such titles shall support planning activities with respect to health services and facilities in the various States. (b) The Secretary, after consultation with the Governor (or other chief executive officer) and with appropriate local public officials, shall make an agreement with any State which is able and willing to do so under which a designated planning agency (which shall be an agency described in clause (ii) of subsection (d) (1) (B) that has a governing body or advisory board at least half of whose members represent consumer interests) will— “(1) make, and submit to the Secretary together with such supporting materials as he may find necessary, findings and recommendations with respect to capital expenditures proposed by or on behalf of any health care facility or health maintenance organization in such State within the field of its responsibilities. (2) receive from other agencies described in clause (ii) of subsection (d) (1) (B), and submit to the Secretary together with such supporting material as he may find necessary, the findings and recommendations of such other agencies with respect to capital expenditures proposed by or on behalf of health care facilities or health maintenance organizations in such State within the fields of their respective responsibilities, and “(3) establish and maintain procedures pursuant to which a person proposing any such capital expenditure may appeal a recommendation by the designated agency and will be granted an opportunity for a fair hearing by such agency or person other than the designated agency as the Governor (or other chief executive officer) may designate to hold such hearings, whenever and to the extent that the findings of such designated agency or any such other agency indicate that any such expenditure is not consistent with the standards, criteria, or plans developed pursuant 58 Stat. 682. 42 USC 201 note. 77 Stat. 282. 42 USC 2661 note. to the Public Health Service Act (or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963) to meet the need for adequate health care facilities in the area covered by the plan or plans so developed. “(c) The Secretary shall pay any such State from the Federal Hospital Insurance Trust Fund, in advance or by way of reimbursement as may be provided in the agreement with it (and may make adjustments in such payments on account of overpayments or underpayments previously made), for the reasonable cost of performing the functions specified in subsection (b). “(d) (1) Except as provided in paragraph (2), if the Secretary determines that— “(A) neither the planning agency designated in the agreement described in subsection (b) nor an agency described in clause (ii) of subparagraph (B) of this paragraph had been given notice of any proposed capital expenditure (in accordance with such procedure or in such detail as may be required by such agency) at least 60 days prior to obligation for such expenditure; or “(B) (i) the planning agency so designated or an agency so described had received such timely notice of the intention to make such capital expenditure and had, within a reasonable period after receiving such notice and prior to obligation for such expenditure, notified the person proposing such expenditure that the expenditure would not be in conformity with the standards, criteria, or plans developed by such agency or any other agency described in clause (ii) for adequate health care facilities in such State or in the area for which such other agency has responsibility, and “(ii) the planning agency so designated had, prior to submitting to the Secretary the findings referred to in subsection (b)— “(I) consulted with, and taken into consideration the findings and recommendations of, the State planning agencies established pursuant to sections 314(a) and 604(a) of the Public Health Service Act (to the extent that either such 42 USC 246, 291d. agency is not the agency so designated) as well as the public or nonprofit private agency or organization responsible, for the comprehensive regional, metropolitan area, or other local area plan or plans referred to in section 314(b) of the Public Health Service Act and covering the area in which the health care facility or health maintenance organization proposing such capital expenditure is located (where such agency is not the agency designated in the agreement), or, if there is no such agency, such other public or nonprofit private agency or organization (if any) as performs, as determined in accordance with criteria included in regulations, similar functions, and “(II) granted to the person proposing such capital expenditure an opportunity for a fair hearing with respect to such findings; then, for such period as he finds necessary in any case to effectuate the purpose of this section, he shall, in determining the Federal payments to be made under titles V, XVIII, and XIX with respect to services 42 USC 701, 1395, 1396. furnished in the health care facility for which such capital expenditure is made, not include any amount which is attributable to depreciation. interest on borrowed funds, a return on equity capital (in the ease of proprietary facilities), or other expenses related to such capital expenditure. With respect, to any organization which is reimbursed on a per capita basis, in determining the Federal payments to be made under titles V. XVIII, and XIX. the Secretary shall exclude an amount which in his judgment is a reasonable equivalent to the amount which would otherwise be excluded under this subsection if payment were to be made on other than a per capita basis. “(2) If the Secretary, after submitting the matters involved to the advisory council established or designated under subsection (i), determines that an exclusion of expenses related to any capital expenditure of any health care facility or health maintenance organization would discourage the operation or expansion of such facility or organization, or of any facility of such organization, which has demonstrated to his satisfaction proof of capability to provide comprehensive health care services (including institutional services) efficiently, effectively, and economically, or would otherwise be inconsistent with the effective organization and delivery of health services 42 USC 701, 1395, 1396. or the effective administration of title V, XVIII, or XIX, he shall not include such expenses pursuant to paragraph (1). “(e) Where a person obtains under lease or comparable arrangement any facility or part thereof, or equipment for a facility, which would have been subject to an exclusion under subsection (d) if the person had acquired it. by purchase, the Secretary shall (1) in computing such person’s rental expense, in determining the Federal payments to be made under titles V, XVIII, and XIX with respect to services furnished in such facility, deduct the amount which in his judgment is a reasonable equivalent of the amount that would have been excluded if the person had acquired such facility or such equipment by purchase, and (2) in computing such person’s return on equity capital deduct any amount deposited under the terms of the lease or comparable arrangement. “(f) Any person dissatisfied with a determination by the Secretary under this section may within six months following notification of such determination request the Secretary to reconsider such determination. A determination by the Secretary under this section shall not be subject to administrative or judicial review. “(g) For the purposes of this section, a ‘capital expenditure’ is an expenditure which, under generally accepted accounting principles, is not properly chargeable as an expense of operation and maintenance and which (1) exceeds $100,000, (2) changes the bed capacity of the facility with respect to which such expenditure is made, or (3) substantially changes the services of the facility with respect to which such expenditure is made. For purposes of clause (1) of the preceding sentence, the cost of the studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, expansion, or replacement of the plant and equipment with respect to which such expenditure is made shall be included in determining whether such expenditure exceeds $100,000. “(h) The previsions of this section shall not apply to Christian Science sanatoriums operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts. “(i) (1) The Secretary shall establish a national advisory council, or designate an appropriate existing national advisory council, to advise and assist him in the preparation of general regulations to carry out the purposes of this section and on policy matters arising in the administration of this section, including the coordination of activities under this section with those under other parts of this Act or under other Federal or federally assisted health programs. “(2) The Secretary shall make appropriate provision for consultation between and coordination of the work of the advisory council established or designated under paragraph (1) and the Federal Hospital Council, the National Advisory Health Council, the Health Insurance Benefits Advisory Council, and other appropriate national advisory councils with respect to matters bearing on the purposes and administration of this section and the coordination of activities under this section with related Federal health programs. “(3) If an advisory council is established by the Secretary under paragraph (1), it shall be composed of members who are not otherwise in the regular full-time employ of the United States, and who shall be appointed by the Secretary without regard to the civil service laws from among leaders in the fields of the fundamental sciences, the med-ical sciences, and the organization, delivery, and financing of health care, and persons who are State or local officials or are active in community affairs or public or civic affairs or who are representative of minority groups. Members of such advisory council, while attending meetings of the council or otherwise serving on business of the council, shall be entitled to receive compensation at rates fixed by the Secretary, but not exceeding the maximum rate specified at the time of such service for grade GS–18 in section 5332 of title 5, United States Code, 5 USC 5332 note. including traveltime, and while away from their homes or regular places of business they may also be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5703(b) of such title 5 for persons in the Government service employed intermittently.” 80 Stat. 499. Effective date. (b) The amendment made by subsection (a) shall apply only with respect to a capital expenditure the obligation for which is incurred by or on behalf of a health care facility or health maintenance organization subsequent to whichever of the following is earlier: (A) December 31, 1972, or (B) with respect to any State or any part thereof specified by such State, the last day of the calendar quarter in which the State requests that the amendment made by subsection (a) of this section apply in such State or such part thereof. (c) (1) Section 505(a)(6) of such Act (as amended by section 232(b) of this Act) is further amended by inserting “, consistent Post, p. 1411. with section 1122,” after “standards” where it first appears. (2) Section 506 of such Act (as amended by sections 224(d), 229 (d), 233 (d), and 237 (b) of this Act) is further amended by adding Post, p. 1395. at the end thereof the following new subsection: “(g) For limitation on Federal participation for capital expenditures which are out of conformity with a comprehensive plan of a State or area wide planning agency, see section 1122.” Ante, p. 1386. (3) Clause (2) of the second sentence of section 509(a) of such Act is amended by inserting “, consistent with section 1122,” after 42 USC 709. “standards”. (4) Section 1861 (v) of such Act is amended by adding at the end 79 Stat. 313. 42 USC 1395x. thereof the following new paragraph: “(5) For limitation on Federal participation for capital expenditures which are out of conformity with a comprehensive plan of a State or areawide planning agency, see section 1122.” (5) Section 1902(a) (13) (D) of such Act (as amended by section 232(a) of this Act) is further amended by inserting “, consistent with Post, p. 1410. section 1122,” after “standards” where it first appears. (6) Section 1903(b) of such Act is amended by adding at the end 42 USC 1396b. thereof the following new paragraph: “(3) For limitation on Federal participation for capital expenditures which are out of conformity with a comprehensive plan of a State, or areawide planning agency, see section 1122,” (d) In the case of a health care facility providing health care services as of December 18, 1970, which on such date is committed to a formal plan of expansion or replacement, the amendments made by the preceding provisions of this section shall not apply with respect to such expenditures as may be made or obligations incurred for capital items included in such plan where preliminary expenditures toward the plan of expansion or replacement (including payments for studies, surveys, designs, plans, working drawings, specifications, and site acquisition, essential to the acquisition, improvement, expansion, or replacement of the health care facility or equipment concerned) of $100,000 or more, had been made during the three-year period ended December 17, 1970. Sec. 222. demonstrations and reports; prospective reimbursement; extended care; intermediate care and homemaker services; ambulatory surgical centers; physicians’ assistants; performance incentive contracts (a) (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 42 USC 1395. under title XVIII of the Social Security Act and under State plans 42 USC 1396, 701. approved under titles XIX and V of such Act, including alternative methods for classifying providers, for establishing prospective rates of payment, and for implementing on a gradual, selective, or other basis the establishment of a prospective payment system, in order to stimulate such providers through positive (or negative) financial incentives to use their facilities and personnel more efficiently and thereby to reduce the total costs of the health programs involved without adversely affecting the quality of services by containing or lowering the rate of increase in provider costs that has been and is being experienced under the existing system of retroactive cost reimbursement. (2) The experiments and demonstration projects developed under paragraph (1) shall be of sufficient scope and shall be carried out on a wide enough scale to permit a thorough evaluation of the alternative methods of prospective payment under consideration while giving assurance that the results derived from the experiments and projects will obtain generally in the operation of the programs involved (without committing such programs to the adoption of any prospective payment system either locally or nationally). (3) In the case of any experiment or demonstration project under paragraph (1), the Secretary may waive compliance with the requirements of titles XVIII, XIX, and V of the Social Security Act insofar as such requirements relate to methods of payment for services provided; and costs incurred in such experiment or project in excess of those which would otherwise be reimbursed or paid under such titles 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 developed or carried out under paragraph (1) until the Secretary obtains the advice and recommendations of specialists who are competent to evaluate the proposed experiment or project as to the soundness of its objectives, the possibilities of securing productive results, the adequacy of resources to conduct it, and its relationship to other similar experiments or projects already completed or in process; and no such experiment or project shall be actually placed in operation unless at least 30 days prior thereto a written report, prepared for purposes of notification and information only, containing a full and complete description thereof has been transmitted to the Committee on Ways and Means of the House of Representatives and to the Committee on Finance of the Senate. (4) Grants, payments under contracts, and other expenditures made for experiments and demonstration projects under this subsection shall be made in appropriate part from the Federal Hospital Insurance 42 USC 1395i. Trust Fund (established by section 1817 of the Social Security Act) and the Federal Supplementary Medical Insurance Trust Fund (established 42 USC 1393t. by section 1841 of the Social Security Act) and from funds appropriated under titles V and XIX of such Act. 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 subsection. 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 titles V and XIX) shall be determined by the Secretary, 42 USC 701, 1396. giving due regard to the purposes of the experiment or project involved. (5) The Secretary shall submit to the Congress no later than July Report to Congress. 1, 1974, a full report on the experiments and demonstration projects earned out under this subsection and on the experience of other programs with respect to prospective reimbursement together with any related data and materials which he may consider appropriate. Such report shall include detailed recommendations with respect to the specific methods which could be used in the full implementation of a system of prospective payment to providers of services under the programs involved. (b) (1) Section 402(a) of the Social Security Amendments of 1967 81 Stat. 930. 42 USC 1395b–1. is amended to read as follows: “(a) (1) The Secretary of Health, Education, and Welfare is authorized, either directly or through grants to public or nonprofit private agencies, institutions, and organizations or contracts with public or private agencies, institutions, and organizations, to develop and engage in experiments and demonstration projects for the following purposes: “(A) to determine whether, and if so which, changes in methods of payment or reimbursement (other than those dealt with in section 222(a) of the Social Security Amendments of 1972) for Ante, p. 1390. health care and services under health programs established by the Social Security Act, including a change to methods based on 49 Stat. 620. 42 USC 1305. negotiated rates, would have the effect of increasing the efficiency and economy of health services under such programs through the creation of additional incentives to these ends 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 401(c) of the Mental Retardation Facilities and Community Health Centers Construction Act of 1963), 77 Stat. 296. 42 USC 2691. “(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 established by the Social Security Act, 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 alternatives to post hospital benefits presently provided under title 42 USC 1395. XVIII of the Social Security Act; such experiment and demonstration projects may include: “(i) 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 the Social Security 42 USC 1305. Act; “(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 the. Social Security Act 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 title XVIII and title XIX 42 USC 1395j, 1396. of the Social Security Act, 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 titles XVIII and XIX of this Act in a manner consistent with quality of care and equitable and efficient administration. For purposes of this subsection, ‘health programs established by the Definition. Social Security Act’ means the program established by title XVIII of such Act, a program established by a plan of a State approved 42 USC 1395. under title XIX of such Act, and a program established by a plan 42 USC 1396. of a State approved under title V of such Act. 42 USC 701. “(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 1817 of the Social Security Act) and the Federal Supplementary Medical Insurance 42 USC 1395i. Trust Fund (established by section 1841 of the Social Security Act) 42 USC 1395t. and from funds appropriated under titles V and XIX of such Act. 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 titles V and XIX) shall be determined by the Secretary, giving due regard to the purposes of the experiment or project involved.” (2) Section 402 (b) of such amendments is amended— 42 USC 1395b–1. (A) by striking out “experiment” each time it appears and inserting in lieu thereof “experiment or demonstration project”; (B) by striking out “experiments” and inserting in lieu thereof “experiments and projects”; and (C) by striking out “reasonable charge” and inserting in lieu thereof “reasonable charge, or to reimbursement or payment only for such services or items as may be specified in the experiment”. (c) Section 1875(b) of the Social Security Act is amended— 42 USC 1395ll. (1) by striking out “experimentation” and inserting in lieu thereof “experiments and demonstration projects”, and (2) by inserting “and the experiments and demonstration projects authorized by section 222(a) of the Social Security Amendments of 1972” after “1967”. Ante, p. 1390. Sec. 223. limitations on coverage of costs under medicare (a) The first sentence of section 1861 (v) (1) of the Social Security Act is amended by inserting immediately before “determined” 42 USC 1395x. where it first appears the following: “the cost actually incurred, excluding therefrom any part of incurred cost found to be unnecessary in the efficient delivery of needed health services, and shall be”. (b) The third sentence of section 1861 (v) (1) of such Act is amended by striking out the comma after “services,” where it last appeal’s and inserting in lieu thereof the following: “may provide for the establishment of limits on the direct or indirect overall incurred costs or incurred costs of specific items or services or groups of items or services to be recognized as reasonable based on estimates of the costs necessary in the efficient delivery of needed health services to individuals covered by the insurance programs established under this title,”. (c) The fourth sentence of section 1861 (v) (1) of such Act is amended by inserting after “services” when it first appears the following: “(excluding therefrom any such costs, including standby costs, which are determined in accordance with regulations to be unnecessary in the efficient delivery of services covered by the insurance programs established under this title)”. (d) The fourth sentence of section 1861(v) (1) of such Act is further amended by striking out “costs with respect” where it first appears and inserting in lieu thereof the following: “necessary costs of efficiently delivering covered services”. (e) Section 1866(a) (2) (B) of such Act is amended (1) by inserting “(i)” after “(B)”, and (2) by adding at the end thereof the following new clause: “(ii) Where a provider of services customarily furnishes an individual items or services which are more expensive than the items or services determined to be necessary in the efficient delivery of needed health services under this title and which have not been requested by such individual, such provider may (except with respect to emergency services) also charge such individual or other person for such more expensive items or services to the extent that the costs of (or, if less, the customary charges for) such more expensive items or services experienced by such provider in the second fiscal period immediately preceding the fiscal period in which such charges are imposed exceed the cost of such items or services determined to be necessary in the efficient delivery of needed health services, but only if— “(I) the Secretary has provided notice to the public of any charges being imposed on individuals entitled to benefits under this title on account of costs in excess of the costs determined to be necessary in the efficient delivery of needed health services under this title by particular providers of services in the area in which such items or services are furnished, and “(II) the provider of services has identified such charges to such individual or other person, in such manner as the Secretary may prescribe, as charges to meet costs in excess of the cost determined to be necessary in the efficient delivery of needed health services under this title.” (f) Section 1861 (v) of such Act (as amended by section 221(c) (4) Ante, p. 1389. of this Act) is further amended by redesignating paragraphs (4) and (5) as paragraphs (5) and (6), respectively, and by inserting after paragraph (3) the following new paragraph: “(4) If a provider of services furnishes items or services to an individual which are in excess of or more expensive than the items or services determined to be necessary in the efficient delivery of needed health services and charges are imposed for such more expensive items or services Supra. under the authority granted in section 1866(a) (2) (B) (ii), the amount of payment with respect to such items or services otherwise due such provider in any fiscal period shall be reduced to the extent that such payment plus such charges exceed the cost actually incurred for such items or services in the fiscal period in which such charges are imposed.” (g) (1) Section 1866(a)(2) of such Act is amended by inserting after subparagraph (C) the following new subparagraph: “(D) Where a provider of services customarily furnishes items or services which are in excess of or more expensive than the items or services with respect to which payment may be made under this title, such provider, notwithstanding the preceding provisions of this paragraph, may not, under the authority of section 1866(a) (2) (B) (ii), charge any individual or other person any amount for such items or services in excess of the amount of the payment which may otherwise be made for such items or services under this title if the admitting physician has a direct or indirect financial interest in such provider.” (2) The last paragraph of section 1866(a) (2) is amended by striking out “clause (iii) of the preceding sentence” and inserting in lieu thereof “subparagraph (C)”. (h) The amendments made by this section shall be effective with respect to accounting periods beginning after December 31, 1972. Sec. 224. limits on prevailing charge levels (a) Section 1842(b)(3) of the Social Security Act is 42 USC 1395u. amended by adding at the end thereof the following new sentences: “No charge may be determined to be reasonable in the case of bills submitted or requests for payment made under this part after December 31, 1970, if it exceeds the higher of (i) the prevailing charge recognized by the carrier and found acceptable by the Secretary for similar services in the same locality in administering this part on December 31, 1970, or (ii) the prevailing charge level that, on the basis of statistical data and methodology acceptable to the Secretary, would cover 75 percent of the customary charges made for similar services in the same locality during the last preceding calendar year elapsing prior to the start of the fiscal year in which the bill is submitted or the request for payment is made. In the case of physician services the prevailing charge level determined for purposes of clause (ii) of the preceding sentence for any fiscal year beginning after June 30, 1973, may not exceed (in the aggregate) the level determined under such clause for the fiscal year ending June 30, 1973, except to the extent that the Secretary finds, on the basis of appropriate economic index data, that such higher level is justified by economic changes. In the case of medical services, supplies, and equipment (including equipment servicing) that, in the judgment of the Secretary, do not generally vary significantly in quality from one supplier to another, the charges incurred after December 31, 1972, determined to be reasonable may not exceed the lowest charge, levels at which such services, supplies, and equipment are widely and consistently available in a locality except to the extent and under the circumstances specified by the Secretary’.” (b) The Health Insurance Benefits Advisory Council established Reimbursement for physicians’ services, study. Post, p. 1457. under section 1867 of the Social Security’ Act shall conduct a study of the methods of reimbursement for physicians’ services under Medicare for the purpose of evaluating their effects on (1) physicians’ fees generally, (2) the extent of assignments accepted by physicians, and (3) the share of total physician-fee costs which the Medicare program does not pay and which the beneficiary must assume. The Council Report to Congress. shall report the results of such study to the Congress no later than January 1, 1973, together with a presentation of alternatives to the present methods and its recommendations as to the preferred method. (c) Section 1903 of such Act is amended by adding at the end thereof 42 USC 1396b. (after the new subsections added by section 207(a) (1) of this Act) Ante, p. 1379. the following new subsection: “(i) Payment under the preceding provisions of this section shall not be made, with respect to any amount paid for items or services furnished under the plan after December 31, 1972, to the extent that such amount exceeds the charge which would be determined to be reasonable for such items or services under the third, fourth, and fifth sentences of section 1842(b) (3).” Supra. (d) Section 506 of such Act is amended by adding at the end thereof 81 Stat. 924. 42 USC 706. the following new subsection: “(f) Notwithstanding the preceding provisions of this section, no payment shall be made to any State thereunder with respect to any amount paid for items or services furnished under the plan after December 31, 1972, to the extent that such amount exceeds the charge which would be determined to be reasonable for such items or services under the third, fourth, and fifth sentences of section 1842(b) (3),” Supra. Sec. 225. limits ox payment for skilled nursing home and intermediate care facility services Section 1903 of the Social Security Act is amended by adding at the end thereof (after the new subsection added by section 224 Ante, p. 1395. (c) of this Act) the following new subsection: “(j) Notwithstanding the preceding provisions of this section— “(1) in determining the amount payable to any State with respect to expenditures for skilled nursing home services furnished in any calendar quarter beginning after December 31, 1972, there shall not be included as expenditures under the State plan any amount in excess of the product of (A) the number of inpatient days of skilled nursing home services provided under the State plan in such quarter, and (B) 105 per centum of the average per diem cost of such services for the fourth calendar quarter preceding such calendar quarter; and “(2) in determining the amount payable to any State with respect to expenditures for intermediate care facility services furnished in any calendar quarter beginning after December 31, 1972, there shall not be included as expenditures under the State plan any amount in excess of the product of (A) the number of inpatient days of intermediate care facility services provided in such quarter under each of the plans of such State approved under 42 USC 301, 1201, 1351, 1381, 1396. titles I, X, XIV, XVI. and XIX, and (B) 105 per centum of the average per diem cost of such services for the fourth calendar quarter preceding such calendar quarter. For purposes of determining the amount payable to any State with respect to any quarter under paragraphs (1) and (2), the Secretary may by regulation increase the percentage specified in clause (B) of each such paragraph to the extent necessary to take account of increases in per diem costs which result directly from increases in the Federal minimum wage, or which otherwise result directly from cost increases which the Secretary’ determines are attributable to the upgrading of services and facilities required by this Act or from provisions of Federal law enacted (or amendments to Federal law made) after the date of the enactment of the Social Security Amendments of 1972.” Sec. 226. payments to health maintenance organizations (a) Title XVIII of the Social Security Act is amended by adding at the end thereof the following new section: “Sec. 1876. “payments to health maintenance organizations (a) (1) In lieu of amounts which would otherwise be Post, p. 1411. 42 USC 1395l. payable pursuant to sections 1814(b) and 1833(a), the Secretary is authorized to determine, by actuarial methods, as provided in this section, but only with respect to a health maintenance organization with which he has entered into a contract under subsection (i), a per capita rate of payment— “(A) for services provided under parts A and B for individuals enrolled with such organization pursuant to subsection (e) who are entitled to hospital insurance benefits under part A and enrolled for medical insurance benefits under part B, and “(B) for services provided under part B for individuals enrolled with such organization pursuant to subsection (e) who are not entitled to benefits under part A but who are enrolled for benefits under part B. “(2) An interim per capita rate of payment for each health Interim per capita rate. maintenance organization shall be determined annually by the Secretary on the basis of each organization’s animal operating budget and enrollment forecast which shall be submitted (in such form and in such detail as the Secretary may prescribe) at least 90 days before the beginning of each contract year. Each interim rate shall be equal to the estimated per capita cost (based upon types and components of expenses otherwise reimbursable under this title) of providing services defined in paragraph (3) (A) (iii). In the event that the data Infra. requested to be furnished by a health maintenance organization are not furnished timely, such reduction in interim payments may be made by the Secretary as is appropriate, until such time as a reasonable estimate of per capita costs can be made. Each month, the Secretary shall pay each such organization its interim per capita rate, in advance, for each individual enrolled with it pursuant to subsection (e). Each such organization shall submit interim estimated cost reports Interim estimated cost reports. and enrollment data on a quarterly basis in such form and manner satisfactory to the Secretary, and the Secretary shall adjust each interim per capita rate to the extent necessary to maintain interim payments at the level of current costs. Interim payments made under this paragraph shall be subject to retroactive adjustment at the end of each contract year as provided in paragraph (3). “(3) (A) With respect, to any health maintenance organization Adjustments. which has entered into a risk sharing contract with the Secretary pursuant to subsection (i)(2)(A), payments made to such organization shall be subject, to the following adjustments at the end of each contract year: “(i) if the Secretary determines that the per capita incurred Per capita incurred cost, apportionment. cost of any such organization in any contract year for providing services described in paragraph (1) is less than the adjusted average per capita incurred cost (as defined herein) of providing such services, the resulting difference (hereinafter referred to as ‘savings’) shall be apportioned following the close of a contract year for such year between such organization and the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust. Fund (hereinafter collectively referred to as the ‘Medicare Trust Funds’) as follows: “(I) savings up to 20 percent of the adjusted average per capita cost shall be apportioned equally between such organization and the Medicare Trust Funds; “(II) savings in excess of 20 percent of the adjusted average per capita cost shall be apportioned entirely to such Trust Funds; “(ii) if the Secretary determines that the per capita incurred Losses. cost, of any such organization in any contract year for providing services described in paragraph (1) is greater than the adjusted average per capita incurred cost of providing such services, the resulting difference (hereinafter referred to as ‘losses’), shall be absorbed by such organization, and shall be carried forward and offset, from savings realized in later years, with the apportionment of savings being proportional to the losses absorbed and not yet offset; “(iii) determination of any amounts payable at the close of the contract year to such organization or to the Trust Funds shall be made as follows: “(I) within 90 days after close of a contract year, interim determination of the amount of estimated savings and apportionment thereof shall be made, actuarially, on the basis of interim reports of costs incurred by an organization, and adjusted average per capita costs incurred (as defined herein), and other evidence acceptable to the Secretary and one-half of any amounts deemed payable to such organization or the Trust Funds shall be paid by such organization or the Secretary as appropriate; “(II) final settlement and payment by the Secretary or organization, as appropriate, of any additional amounts’ due on basis of such final settlement will be made where adequate data for actuarial computation are available, in timely fashion following submission by such organization of reports specified in subparagraph (C) of this paragraph; and “(III) where such final settlement is reached more than 90 days following submission of reports specified in subparagraph (C) of this paragraph, any amount payable by the Secretary or organization shall be increased by an interest amount, accruing from the 91st day following submission of such report, equal to the average rate of interest payable on Federal obligations if issued on such 91st day for purchase by the Trust Funds. “(iv) The term ‘adjusted average per capita cost’ means the average per capita amount that the Secretary determines (on the basis of actual experience, or retrospective actuarial equivalent based upon an adequate sample and other information and data, in the geographic area served by a health maintenance organization or in a similar area, with appropriate adjustment to assure actuarial equivalence, including adjustments relating to age distribution, sex, race, institutional status, disability status, and any other relevant factors) would be payable in any contract year for services covered under this title, and types of expenses otherwise reimbursable under this title (including administrative costs 79 Stat. 297; Post, p. 1449. 42 USC 1395h, 1395u. incurred by organizations described in sections 1816 and 1842) if such services were to be furnished by other than such health maintenance organization. “(B) With respect to any health maintenance organization which has entered into a reasonable cost reimbursement contract with the Secretary pursuant to subsection (i) (2) (B), payments made to such organization shall be subject to suitable retroactive corrective adjustments at the end of each contract year so as to assure, that such organization is paid for the reasonable cost actually incurred (excluding therefrom any part of incurred cost found to be unnecessary in the efficient delivery of health services) for the types of expenses otherwise reimbursable under this title for providing services covered under this title to individuals described in paragraph (1). “(C) Any contract with a health maintenance organization under this title shall provide that the Secretary shall require, at such time following the expiration of each accounting period of a health maintenance organization (and in such form and in such detail) as he may prescribe: “(i) that such health maintenance organization report to him in an independently certified financial statement its per capita incurred cost based on the types and components of expenses otherwise reimbursable under this title for providing services described in paragraph (1), including therein, in accordance with accounting procedures prescribed by the Secretary, its methods of allocating costs between individuals enrolled under this section and other individuals enrolled with such organization; “(ii) that failure to report such information as may be required may be deemed to constitute evidence of likely overpayment on the basis of which appropriate collection action may be taken; “(iii) that in any case in which a health maintenance organization is related to another organization ‘by common ownership or control, a consolidated financial statement shall be filed and that the allowable costs for such organization may not include costs for the types of expense otherwise reimbursable under this title, in excess of those which would be determined to be reasonable in accordance with regulations (providing for limiting reimbursement to costs rather than charges to the health maintenance organization by related organizations and owners) issued by the Secretary in accordance with section 1861 (v) of the Social Security Act; and 42 USC 1395x. “(iv) that in any case in which compensation is paid by a health maintenance organization substantially in excess of what is normally paid for similar services by similar practitioners (regardless of method of compensation), such compensation may as appropriate be considered to constitute a distribution of profits. “(4) The payments to health maintenance organizations under this subparagraph with respect to individuals described in subsection (a) (1)(A) shall be made from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund. The portion of such payment to such an organization for a month to be paid by the latter trust fund shall be equal to 200 percent of the sum of— “(A) the product of (i) the number of covered enrollees of such organization for such month (as described in paragraph (1)) who have attained age 65, and (ii) the monthly actuarial rate for supplementary medical insurance for such month as determined under section 1839 (c) (1), and Ante, p. 1376. “(B) the product of (i) the number of covered enrollees of such organization for such month (as described in paragraph (1)) who have not attained age 65, and (ii) the monthly actuarial rate for supplementary medical insurance for such month as determined under section 1839 (c) (4). Ante, P. 1377. The remainder of such payment shall be paid by the former trust fund. For limitation on Federal participation for capital expenditures which are out of conformity with a comprehensive plan of a State or areawide planning agency, see section 1122. Ante, p. 1386. “Health maintenance organization.” “(b) The term ‘health maintenance organization’ means a public or private organization which— “(1) provides, either directly or through arrangements with others, health services to individuals enrolled with such organization on the basis of a predetermined periodic rate without regard to the frequency or extent of services furnished to any particular enrollee; “(2) provides, either directly or through arrangements with others, to the extent applicable in subsection (c) (through institutions, entities, and persons meeting the applicable requirements of section 1861), all of the services and benefits covered under 42 USC 1395x. parts A and B of this title which are available to individuals 42 USC 1395c, 1395j. residing in the geographic area served by the health maintenance organization; “(3) provides physicians’ services primarily (A) directly through physicians who are either employees or partners of such organization, or (B) under arrangements with one or more groups of physicians (organized on a group practice, or individual practice basis) under which, each such group is reimbursed for its services primarily on the basis of an aggregate fixed sum or on a per capita basis, regardless of whether the individual physician members of any such group are paid on a fee-for-service or other basis; “(4) provides either directly or under arrangements with others, the services of a sufficient number of primary care and specialty care physicians to meet the health needs of its members; “Specialty care physician.” for purposes of this section the term ‘specialty care physician’ means a physician who is either hoard certified or eligible for board certification, except that the Secretary may by regulation prescribe conditions under which physicians who have a record of demonstrated proficiency but who are not eligible for board certification may, on the basis of training and experience, be recognized as specialty care physicians; “(5) has effective arrangements to assure that its members have access to qualified practitioners in those specialties which are generally available in the geographic area served by the health maintenance organization; “(6) demonstrates to the satisfaction of the Secretary proof of financial responsibility and proof of capability to provide comprehensive health care services, including institutional services, efficiently, effectively, and economically; “(7) except as provided in subsection (h), has at least half of its enrolled members consisting of individuals under age 65; “(8) assures that the health services required by its members are received promptly and appropriately and that the services that are received measure up to quality standards which it establishes in accordance with regulations; and “(9) has an open enrollment period at least every year under which it accepts up to the limits of its capacity and without restrictions, except as may be authorized in regulations, individuals who are eligible to enroll under subsection (d) in the order in which they apply for enrollment (unless to do so would result in failure to meet the requirements of paragraph (7)) or would result in enrollment of enrollees substantially nonrepresentative, as determined in accordance with regulations of the Secretary, of the population in the geographic area served by such health maintenance organization. “(c) The benefits provided under this section to enrollees of an organization which has entered into a risk sharing contract with the Post, p. 1401. Secretary pursuant to subsection (i) (2) (A) shall consist of— “(1) in the case of an individual who is entitled to hospital 42 USC 1395c. 42 USC 1395j. insurance benefits under part A and enrolled for medical insurance benefits under part B— “(A) entitlement to have payment made on his behalf for 79 Stat. 291. 42 USC 1395d. Post, p. 1406. all services described in section 1812 and section 1832 which are furnished to him by the health maintenance organization with which he is enrolled pursuant to subsection (e) of this section; and “(B) entitlement to have payment, made by such health maintenance organization to him or on his behalf for (i) such emergency services (as defined in regulations.), (ii) such urgently needed services (as defined in regulations) furnished to him during a period of temporary absence (as defined in regulations) from the geographic area served by the health maintenance organization with which he is enrolled, and (iii) such other services as may be determined, in accordance with subsection (f), to be services which the individual was entitled to have furnished by the health maintenance organization, as may be furnished to him by a physician, supplier, or provider of services, other than the health maintenance organization with which he is enrolled; and “(2) in the case of an individual who is not entitled to hospital insurance benefits under part A but who is enrolled for medical 42 USC 1395c. insurance benefits under part B, entitlement to have payment 42 USC 1395j. made for services described in paragraph (1), but only to the extent that such services are also described in section 1832. 79 Stat. 302. 42 USC 1395k. “(d) Subject to the provisions of subsection (e), every individual described in subsection (c) shall be eligible to enroll with any health maintenance organization (as defined in subsection (b)) which serves the geographic area in which such individual resides. “(e) An individual may enroll with a health maintenance organization under this section, and may terminate such enrollment, as may be prescribed by regulations. “(f) Any individual enrolled with a health maintenance organization Hearings; judicial review. under this section who is dissatisfied by reason of his failure to receive without additional cost to him any health service to which he believes he is entitled shall, if the amount in controversy is $100 or more, be entitled to a hearing before the Secretary to the same extent as is provided in section 205(b) and in any such hearing the Secretary 53 Stat. 1368. 42 USC 405. shall make such health maintenance, organization a party thereto. If the amount in controversy is $1,000 or more, such individual or health maintenance organization shall be entitled to judicial review of the Secretary’s final decision after such hearing as is provided in section 205(g). “ “(g) (1) If the health maintenance organization provides its enrollees under this section only the services described in subsection (c), its premium rate, or other charges for such enrollees shall not exceed the actuarial value of the deductible and coinsurance which would otherwise be applicable to such enrollees under part A and part B, if they were not enrolled under this section. “(2) If the health maintenance organization provides to its enrollees under this section services in addition to those described in subsection (c), election of coverage for such additional services shall be optional for such enrollees and such organization shall furnish such enrollees with information on the portion of its premium rate or other charges applicable to such additional services. The portion applicable to the services described in subsection (c) may not exceed (i) the actuarial value of the deductible and coinsurance which would otherwise be applicable to such enrollees under part A and part B if they were not enrolled under this section less (ii) the actuarial value of other charges made in lieu of such deductible and coinsurance. “(h) The provisions of paragraph (7) of subsection (b) shall not Nonapplicability. apply with respect to any health maintenance organization for such period not to exceed three years from the date such organization enters into an agreement with the Secretary pursuant to subsection (i), as the Secretary may permit, but only so long as such organization demonstrates to the satisfaction of the Secretary by the submission of its plans for each year that it is making continuous efforts and progress toward achieving compliance with the provisions of such paragraph (7) within such three-year period. “(i) (1) Subject to the limitations contained in subparagraphs (A) Contract authority. and (B) of paragraph (2), the Secretary is authorized to enter into a contract with any health maintenance organization which undertakes to provide, on an interim per capita prepayment basis, the services described in section 1832 (and section 1812, in the case of indi- 42 USC 1395d. 42 USC 1395c. viduals who are entitled to hospital insurance benefits under part A) to individuals enrolled with such organization pursuant to subsection (e). “(2) (A) If the health maintenance organization (i) has a current enrollment of not less than 25,000 members on a prepaid capitation basis and has been the primary source of health care of at least 8,000 persons in each of the two years immediately preceding the contract year, or (ii) serves a nonurban geographic area, has a current enrollment of not less than 5,000 members on a prepaid capitation basis and has been the primary source of health care for at least 1,500 persons in each of the three years immediately preceding the contract year, the Secretary may enter into a risk sharing contract with such organization pursuant to which any savings, as determined pursuant to subsection (a)(3)(A), are shared between such organization and the Medicare Trust Funds in the manner prescribed in such subsection. Nonurban geographic area. For purposes of this subparagraph, a health maintenance organization shall be considered to serve a nonurban geographic area if it is located in a nonmetropolitan county (that is, a county with fewer than 50,000 inhabitants), or if it has at least one such county in its normal service area, or if it is located outside of a metropolitan area and its facilities are within reasonable travel distance (as defined Prohibition. by the Secretary) of fewer than 50,000 individuals. No health maintenance organization which has entered into a risk-sharing contract with the Secretary under this subparagraph and has voluntarily terminated such contract may again enter into such a contract. “(B) If the health maintenance organization does not meet the requirements of subparagraph (A), or if the Secretary’ is not satisfied that the health maintenance organization has the capacity to bear the risk of potential losses as determined under clause (ii) of subsection (a)(3)(A), or if the health maintenance organization meeting the requirements of subparagraph (A) so elects, or if an organization does Ante, p. 1399. not fully meet the requirements of section 1876(b) but has demonstrated to the satisfaction of the Secretary that it is making reasonable efforts to meet, and is developing the capability to fully meet, such requirements, and that it fully meets such basic requirements as the Secretary shall prescribe, in regulations, the Secretary may, if he is otherwise satisfied that the health maintenance organization or other organization is able to perform its contractual obligations effectively and efficiently, enter into a contract with such organization pursuant to which such organization is reimbursed on the basis of its reasonable 42 USC 1395x. cost (as defined in section 1861 (v)) in the manner prescribed in subsection (a) (3) (B). “(3) Such contract may, at the option of such organization, provide that the Secretary (A) will reimburse hospitals and extended care facilities for the reasonable cost (as determined under section 1861 (v)) of services furnished to individuals enrolled with such organization pursuant to subsection (e), and (B) will deduct the amount of such reimbursement from payments which would otherwise be made to such organization. If a health maintenance organization pays a hospital or extended care facility directly, the amount paid shall not exceed the reasonable cost of the services (as determined under section 1861 (v)) unless such organization demonstrates to the satisfaction of the Secretary that such excess payments are justified on the basis of advantages gained by the organization. “(4) Each contract under this section shall be for a term of at least one year, as determined by the Secretary, and may be made automatically renewable from term to term in the absence of notice by either party of intention to terminate at the end of the current term; except that the Secretary may terminate any such contract at any time (after such reasonable notice and opportunity for hearing to the health maintenance organization involved as he may provide in regulations), Contract termination, notice, hearing. if he finds that the organization (A) has failed substantially to carry out the contract, (B) is carrying out the contract in a manner inconsistent with the efficient and effective administration of this section, or (C) no longer substantially meets the applicable conditions of subsection (b). “(5) The effective date of any contract executed pursuant to this subsection shall be specified in such contract pursuant to the regulations. “(6) Each contract under this section— “(A) shall provide that the Secretary, or any person or organization designated by him— “(i) shall have the right to inspect or otherwise evaluate Inspection authority. the quality, appropriateness, and timeliness of services performed under such contract; and “(ii) shall have the right to audit and inspect any books and records of such health maintenance organization which pertain to services performed and determinations of amounts payable under such contract; “(B) shall provide that no reinsurance costs (other than those with respect to out-of-area services), including any underwriting of risk relating to costs in excess of adjusted average per capita cost, as defined in clause (iii) of subsection (a) (3) (A), shall be allowed for purposes of determining payments authorized under this section; and “(C) shall contain such other terms and conditions not inconsistent with this section as the Secretary may find necessary. “(j) The function vested in the Secretary by subsection (i) may be performed without regard to such provisions of law or of other regulations relating to the making, performance, amendment, or modification of contracts of the United States as the Secretary may determine to be inconsistent with the furtherance of the purposes of this title.” (b) (1) Notwithstanding the provisions of section 1814 and section 1833 of the Social Security Act, any health maintenance organization 42 USC 1395f, 1395l. which has entered into a contract with the Secretary pursuant to section 1876 of such Act shall, for the duration of such Ante, p. 1396. contract, (except as provided in paragraph (2)) be entitled to reimbursement only as provided in section 1876 of such Act for individuals who are members of such organizations. (2) With respect to individuals who are members of organizations which have entered into a risk-sharing contract with the Secretary pursuant to subsection (i)(2)(A) prior to July 1, 1973, and who, Ante, p. 1402. although eligible to have payment made pursuant to section 1876 of such Act for services rendered to them, chose (in accordance with regulations) not to have such payment made pursuant to such section, the Secretary shall, for a period not to exceed three years commencing on July 1, 1973, pay to such organization on the basis of an interim per capita rate, determined in accordance with the provisions of section 1876(a)(2) of such Act, with appropriate actuarial adjustments to reflect the difference in utilization of out-of-plan services, which would have been considered sufficiently reasonable and necessary under the rules of the health maintenance organization to be provided by that organization, between such individuals and individuals who are enrolled with such organization pursuant to section 1876 of such Act. Payments under this paragraph shall be subject to retroactive adjustment at the end of each contract year as provided in paragraph (3). (3) If the Secretary determines that the per capita cost of any such organization in any contract year for providing services to individuals described in paragraph (2), when combined with the cost of the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund in such year for providing out-of-plan services to such individuals, is less than or greater than the adjusted Ante, p. 1396. average per capita cost (as defined in section 1876(a) (3) of such Act) of providing such services, the resulting savings shall be apportioned between such organization and such Trust. Funds, or the resulting losses shall be absorbed by such organization, in the manner prescribed in section 1876(a) (3) of such Act. (c) (1) Section 1814(a) of such Act is amended by striking out “Except as provided in subsection (d),” and inserting in lieu thereof the following: “Except as provided in subsection (d) and in section 1876,”. (2) Section 1833(a) of such Act is amended by striking out “Subject to” and inserting in lieu thereof the following: “Except as provided in section 1876, and subject to”. (d) Section 1875(b) of the Social Security Act, as amended by section 222 (c) of this Act, is further amended— (1) by inserting “the operation and administration of health maintenance organizations authorized by section 226 of the Social Ante, p. 1396. Security Amendments of 1972,” after the word “including”; and (2) by striking out “1971” and inserting in lieu thereof “1972”. (e) Section 1903 of such Act, as amended by sections 207, 224, and 290 of this Act, is further amended by adding after subsection (j) the following new subsection: “(k) The Secretary is authorized to provide at the request of any State (and without cost to such State) such technical and actuarial assistance as may be necessary to assist such State to contract with any health maintenance organization which meets the requirements of section 1876 for the purpose of providing medical care and services to individuals who are entitled to medical assistance under this title.” (f) The amendments made by this section shall be effective with respect to services provided on or after July 1, 1973. Sec. 227. payment under medicare for services of physicians rendered at a teaching hospital (a) Section 1861(b) of the Social Security Act is amended by striking out the second sentence and inserting in lieu thereof the following: “Paragraph (4) shall not apply to services provided in a hospital by— “(6) an intern or a resident-in-training under a teaching program approved by the Council on Medical Education of the American Medical Association or, in the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association, or. in the case of services in a hospital or osteopathic hospital by an intern or resident-in-training in the field of dentistry, approved by the Council on Dental Education of the American Dental Association; or “(7) a physician where the hospital has a teaching program approved as specified in paragraph (6), unless (A) such inpatient is a private patient (as defined in regulations), or (B) the hospital establishes that during the two-year period ending December 31, 1967, and each year thereafter all inpatients have been regularly billed by the hospital for services rendered by physicians and reasonable efforts have been made to collect in full from all patients and payment of reasonable charges (including applicable deductibles and coinsurance) has been regularly collected in full or in substantial part from at least 50 percent of all inpatients.” (b) (1) So much of section 1814(a) of such Act as precedes paragraph 42 USC 1395f. (1) (as amended by section 226(c) (1) of this Act) is further amended by striking out “subsection (d)” and inserting in lieu thereof “subsections (d) and (g)”. (2) Section 1814 is further amended by adding at the end thereof the Ante, p. 1382. following new subsection: “(g) “Payment for Services of a Physician Rendered in a Teaching Hospital Pot purposes of services for which the reasonable cost thereof is determined under section 1861 (v) (1) (D), payment under this part Infra. 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 1866, and 42 USC 1395cc. “(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).” (c) Section 1861(v) (1) of such Act (as amended by section 223 of 42 USC 1395x. this Act) is amended— (1) by inserting “(A)” after “(1)”; (2) by striking out “(A) take” and “(B) provide” in the fourth sentence and inserting in lieu thereof “(i) take” and “(ii) provide”, respectively; (3) by inserting “(B)” immediately preceding “Such regulations in the case of extended care services”; and (4) by adding at the end thereof the following new subparagraphs: “(C) Where a hospital has an arrangement with a medical school under which the faculty of such school provides services at such hospital, an amount not in excess of the reasonable cost of such services to the medical school shall be included in determining the reasonable cost to the hospital of furnishing services— “(i) for which payment may be made under part A, 42 USC 1395c. but only if “(I) payment for such services as furnished under such arrangement would be made under part A to the hospital had such services been furnished by the hospital, and “(II) such hospital pays to the medical school at least the reasonable cost of such services to the medical school, or “(ii) for which payment may be made under part B, but only if such hospital pays to the medical school at least the reasonable cost of such services to the medical school. “(D) Where (i) physicians furnish services which are either inpatient hospital services (including services in conjunction with the teaching programs of such hospital) by reason of paragraph (7) of subsection (b) or for which entitlement exists by reason of clause (II) of section 1832 Infra. (a)(2)(B) (i) and (ii) such hospital (or medical school under arrangement with such hospital) incurs no actual cost in the furnishing of such services, the reasonable cost of such services shall (under regulations of the Secretary) be deemed to be the cost such hospital or medical school would have incurred had it paid a salary to such physicians rendering such services approximately equivalent to the average salary paid to all physicians employed by such hospital (or if such employment does not exist, or is minimal in such hospital, by similar hospitals in a geographic area of sufficient size to assure reasonable inclusion of sufficient physicians in development of such average salary).” (d) (1) Section 1861 (u) of such Act is amended by inserting before the period at the end thereof the following: “, or, for purposes of section 1814(g) and Ante, p. 1405; Infra. section 1835 (e), a fund”. (2) So much of section 1866(a) (1) of such Act as precedes subparagraph (A) is amended by inserting “(except a fund designated for purposes of section 1814(g) and section 1835(e))” after “provider of services”. (e) (1) Section 1832(a) (2) (B) of such Act is amended to read as follows: “(B) medical and other health services furnished by a provider of services or by others under arrangement with them made by a provider of services, excluding— “(i) physician services except where furnished by— “(I) a resident or intern of a hospital, or “(II) a physician to a patient in a hospital which has a teaching program approved as specified in Ante, p. 1404. paragraph (6) of section 1861(b) (including services in conjunction with the teaching programs of such hospital whether or not such patient is an inpatient of such hospital), unless either clause (A) or (B) of paragraph (7) of such section is met, and “(ii) services for which payment may be made pursuant to section 1835(b) (2); and”. (2) (A) So much of section 1835(a) of such Act as precedes paragraph (1) is amended by striking out “subsections (b) and (c),” and inserting in lieu thereof “subsections (b), (c), and (e),”. (B) Section 1835 of such Act is further amended by adding at the end thereof the following new subsection: “(e) For purposes of services (1) which are inpatient hospital Ante, p. 1404. services by reason of paragraph (7) of section 1861(b) or for which entitlement exists by reason of clause (II) of section 1832(a) (2)(B) Supra. (i), and (2) for which the reasonable cost thereof is determined under Ante, p. 1405. section 1861 (v) (1) (D), 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 1866, and 42 USC 1395cc. “(2) the Secretary has received written assurances that such payment will be used by such fund solely for the improvement of care to patients in such hospital 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 for any moneys incorrectly collected).” (3) Section 1842(a) of such Act is amended by inserting after 42 USC 1395u. “which involve payments for physicians’ services” the following: “on a reasonable charge basis”. (f) Section 1861 (q) of such Act is amended by striking out the 42 USC 1395x. parenthetical phrase “(but not including services described in the last sentence of subsection (b))” and inserting in lieu thereof “(but not including services described in subsection (b)(6))”. Ante, p. 1404. (g) The amendments made by this section shall apply with respect Effective date. to accounting periods beginning after June 30, 1973. Sec. 228. advance approval of extended care and home health coverage under medicare (a) Section 1814 of the Social Security Act (as amended by section 227(b)(2) of this Act) is amended by adding at the end Ante, p. 1405. thereof the following new subsections: “(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 Post, p. 1425. payment to an extended care facility (subject to the provisions of section 1812) for post hospital extended care services which are furnished 42 USC 1395d. 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 extended care facility, “(B) such certification states that the medical condition of the individual is a condition designated in regulations, “(C) such certification is accompanied by a plan of treatment for providing such services, and “(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. “(2) If the Secretary determines with respect to a physician that Erroneous certification, nonapplicability. 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), (B),or (C) of paragraph (1). “(i) “Payment for Posthospital Home Health Services (1) An individual shall be presumed to require the services 42 USC 1395f. 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 42 USC 1395d. 1812) 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 “(C) there is compliance with such other requirements and procedures as may be specified in regulations, but only for services furnished during such limited numbers 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).” (b) The amendment made by subsection (a) 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. Sec. 229. authority of secretary to terminate payments to suppliers of services (a) Section 1862 of the Social Security Act (as amended Ante, p. 1382. by section 210 of this Act) is further amended by adding at the end thereof the following new subsection: “(d) (1) No payment may be made under this title with respect to any item or services furnished to an individual by a person where the Secretary determines under this subsection that such person— “(A) has knowingly and willfully made, or caused to be made, any false statement or representation of a material fact for use in an application for payment under this title or for use in determining the right to a payment under this title; “(B) has submitted or caused to be submitted (except in the case of a provider of services), bills or requests for payment under this title containing charges (or in applicable cases requests for payment of costs to such person) for services rendered which the Secretary finds, with the concurrence of the appropriate program Post, p. 1409. review team appointed pursuant to paragraph (4), to be substantially in excess of such person’s customary charges (or in applicable cases substantially in excess of such person’s costs) for such services, unless the Secretary finds there is good cause for such bills or requests containing such charges (or in applicable cases, such costs); or “(C) has furnished services or supplies which are determined by the Secretary, with the concurrence of the members of the appropriate program review team appointed pursuant to paragraph (4) who are physicians or other professional personnel in Infra. the health care field, to be substantially in excess of the needs of individuals or to be harmful to individuals or to be of a grossly inferior quality. “(2) A determination made by the Secretary under this subsection Determination effective date, public notice. shall be effective at such time and upon such reasonable notice to the public and to the person furnishing the services involved as may be specified in regulations. Such determination shall be effective with respect to services furnished to an individual on or after the effective date of such determination (except that in the case of inpatient hospital services, posthospital extended care services, and home health services such determination shall be effective in the manner provided in section 1866(b) (3) and (4) with respect to terminations of agreements), Post, p. 1427 and shall remain in effect until the Secretary finds and gives reasonable notice to the public that the basis for such determination has been removed and that there is reasonable assurance that it will not recur. “(3) Any person furnishing services described in paragraph (1) Judicial review. who is dissatisfied with a determination made by the Secretary under this subsection shall be entitled to reasonable notice and opportunity for a hearing thereon by the Secretary to the same extent as is provided in section 205(b), and to judicial review of the Secretary’s final 42 USC 405. decision after such hearing as is provided in section 205(g). “(4) For the purposes of paragraph (1) (B) and (C) of this subsection, Program review teams. Infra. and clause (F) of section 1866(b)(2), the Secretary shall, after consultation with appropriate State and local professional societies, the appropriate carriers and intermediaries utilized in the administration of this title, and consumer representatives familiar with the health needs of residents of the State, appoint one or more program review teams (composed of physicians, other professional personnel in the health care field, and consumer representatives) in each State which shall, among other things— “(A) undertake to review such statistical data on program utilization as may be submitted by the Secretary, “(B) submit to the Secretary periodically, as maybe prescribed Report to Secretary. in regulations, a report on the results of such review, together with recommendations with respect thereto, “(C) undertake to review particular cases where there is a likelihood that the person or persons furnishing services and supplies to individuals may come, within the provisions of paragraph (1) (B) and (C) of this subsection or clause (F) of section 1866(b)(2), and “(D) submit to the Secretary periodically, as may be prescribed Report to Secretary. in regulations, a report of cases reviewed pursuant to subparagraph (C) along with an analysis of, and recommendations with respect to, such cases.” (b) Section 1866(b) (2) of such Act is amended by striking out 42 USC 1395cc. the period at the end thereof and inserting in lieu thereof the following: or (D) that such provider has made, or caused to be made, any false statement or representation of a material fact for use in an application for payment under this title or for use in determining the right to a payment under this title, or (E) that such provider has submitted, or caused to be submitted, requests for payment under this title of amounts for rendering services substantially in excess of the costs incurred by such provider for rendering such services, or (F) that such provider has furnished services or supplies which are determined by the Secretary, with the concurrence of the members of the appropriate program review team appointed pursuant to section Ante, p. 1408. 1862(d)(4) who are physicians or other professional personnel in the health care field, to be substantially in excess of the needs of individuals or to be harmful to individuals or to be of a grossly inferior quality,” (c) Section 1903(i) of such Act (as added by section 224(c) of this Act) is further amended by striking out “shall not be made” and all that follows and inserting in lieu thereof the following: “shall not be made— “(1) with respect to any amount paid for items or services furnished under the plan after December 31, 1972, to the extent that such amount exceeds the charge which would be determined to be reasonable for such items or services under the fourth and Ante, p. 1395; Post, p. 1447. fifth sentences of section 1842(b) (3); or “(2) with respect to any amount paid for services furnished under the plan after December 31, 1972, by a provider or Other person during any period of time, if payment may not be made 42 USC 1395. under title XVIII with respect to services furnished by such provider or person during such period of time solely by reason of a Ante, p. 1408. determination by the Secretary under section 1862(d) (1) or under Ante, p. 1409. clause (D), (E), or (F) of section 1866(b)(2).” (d) Section 506(f) of such Act (as added by section 224(d) of this Act) is further amended by striking out “no payment shall be made” and all that follows and inserting in lieu thereof the following: “no payment shall be made to any State thereunder— “(1) with respect to any amount paid for items or services furnished under the plan after December 31, 1972, to the extent that such amount exceeds the charge which would be determined to be reasonable for such items or services under the fourth and fifth sentences of section 1842(b) (3); or “(2) with respect to any amount paid for services furnished under the plan after December 31, 1972, by a provider or other person during any period of time, if payment may not be made under title XVIII with respect to services furnished by such provider or person during such period of time solely by reason of a determination by the Secretary under section 1862(d) (1) or under clause (D), (E), or (F) of section 1866(b)(2).” Sec. 230. elimination or requirement that states move toward comprehensive medicaid programs Section 1903(e) of the Social Security Act, and section 2(b) of Public Law 91–56 (approved August 9, 1969), are repealed. Sec. 231. repeal of section 1902 (d) of medicaid Section 1902(d) of the Social Security Act is repealed. Sec. 232. determination of reasonable cost of inpatient hospital services under medicaid and under maternal and child health program (a) Section 1902(a) (13) (D) of the Social Security Act is amended to read as follows: “(D) for payment of the reasonable cost of inpatient hospital services provided under the plan, as determined in accordance with methods and standards which shall be developed by the State and reviewed and approved by the Secretary and (after notice of approval by the Secretary) included in the plan, except that the reasonable cost of any such services as determined under such methods and standards shall not exceed the amount which would be determined under section 1861 (v) as the reasonable cost of such services for 42 USC 1395x. purposes of title XVIII;”. 42 USC 1395. (b) Section 505(a) (6) of such Act is amended to read as follows: 42 USC 705. “(6) provides for payment of the reasonable cost of inpatient hospital services provided under the plan, as determined in accordance with methods and standards which shall be developed by the State and included in the plan, except that the reasonable cost of any such services as determined under such methods and standards shall not exceed the amount which would be determined under section 1861 (v) as the reasonable cost of such services for purposes of title XVIII;”. (c) The amendments made by this section shall be effective July 1, Effective date. 1972 (or earlier if the State plan so provides). Sec. 233. amount of payments where customary charges for services furnished are less than reasonable cost (a) Section 1814(b) of the Social Security Act is amended 79 Stat. 294. 42 USC 1395f. to read as follows: “(b) “Amount Paid to Providers 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 1813, be— 42 USC 1395e. “(1) the lesser of (A) the reasonable cost of such services, as determined under section 1861 (v), or (B) the customary charges 42 USC 1395x. 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. “(b) Section 1833(a) (2) of such Act is amended to read as follows: 79 Stat. 302. “(2) in the case of services described in section 1832(a) (2)—80 42 USC 1395l. 42 USC 1395k. percent of— “(A) the lesser of (i) the reasonable cost of such services, as determined under section 1861(v), or (ii) the customary charges with respect to such services; or “(B) if such services are furnished by a public provider of services free of charge or at nominal charges to the public, the amount determined in accordance with section 1814(b)(2).” Supra. (c) Section 1903 (i) of such Act (as added by section 224(c) and amended by section 229(c) of this Act) is further amended by striking Ante, pp. 1395, 1410. out the period at the end of paragraph (2) and inserting in lieu thereof “: or”, and by adding after paragraph (2) the following new paragraph: “(3) with respect, to any amount expended for inpatient, hospital services furnished under the plan to the extent that such amount exceeds the hospital’s customary charges with respect to such services or (if such services are furnished under the plan by a public institution free of charge or at nominal charges to the public) exceeds an amount determined on the basis of those items (specified in regulations prescribed by the Secretary) included in the determination of such payment which the Secretary finds will provide fair compensation to such institution for such services.” (d) Section 506(f) of such Act (as added by section 224(d) and Ante, pp. 1395, 1410. amended by section 229(d) of this Act) is further amended by striking out the period at the end of paragraph (2) and inserting in lieu thereof “; or”, and by adding after paragraph (2) the following new paragraph: “(3) with respect to any amount expended for inpatient hospital services furnished under the plan to the extent that such amount exceeds the hospital’s customary charges with respect to such services or (if such services are furnished under the plan by a public institution free of charge or at nominal charges to the 0 exceeds an amount determined on the basis of those items (specified in regulations prescribed by the Secretary) included in the determination of such payment which the Secretary finds will provide fair compensation to such institution for such services.” (e) Clause (2) of the second sentence of section 509(a) of such Ante, p. 1389. Act (as amended by section 221(e) (3) of this Act) is further amended by inserting “(A)” before “the reasonable cost”, and by inserting after “under the project,” the following: “or (B) if less, the customary charges with respect to such services provided under the project, or (C) if such services are furnished under the project by a public institution free of charge or at nominal charges to the public, an 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 institution for such services”. (f) The amendments made by subsections (a) and (b) 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) shall apply with respect to services furnished by hospitals in accounting periods beginning after December 31, 1972. Sec. 234. institutional planning under medicare (a) The first sentence of section 1861(e) of the Social Ante, p. 1383. Security Act is amended— (1) by striking out “and” at the end of paragraph (7); (2) by redesignating paragraph (8) as paragraph (9); and (3) by inserting after paragraph (7) the following new paragraph: “(8) has in effect an overall plan and budget that meets the Post, p. 1413. requirements of subsection (z); and”. (b) Section 1861(f) (2) of such Act is amended to read as follows: “(2) satisfies the requirements of paragraphs (3) through (9) of subsection (e);”. (c) Section 1861(g) (2) of such Act is amended to read as follows: “(2) satisfies the requirements of paragraphs (3) through (9) of subsection (e);”. (d) The first sentence of section 1861 (j) of such Act is amended— (1) by striking out “and” at the end of paragraph (9); (2) by redesignating paragraph (10) as paragraph (11); and (3) by inserting after paragraph (9) the following new paragraph: “(10) has in effect an overall plan and budget that meets the requirements of subsection (z); and”. Infra. (e) Section 1861 (o) of such Act is amended— 42 USC 1395x. (1) by striking out “and” at the end of paragraph (4); (2) by redesignating paragraph (5) as paragraph (6); and (3) by inserting after paragraph (4) the following new paragraph: “(5) has in effect an overall plan and budget that meets the requirements of subsection (z); and”. (f) Section 1861 of such Act is further amended by adding at the end 79 Stat. 313. 42 USC 1395x. thereof the following new subsection: “(z) “Institutional Planning An overall plan and budget of a hospital, extended care facility, or home health agency shall be considered sufficient if it— “(1) provides for an annual operating budget which includes all anticipated income and expenses related to items which would, under generally accepted accounting principles, be considered income and expense items (except that nothing in this paragraph shall require that there be prepared, in connection with any budget, an item-by-item identification of the components of each type of anticipated expenditure or income); “(2) provides for a capital expenditures plan for at least a 3-year period (including the year to which the operating budget described in subparagraph (1) is applicable) which includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure in excess of $100,000 related to the acquisition of land, the improvement of land, buildings, and equipment, and the replacement, modernization, and expansion of the buildings and equipment which would, under generally accepted accounting principles, be considered capital items; “(3) provides for review and updating at least annually; and “(4) is prepared, under the direction of the governing body of the institution or agency, by a committee consisting of representatives of the governing body, the administrative, staff, and the medical staff (if any) of the institution or agency.” (g) (1) Section 1814(a) (2) (C) and section 1814(a) (2) (D) of such Act are each amended by striking out “and (8)” and inserting in lieu 42 USC 1395f. thereof “and (9)”. (2) Section 1863 of such Act is amended by striking out “subsections 42 USC 1395z. (c)(8), (f)(4), (g)(4), (j)(10), and (o)(5)” and inserting in lieu thereof “subsections (e)(9), (f)(4), (g)(4), (j)(11), and (o)(6)”. (h) Section 1865 of such Act is amended— 42 USC 1395bb. (1) by striking out “(except paragraph (6) thereof)” in the first sentence and inserting in lieu thereof “(except paragraphs (6) and (8) thereof)”, and (2) by striking out the second sentence and inserting in lieu thereof the following: “If such Commission, as a condition for accreditation of a hospital, (1) requires a utilization review plan as defined in section 1861 (k) or imposes another requirement 42 USC 1395x. which serves substantially the same purpose, or (2) requires institutional plans as defined in section 1861 (z) or imposes another Supra. requirement which serves substantially the same purpose, the Secretary is authorized to find that all institutions so accredited by the Commission comply also with section 1861(e) (6) or 1861(e) 42 USC 1395x. (8), as the case may be.” (i) The amendments made by this section shall apply with respect to any provider of services for fiscal years (of such provider) beginning after the fifth month following the month in which this Act is enacted. Sec. 235. payments to states under medicaid for installation and operation of claims processing and information retrieval systems (a) Section 1903(a) of the Social Security Act is amended by redesignating paragraph (3) as paragraph (4), and by inserting after paragraph (2) the following new paragraph: “(3) an amount equal to— “(A) (i) 90 per centum of so much of the sums expended during such quarter as are attributable to the design, development, or installation of such mechanized claims processing and information retrieval systems as the Secretary determines are likely to provide more efficient, economical, and effective administration of the plan and to be compatible with the claims processing and information retrieval systems utilized 42 USC 1395. in the administration of title XVIII, including the State’s share of the cost of installing such a system to be used jointly in the administration of such State’s plan and the plan of any other State approved under this title, and “(ii) 90 per centum of so much of the sums expended during any such quarter in the fiscal year ending June 30, 1972, or the fiscal year ending June 30, 1973, as are attributable to the design, development, or installation of cost determination systems for State-owned general hospitals (except that the total amount paid to all States under this clause for either such fiscal year shall not exceed $150,000), and “(B) 7a per centum of so much of the sums expended during such quarter as are attributable to the operation of systems (whether such systems are operated directly by the State or by another person under a contract with the State) of the type described in subparagraph (A)(i) (whether or not designed, developed, or installed with assistance under such subparagraph) which are approved by the Secretary and which include provision for prompt written notice to each individual who is furnished services covered by the plan of the specific services so covered, the name of the person or persons furnishing the services, the date or dates on which the services were furnished, and the amount of the payment or payments made under the plan on account of the services; plus”. (b) The amendments made by subsection (a) shall apply with respect to expenditures under State plans approved under title XIX 42 USC 1396. of the Social Security Act made after June 30, 1971. Sec. 236. prohibition against reassignment of claims to benefits (a) Section 1842(b) of the Social Security Act is amended by adding at the end thereof the following new paragraph: “(5) No payment under this part for a service provided to any 42 USC 1395gg. individual shall (except as provided in section 1870) be made to anyone other than such individual or (pursuant to an assignment described in subparagraph (B) (ii) of paragraph (3)) the physician Ante, p. 1384; Post, p. 1455. or other person who provided the service, except that payment may be made (A) to the employer of such physician or other person if such physician or other person is required as a condition of his employment to turn over his fee for such service to his employer, or (B) (where the service was provided in a hospital, clinic, or other facility) to the facility in which the service was provided if there is a contractual arrangement between such physician or other person and such facility under which such facility submits the bill for such service.” (b) Section 1902(a) of such Act is amended— 42 USC 1396a. (1) by striking out “and” at the end of paragraph (30); (2) by striking out the period at the end of paragraph (31) and inserting in lieu thereof “; and”; and (3) by inserting after paragraph (31) the following new paragraph: “(32) provide that no payment under the plan for any care or service provided to an individual by a physician, dentist, or other individual practitioner shall be made to anyone other than such individual or such physician, dentist, or practitioner, except that payment may be made (A) to the employer of such physician, dentist, or practitioner if such physician, dentist, or practitioner is required as a condition of his employment to turn over his fee for such care or service to his employer, or (B) (where the care or service was provided in a hospital, clinic, or other facility) to the facility in which the care or service was provided if there is a contractual arrangement between such physician, dentist, or practitioner and such facility under which such facility submits the bill for such care or service.” (c) The amendment made by subsection (a) shall apply with respect Effective dates. to bills submitted and requests for payments made after the date of the enactment of this Act. The amendments made by subsection (b) shall be effective January 1, 1973 (or earlier if the State plan so provides). Sec. 237. utilization review requirements for hospitals and skilled nursing homes under medicaid and under maternal and child health program (a) (1) Section 1903(i) of the Social Security Act (as added by section 224(c) and amended by sections 229(c) and 233(c) of this Act) is further amended by striking out the period at the end Ante, pp. 1395, 1410, 1411. of paragraph (3) and inserting in lieu thereof “; or”, and by adding after paragraph (3) the following new paragraph: “(4) with respect to any amount expended for care or services furnished under the plan by a hospital or skilled nursing home unless such hospital or skilled nursing home has in effect a utilization review plan which meets the requirements imposed by section 1861(k) for purposes of title XVIII; and if such hospital or 42 USC 1395x, 1395. skilled nursing home has in effect such a utilization review plan for purposes of title XVIII, such plan shall serve as the plan required by this subsection (with the same standards and procedures and the same review committee or group) as a condition of payment under this title; the Secretary is authorized to waive the requirements of this paragraph if the State agency demonstrates to his satisfaction that it has in operation utilization review procedures which are superior in their effectiveness to the procedures required under section 1861 (k).” (2) Section 1902(a) (30) of such Act is amended by inserting “(including but not limited to utilization review plans as provided for in section 1903(i) (4))” after “plan” where it, first, appears. (b) Section 506(f) of such Act (as added by section 224(d) and Ante, pp, 1395, 1410, 1412. amended by sections 229(d) and 233(d) of this Act) is further amended by striking out the period at the end of paragraph (3) and inserting in lieu thereof “; or”, and by adding after paragraph (3) the following new paragraph: “(4) with respect to any amount expended for services furnished under the plan by a hospital unless such hospital has in effect a utilization review plan which meets the requirement 42 USC 1395x, 1395. imposed by section 1861 (k) for purposes of title XVIII; and if such hospital has in effect such a utilization review plan for purposes of title XVIII, such plan shall serve as the plan required by this subsection (with the same standards and procedures and the same review committee or group) as a condition of payment under this title; the Secretary is authorized to waive the requirements of this paragraph in any State if the State agency demonstrates to his satisfaction that it has in operation utilization review procedures which are superior in their effectiveness to the procedures required under section 1861 (k).” (c) Section 1861 (k) of such Act is amended by adding at the end thereof the following new sentence: “If the Secretary determines that 42 USC 1396. the utilization review procedures established pursuant to title XIX are superior in their effectiveness to the procedures required under this section, he may, to the extent that he deems it appropriate, require for purposes of this title that the procedures established pursuant to title XIX be utilized instead of the procedures required by this section.” (d) (1) The amendments made by subsections (a) (1) and (b) shall apply with respect to services furnished in calendar quarters beginning after June 30, 1973. (2) The amendment made by subsection (a)(2) shall be effective July 1, 1973. Sec. 238. notification of unnecessary admission to a hospital or extended care facility under medicare (a) Section 1814(a) (7) of the Social Security Act is amended by striking out “as described in section 1861 (k) (4)” and inserting in lieu thereof “as described in section 1861 (k) (4), including any finding made in the course of a sample or other review of admissions to the institution”. (b) The amendment made by subsection (a) shall apply with respect to services furnished after the second month following the month in which this Act is enacted. Sec. 239. use of state health agency to perform certain functions under medicaid and under maternal and child health program (a) Section 1902(a)(9) of the Social Security Act is amended to read as follows: “(9) provide— “(A) that the State health agency, or other appropriate State medical agency (whichever is utilized by the Secretary for the purpose specified in the first, sentence of section 1864 42 USC 1395aa. (a)), shall be responsible for establishing and maintaining health standards for private or public institutions in which recipients of medical assistance under the plan may receive care or services, and “(B) for the establishment or designation of a State authority or authorities which shall be responsible for establishing and maintaining standards, other than those relating to health, for such institutions;”. (b) Section 1900(a) of such Act (as amended by section 236(b) of this Act) is further amended— Ante, p. 1415. (1) 1) by striking out “and” at the end of paragraph (31); (2) by striking out the period at the end of paragraph (32) and inserting in lieu thereof “; and”; and (3) by inserting after paragraph (32) the following new paragraph: “(33) provide— “(A) that the State health agency, or other appropriate State medical agency, shall be responsible for establishing a plan, consistent with regulations prescribed by the Secretary, or the review by appropriate, professional health personnel of the appropriateness and quality of care and services furnished to recipients of medical assistance under the plan in order to provide guidance with respect thereto in the administration of the plan to the State agency established or designated pursuant to paragraph (5) and, where applicable, to the State agency described in the last sentence of this subsection; and “(B) that the State or local agency utilized by the Secretary for the purpose specified in the first sentence of section 1864(a), or, if such agency is not the State agency which is 42 USC 1395aa. responsible for licensing health institutions, the State agency responsible for such licensing, will perform for the State agency administering or supervising the administration of the plan approved under this title the function of determining whether institutions and agencies meet the requirements for participation in the program under such plan,” (c) Section 505 (a) of such Act is amended— 81 Stat. 923. 42 USC 705. (1) by striking out “and” at the end of paragraph (13); (2) by striking out the period at the end of paragraph (14) and inserting in lieu thereof “; and”: and (3) by adding after paragraph (14) the following new paragraph: “(15) provides— “(A) that the State health agency, or other appropriate State medical agency, shall be responsible for establishing a plan, consistent with regulations prescribed by the Secretary, for the review by appropriate professional health personnel of the appropriateness and quality of care and services furnished to recipients of services under the plan and, where applicable, for providing guidance, with respect thereto to the other State agency referred to in paragraph (2); and “(B) that the State or local agency utilized by the Secretary for the purpose specified in the first sentence of section 1864(a), or, if such agency is not the State agency which is 42 USC 1395aa. responsible for licensing health institutions, the State agency responsible for such licensing, will perform the function of determining whether institutions and agencies meet the requirements for participation in the program under the plan under this title.” (d) The amendments made by this section shall be effective January 1, 1973 (or earlier if the State plan so provides). Sec. 240. relationship between medicaid and comprehensive health care programs Section 1902(a) (23) of the Social Security Act is amended by adding after the semicolon at the end thereof the following: “and a State plan shall not be deemed to be out of compliance with the requirements of this paragraph or paragraph (1) or (10) solely by reason of the fact that the State (or any political subdivision thereof) has entered into a contract with an organization which has agreed to provide care and services in addition to those offered under the State plan to individuals eligible for medical assistance who reside in the geographic area served by such organization and who elect to obtain such care and services from such organization;”. Sec. 241. program for determining qualifications for certain health care personnel Title XI of the Social Security Act is amended by adding Ante, p. 1386. after section 1122 (as added by section 221(a) of this Act) the following new section: “Sec. 1123. “program for determining qualifications for certain health care personnel (a) The Secretary, in carrying out his functions relating 42 USC 1395. to the qualifications for health care personnel under title XVIII, shall develop (in consultation with appropriate professional health organizations and State health and licensure agencies) and conduct (in conjunction with State health and licensure agencies) until December 31, 1977, a program designed to determine the proficiency of individuals (who do not otherwise meet the formal educational, professional membership, or other specific criteria established for determining the qualifications of practical nurses, therapists, laboratory technicians, and technologists, and cytotechnologists, X-ray technicians, psychiatric technicians, or other health care technicians and technologists) to perform the duties and functions of practical nurses, therapists, laboratory technicians, technologists, and cytotechnologists, X-ray technicians, psychiatric technicians, or other health care technicians and technologists. Such program shall include (but not be limited to) the employment of procedures for the formal testing of the proficiency of individuals. In the conduct of such program, no individual who otherwise meets the proficiency requirements for any health care specialty shall be denied a satisfactory proficiency rating solely because of his failure to meet formal educational or professional membership requirements. “(b) If any individual has been determined, under the program established pursuant to subsection (a), to be qualified to perform the duties and functions of any health care specialty, no person or provider utilizing the services of such individual to perform such duties and functions shall be denied payment, under title XVIII or under 42 USC 1396. any State plan approved under title XIX, for any health care services provided by such person on the grounds that such individual is not qualified to perform such duties and functions.” Sec. 242. penalties for fraudulent acts and false reporting under medicare and medicaid (a) Section 1872 of the Social Security Act is amended 42 USC 1395ii. by striking out “208,”. (b) Title XVIII of the Social Security Act is amended by adding at the end thereof Rafter the new section added by section 226(a) of this Act) the following new section: Ante, p. 1396. “Sec. 1877. “penalties (a) Whoever— “(1) knowingly and willfully makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under this title, “(2) at any time knowingly and willfully makes or causes to be made any false statement or representation of a material fact for use in determining rights to any such benefit or payment, “(3) having knowledge of the occurrence of any event affecting (A) his initial or continued right to any such benefit or payment, or (B) the initial or continued right to any such benefit or payment of any other individual in whose behalf he has applied for or is receiving such benefit or payment, conceals or fails to disclose such event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized, or “(4) having made application to receive any such benefit or payment for the use and benefit of another and having received it, knowingly and willfully converts such benefit or payment or any part thereof to a use other than for the use and benefit of such other person, shall be guilty of a misdemeanor and upon conviction thereof shall be fined not more than $10,000 or imprisoned for not more than one year, or both. “(b) Whoever furnishes items or services to an individual for which payment is or may be made under this title and who solicits, offers, or receives any— “(1) kickback or bribe in connection with the furnishing of such items or services or the making or receipt of such payment, or “(2) rebate of any fee or charge for referring any such individual to another person for the furnishing of such items or services, shall be guilty of a misdemeanor and upon conviction thereof shall be fined not more than $10,000 or imprisoned for not more than one year, or both. “(c) Whoever knowingly and willfully makes or causes to be made, or induces or seeks to induce the making of, any false statement or representation of a material fact with respect to the conditions or operation of any institution or facility in order that such institution or facility may qualify (either upon initial certification or upon recertification) as a hospital, skilled nursing facility, or home health agency (as those terms are defined in section 1861), shall be guilty of a misdemeanor 42 USC 1395x. and upon conviction thereof shall be fined not more than $2,000 or imprisoned for not more than 6 months, or both.” (c) Title XIX of such Act is amended by adding after section 1908 42 USC 1396. the following new section: “Sec. 1909. “penalties (a) Whoever— “(1) knowingly and willfully makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under a State plan approved under this title, “(2) at any time knowingly and willfully makes or causes to be made any false statement or representation of a material fact for use in determining rights to such benefit or payment, “(3) having knowledge of the occurrence of any event affecting (A) his initial or continued right to any such benefit or payment, or (B) the initial or continued right to any such benefit or payment of any other individual in whose, behalf he has applied for or is receiving such benefit or payment, conceals or fails to disclose such event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized, or “(4) having made application to receive any such benefit or payment for the use and benefit of another and having received it, knowingly and willfully converts such benefit or payment or any part thereof to a use other than for the use and benefit of such other person, shall be guilty of a misdemeanor and upon conviction thereof shall be fined not more than $10,000 or imprisoned for not more than one year, or both. “(b) Whoever furnishes items or services to an individual for which payment is or may be made in whole or in part out of Federal funds under a State plan approved under this title and who solicits, offers, or receives any— “(1) kickback or bribe in connection with the furnishing of such items or services or the making or receipt of such payment, or “(2) rebate of any fee or charge for referring any such individual to another person for the furnishing of such items or services shall be guilty of a misdemeanor and upon conviction thereof shall be fined not more than $10,000 or imprisoned for not more than one year, or both. “(c) Whoever knowingly and willfully makes or causes to be made,, or induces or seeks to induce the making of, any false statement or representation of a material fact with respect to the conditions or operation of any institution or facility in order that such institution or facility may qualify (either upon initial certification or upon recertification) as a hospital, skilled nursing home, intermediate care facility, or home health agency (as those terms are employed in this title) shall be guilty of a misdemeanor and upon conviction thereof shall be fined not more than $2,000 or imprisoned for not more than 6 months, or both.” (d) The provisions of amendments made by this section shall not be applicable to any acts, statements, or representations made or committed prior to the enactment of this Act. Sec. 243. provider reimbursement review board (a) Title XVIII of the Social Security Act is amended by adding at the end thereof (after the new sections added by section Ante, p. 1419. 226(a) and section 242 (b) of this Act) the following new section: “Sec. 1878. “provider reimbursement review board (a) Any provider of services which has filed a required Establishment. cost report within the time specified in regulations may obtain a hearing with respect, to such cost report by a Provider Reimbursement Review Board (hereinafter referred to as the ‘Board’) which shall be established by the Secretary in accordance with subsection (h), if— Conditions. “(1) such provider— “(A) is dissatisfied with a final determination of the organization serving as its fiscal intermediary pursuant to section 1816 as to the amount of total program reimbursement 42 USC 1395h. due the provider for the items and services furnished to individuals for which payment may be made under this title for the period covered by such report, “(B) has not received such final determination from such intermediary on a timely basis after filing such report., where such report complied with the rules and regulations of the Secretary relating to such report, or “(C) has not received such final determination on a timely basis after filing a supplementary cost report, where such cost report did not so comply and such supplementary cost report did so comply, “(2) the amount in controversy is $10,000 or more, and “(3) such provider files a request for a hearing within 180 days after notice of the intermediary’s final determination under paragraph (1) (A) or with respect to appeals pursuant to paragraph (1) (B) or (C), within 180 days after notice of such determination would have been received if such determination had been made on a timely basis. “(b) The provisions of subsection (a) shall apply to any group of Group appeal. providers of services if each provider of services in such group would, upon the filing of an appeal (but without regard to the $10,000 limitation), be entitled to such a hearing, but only if the matters in controversy involve a common question of fact or interpretation of law or regulations and the amount in controversy is, in the aggregate, $50,000 or more. “(c) At such hearing, the provider of services shall have the right to be represented by counsel, to introduce evidence, and to examine and cross-examine witnesses. Evidence may be received at any such hearing even though inadmissable under rules of evidence applicable to court procedure. “(d) A decision by the Board shall be based upon the record made at such hearing, which shall include the evidence considered by the intermediary and such other evidence as may be obtained or received by the Board, and shall be supported by substantial evidence when the record is viewed as a whole. The Board shall have the power to affirm, modify, or reverse a final determination of the fiscal intermediary with respect to a cost report and to make any other revisions on matters covered by such cost report, (including revisions adverse to the provider of services) even though such matters were not considered by the intermediary in making such final determination. “(e) The Board shall have full power and authority to make rules Rules and regulations. and establish procedures, not inconsistent with the provisions of this title or regulations of the Secretary, which are necessary or appropriate to carry out the provisions of this section. In the course of any hearing the Board may administer oaths and affirmations. The provisions of subsections (d), (e), and (f) of section 205 with respect to subpenas 42 USC 405. shall apply to the Board to the same extent as they apply to the Secretary 42 USC 401. Board decision, reviewability. with respect to title II. “(f) A decision of the Board shall be final unless the Secretary, on his own motion, and within 60 days after the provider of services is notified of the Board’s decision, reverses or modifies (adversely to such provider) the Board’s decision. In any case where such a reversal or modification occurs the provider of services may obtain a review of such decision by a civil action commenced within 60 days of the date he is notified of the Secretary’s reversal or modification. Such action shall be, brought in the district court of the United States for the judicial district in which the provider is located or in the District Court for the District of Columbia and shall be tried pursuant to the applicable 5 USC 701. provisions under chapter 7 of title 5, United States Code, notwithstanding 42 USC 405. any other provisions in section 205. “(g) The finding of a fiscal intermediary that no payment may be made under this title for any expenses incurred for items or services furnished to an individual because such items or services are listed in 42 USC 1395y. section 1862 shall not be reviewed by the Board, or by any court pursuant to an action brought under subsection (f). “(h) The Board shall be composed of five members appointed by the Secretary without regard to the provisions of title 5, United States 5 USC 101 et seq. Code, governing appointments in the competitive services. Two of such members shall be representative of providers of services. All of the members of the Board shall be persons knowledgeable in the field of cost reimbursement, and at least one of them shall be a certified Compensation. public accountant. Members of the Board shall be entitled to receive compensation at rates fixed by the Secretary, but not exceeding the rate specified (at the time the service involved is rendered by such members) for grade GS–18 in section 5332 of title 5, United States 5 USC 5332 note. Code. The term of office shall be three years, except that the Secretary shall appoint the initial members of the Board for shorter terms to the extent necessary to permit staggered terms of office. “(i) The Board is authorized to engage such technical assistance as may be required to carry out its functions, and the Secretary shall, in addition, make available to the Board such secretarial, clerical, and other assistance as the Board may require to carry out its functions.” (b) The first sentence of section 1816(a) of such Act is amended by striking out “subject to” in the parenthetical phrase and inserting in lieu thereof “subject to the provisions of section 1878 and to”. (c) The amendments made by this section shall apply with respect to cost reports of providers of services, as defined in title XVIII of 42 USC 1395. the Social Security Act, for accounting periods ending on or after June 30, 1973. Sec. 244. validation of surveys made by joint commission on the accreditation of hospitals (a) Section 1864 of the Social Security Act is amended by inserting at the end thereof the following new subsection: “(c) The Secretary is authorized to enter into an agreement with any State under which the appropriate State or local agency which performs the certification function described in subsection (a) will survey, on a selective sample basis (or where the Secretary finds that a survey is appropriate because of substantial allegations of the existence of a significant deficiency or deficiencies which would, if found to be present, adversely affect health and safety of patients), hospitals 42 USC 1395cc. which have an agreement with the Secretary under section 1866 and which are accredited by the Joint Commission on the Accreditation of Hospitals. The Secretary shall pay for such services in the manner prescribed in subsection (b).” (b) (1) Section 1865 of such Act, as amended by section 234 of this Act, is further amended by striking out “Sec. 1865” and the first two Ante, p. 1413. sentences of such section and inserting in lieu thereof the following: “Sec. 1865. (a) Except as provided in subsection (b) and the second sentence of section 1863, if— 42 USC 1395z. “(1) an institution is accredited as a hospital by the Joint Commission on Accreditation of Hospitals, and “(2) such institution (if it is included within a survey described in section 1864 (c)) authorizes the Commission to release to the Ante, p. 1422. Secretary (on a confidential basis) upon his request (or such State agency as the Secretary may designate) a copy of the most current accreditation survey of such institution made by such Commission, then, such institution shall be deemed to meet the requirements of the numbered paragraphs of section 1861 (e); except— 42 USC 1395x. “(3) paragraph (6) thereof, and “(4) any standard, promulgated by the Secretary pursuant to paragraph (9) thereof, which is higher than the requirements prescribed for accreditation by such Commission. If such Commission, as a condition for accreditation of a hospital, requires a utilization review plan (or imposes another requirement which serves substantially the same purpose) or imposes a standard which the Secretary determines is at least equivalent to the standard promulgated by the Secretary as described in paragraph (4) of this subsection, the Secretary is authorized to find that all institutions so accredited by such Commission comply also with section 1861(e) (6) or the standard described in such paragraph (4), as the case may be.” (2) Such section 1865 (as so amended) is further amended by adding after subsection (a) thereof the following: “(b) Notwithstanding any other provision of this title, if the Secretary finds following a survey made pursuant to section 1864(c) that Ante, p. 1422. an institution has significant, deficiencies (as defined in regulations pertaining to health and safety), such institution shall, after the date of notice of such finding to the hospital and for such period as may be prescribed In regulations, be deemed not to meet the requirements of the numbered paragraphs of section 1861(e).” (c) Section 1861(e) of such Act, as amended by sections 211 and 234 of this Act, is further amended by striking out, in subsection (9), Ante, pp. 1383, 1412. everything after the word “institution” and inserting in lieu thereof a period. (d) Section 1875(b) of such Act, as amended by sections 222 and 226 of this Act, is further amended by inserting, after “including” and Ante, pp. 1393, 1404. before “the operation”, the following: “a validation of the accreditation process of the Joint Commission on the Accreditation of Hospitals,”. Sec. 245. payment for durable medical equipment under medicare (a) The Secretary is authorized to conduct reimbursement experiments designed to eliminate unreasonable expenses resulting from prolonged rentals of durable medical equipment described in section 1861(s) (6) of the Social Security Act. 42 USC 1395x. (b) Such experiment may be conducted in one or more geographic areas, as the Secretary deems appropriate, and may, pursuant to agreements with suppliers, provide for reimbursement for such equipment on a lump-sum basis whenever it is determined (in accordance with guidelines established by the Secretary) that a lump-sum payment would be more economical than the anticipated period of rental payments. Such experiments may also provide for incentives to beneficiaries (including waiver of the 20 percent coinsurance amount 79 Stat. 302. 42 USC 1395l. applicable under section 1833 of the Social Security Act) to purchase used equipment whenever the purchase price is at least 25 percent less than the reasonable charge for new equipment. (c) The Secretary is authorized, at such time as he deems appropriate, to implement on a nationwide basis any such reimbursement procedures winch he finds to be workable, desirable and economical and which are consistent with the purposes of this section. (d) Section 1833(f) of the Social Security Act is amended— (1) by striking out “with respect to purchases of inexpensive equipment (as determined by the Secretary)” and inserting in lieu thereof “(A)”, and (2) by inserting before the period at the end thereof the following: “, and (B) with respect to purchases of used equipment the Secretary is authorized to waive the 20 percent coinsurance amount applicable under subsection (a) whenever the purchase price of such equipment is at least 25 percent less than the reasonable charge for comparable new equipment.” (3) by inserting “(1)” after “(f)” and by adding after paragraph (1) the following new paragraph: “(2) In the case of rental of durable medical equipment, the Secretary may, pursuant to agreements made with suppliers of such equipment, establish any reimbursement procedures (including payment on a lump-sum basis in lieu of prolonged rental payments) which he finds to be equitable, economical, and feasible.” Sec. 246. uniform standards for skilled nursing facilities under medicare and medicaid (a) Section 1902(a) (28) of the Social Security Act is amended to read as follows: “(28) provide that any skilled nursing facility receiving payments under such plan must satisfy all of the requirements contained in section 1861(f), except, that the exclusion contained therein with respect to institutions which are primarily for the care and treatment of mental diseases and tuberculosis shall not apply for purposes of this title;” (b) Section 1861(j) of such Act, as amended by section 234(d) of Ante, p. 1412. this Act, is further amended— (1) by striking out “and” at the end of paragraph (10); (2) by redesignating paragraph (11) as paragraph (15); (3) by inserting after paragraph (10) the following new paragraphs: “(11) supplies full and complete information to the Secretary or his delegate as to the identity (A) of each person who has any direct or indirect ownership interest of 10 per centum or more in such skilled nursing facility or who is the owner (in whole or in part) of any mortgage, deed of trust, note, or other obligation secured (in whole or in part) by such skilled nursing facility or any of the property or assets of such skilled nursing facility, (B) in case a skilled nursing facility is organized as a corporation, of each officer and director of the corporation, and (C) in case a skilled nursing facility is organized as a partnership, of each partner; and promptly reports any changes which would affect the current accuracy of the information so required to be supplied; “(12) cooperates in an effective program which provides for a regular program of independent medical evaluation and audit of the patients in the facility to the extent required by the programs in which the facility participates (including medical evaluation of each patient’s need for skilled nursing facility care); “(13) meets such provisions of the Life Safety Code of the National Fire Protection Association (21st edition, 1967) as are applicable to nursing homes; except that the Secretary may waive, for such periods as he deems appropriate, specific provisions of such Code which if rigidly applied would result in unreasonable hardship upon a nursing home, but only if such waiver will not adversely affect the health and safety or the patients; except that the provisions of such Code shall not apply in any State if the Secretary finds that in such State there is in effect a fire and safety code, imposed by State law, which adequately protects patients in nursing facilities; and” and (4) by adding at the end of paragraph (15) (as redesignated by paragraph (2) of this subsection) the following new sentence: “Notwithstanding any other provision of law, all information concerning skilled nursing facilities required by this subsection to be filed with the Secretary shall be made available to Federal or State employees for purposes consistent with the effective administration of programs established under titles XVIII and XIX of this Act.” 42 USC 1395, 1396. Effective date. (c) The amendments made by this section shall be effective July 1, 1973. Sec. 247. level of care requirements for skilled nursing home services (a) Section 1814(a)(2)(C) of the Social Security Act 42 USC 1395f. is amended by striking out everything which appears before “(or services” and inserting in lieu thereof the following: “(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”. (b) Section 1905 of the Social Security Act. as amended by section 212 of this Act, is further amended by adding at the end thereof the Ante, p. 1384. following new subsection: “(f) For purposes of this title, the term ‘skilled nursing facility “Skilled nursing facility services.” services’ means services which are or were required to be given an individual who 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.” (c) The amendments made by this section shall be effective with Effective date. respect to services furnished after December 31, 1972. Sec. 248. modification of medicare’s 14-day transfer requirement for extended care benefits Section 1861 (i) of the Social Security Act is amended 42 USC 1395x. by striking out “within 14 days after discharge from such hospital;” and inserting in lieu thereof the following: “(A) within 14 days after discharge from such hospital, or (B) within 28 days after such discharge, in the case of an individual who was unable to be admitted to a skilled nursing facility within such 14 days because of a shortage of appropriate bed space in the geographic area in which he resides, or (C) within such time as it would be medically appropriate to begin an active course of treatment, in the case of an individual whose condition is such that skilled nursing facility care would not be medically appropriate within 14 days after discharge from a hospital;” Sec. 249. reimbursement rates for skilled nursing and intermediate cake facilities (a) Section 1902(a) (13) of the Social Security Act, as Ante, p. 1410. amended by section 221 (c) (5) of this Act, is further amended— (1) by inserting “and” at the end of subparagraph (D), and (2) by inserting after subparagraph (I)) the following new paragraph: “(E) effective July 1, 1976, for payment of the skilled nursing facility and intermediate care facility services provided under the plan on a reasonable cost related basis, as determined in accordance with methods and standards which shall be developed by the State on the basis of cost-finding methods approved and verified by the Secretary;”. (b) Section 1861 (v)(1) of such Act, as amended by sections 223 Ante, p. 1405. and 227 of this Act, is further amended by inserting after subparagraph (D) the following new subparagraph: “(E) Such regulations may, in the case of skilled nursing facilities in any State, provide for the uses of rates, developed by the State in which such facilities are located, for the payment of the cost of skilled nursing facility services furnished under the State’s plan approved 42 USC 1396. under title XIX (and such rates may be increased by the Secretary on a class or size of institution or on a geographical basis by a percentage factor not in excess of 10 percent to take into account determinable items or services or other requirements under this title not otherwise included in the computation of such State rates), if the Secretary finds that such rates are reasonably related to (but not necessarily limited to) analyses undertaken by such State of costs of care in comparable facilities in such State; except that the foregoing provisions of this subparagraph shall not apply to any skilled nursing facility in such State if— “(i) such facility is a distinct part of or directly operated by a hospital, or “(ii) such facility operates in a close, formal satellite relationship (as defined in regulations of the Secretary) with a participating hospital or hospitals. Notwithstanding the previous provisions of this paragraph in the case of a facility specified in clause (ii) of this subparagraph, the reasonable cost of any services furnished by such facility as determined by the Secretary under this subsection shall not exceed 150 percent of the costs determined by the application of this subparagraph (without regard to such clause (ii)).”. Sec. 249A. medicaid certification and approval of skilled nursing facilities (a) Title XIX of the Social Security Act is amended by adding at the end thereof (after the new section 1909 added by Ante, p. 1420. this Act) the following new section: “Sec. 1910. “certification and approval of skilled nursing facilities (a) Whenever the Secretary certifies an institution in a State to be qualified as a skilled nursing facility under title XVIII, 41 USC 1395. such institution shall be deemed to meet the standards for certification as a skilled nursing facility for purposes of section 1902(a) (28). Ante, p. 1424. “(b) The Secretary shall notify the State agency administering the Notification. medical assistance plan of his approval or disapproval of any institution which has applied for certification by him as a qualified skilled nursing facility.” (b) Section 1866(a) (1) of the Social Security Act is amended by 42 USC 1395cc. adding at the end thereof the following sentence: “An agreement under tills paragraph with an extended care facility shall be for a term of not exceeding 12 months, except that the Secretary may extend such term for a period not exceeding 2 months, where the health and safety of patients will not be jeopardized thereby, if he finds that such extension is necessary to prevent irreparable harm to such facility or hardship to the individuals being furnished items or services by such facility or if he finds it impracticable within such 12-month period to determine whether such facility is complying with the provisions of this title and regulations thereunder.” (c) Section 1866(b) of such Act is amended by— (1) striking out, in the material which precedes clause (1), “terminated-” and inserting in lieu thereof “terminated (and in the case of an extended care facility, prior to the end of the term specified in subsection (a)(1))-”; and (2) by striking out all of clause (3) appearing after the phrase “Any termination shall be applicable—” and inserting in lieu thereof the following: “(3) in the case of inpatient hospital services (including tuberculosis hospital services and inpatient psychiatric hospital services) or post-hospital extended care services, with respect to services furnished after the effective date of such termination, except that payment may be made for up to thirty days with respect to inpatient institutional services furnished to any eligible individual who was admitted to such institution prior to the effective date of such termination,”. (d) Section 1866(c) of such Act is amended by inserting “(1)” after “(c)” and by adding at the end thereof the following new paragraph: “(2) In the case of a skilled nursing facility participating in the programs established by this title and title XIX, the Secretary may 42 USC 1395, 1396. enter into an agreement under this section only if such facility has been approved pursuant to section 1910, and the term of any such agreement shall be in accordance with the period of approval of eligibility specified by the Secretary pursuant to such section.” (e) The provisions of this section shall be effective with respect to Effective date. agreements filed with the Secretary under section 1866 of the Social Security Act by skilled nursing facilities (as defined in section 1861 (j) of such Act) before, on, or after the date of enactment of this Act, 42 USC 1395x. but accepted by him on or after such date. (f) Notwithstanding any other provision of law, any agreement, Termination date. filed by a skilled nursing facility (as defined in section 1861 (j) of the Social Security Act) with the Secretary under section 1866 of such Act and accepted by him prior to the date of enactment of this Act, which was in effect on such date shall be deemed to be for a specified term ending on December 31, 1973. Sec. 249B. payments to states under medicaid for compensation of inspectors responsible for maintaining compliance with federal standards Section 1903(a) of the Social Security Act, as amended Ante, pp. 1380, 1414. Effective period. by sections 207(a)(2) and 235(a) of this Act, is further amended, effective for the period beginning October 1, 1972, and ending June 30, 1974, by redesignating paragraph (4) as paragraph (5), and by inserting after paragraph (3) the following new paragraph: “(4) an amount equal to 100 per centum of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) which are attributable to compensation or training of personnel (of the State agency or any other public agency) responsible for inspecting public or private institutions (or portions thereof) providing long-term care to recipients of medical assistance to determine whether such institutions comply with health or safety standards applicable to such institutions under this Act; plus”. Sec. 249C. disclosure of information concerning the performance of carriers, intermediaries, state agencies, and providers of services under medicare and medicaid (a) Section 1106 of the Social Security Act is amended by adding at the end thereof the following new subsections: “(d) Notwithstanding any other provision of this section the Secretary shall make available to each State agency operating a program 42 USC 1396. under title XIX and shall, subject to the limitations contained in subsection (e), make available for public inspection in readily accessible form and fashion, the following official reports (not including, however, references to any internal tolerance rules and practices that may be contained therein, internal working papers or other informal memoranda) dealing with the operation of the health programs established 42 USC 1395, 1396. by titles XVIII and XIX— “(1) individual contractor performance reviews and other formal evaluations of the performance of carriers, intermediaries, and State agencies, including the reports of follow-up reviews; “(2) comparative evaluations of the performance of such contractors, including comparisons of either overall performance or of any particular aspect of contractor operation; and “(3) program validation survey reports and other formal evaluations of the performance of providers of services, including the reports of follow-up reviews, except that such reports shall not identify individual patients, individual health care practitioners, or other individuals. “(e) No report described in subsection (d) shall be made public by the Secretary or the State title XIX agency until the contractor or provider of services whose performance is being evaluated has had a reasonable opportunity (not exceeding 60 days) to review such report and to offer comments pertinent parts of which may be incorporated in the public report; nor shall the Secretary be required to include in any such report information with respect to any deficiency (or improper practice or procedures) which is known by the Secretary to have been fully corrected, within 60 days of the date such deficiency was first brought to the attention of such contractor or provider of services, as the case may be.” (b) The provisions of subsection (a) shall apply with respect to reports which are completed by the Secretary after the third calendar month following the enactment of this Act. Sec. 249D. limitation on institutional care Section 121(b) of the Social Security Amendments of 1965 is amended by adding at the end thereof the following new 79 Stat. 352. 42 USC 1396b note. sentence: “After the date of enactment of the Social Security Amendments of 1972, Federal matching shall not be available for any portion of any payment by any State under title I, X, XIV, or XVI, or part A of title IV, of the Social Security Act, for or on account 42 USC 301, 1201, 1351, 1381, 601. of any medical or any other type of remedial care provided by an institution to any individual as an inpatient thereof, in the case of any State which has a plan approved under title XIX of such Act, 42 USC 1396. if such care is (or could be) provided under a State plan approved under title XIX of such Act by an institution certified under such title XIX.”. Sec. 249E. determining eligibility for assistance under title xix for certain individuals For purposes of section 1902(a) (10) of the Social Security Act any individual who, for the month of August 1972, was eligible for or receiving aid or assistance under a State plan approved under title I, X, XIV, or XVI, or part A of title IV of such Act and who for such month was entitled to monthly insurance benefits under title II of such Act shall be deemed to be eligible for such aid or assistance for any month thereafter prior to October 1974 if such individual would have been eligible for such aid or assistance for such month had the increase in monthly insurance benefits under title II of such Act resulting from enactment of Public Law 92–336 not been applicable to such individual. Sec. 249F. professional standards review (a) The heading to title XI of the Social Security Act is amended by striking out “TITLE XI— GENERAL PROVISIONS” and inserting in lieu thereof “TITLE XI— GENERAL PROVISIONS AND PROFESSIONAL STANDARDS REVIEW “Part A— General Provisions” (b) Title XI of such Act is further amended by adding the following: “Part B— Professional Standards Review “Sec. 1151. “declaration of purpose In order to promote the effective, efficient, and economical delivery of health care services of proper quality for which payment may be made (in whole or in part) under this Act and in recognition of the interests of patients, the public, practitioners, and providers in improved health care services, it is the purpose of this part to assure, through the application of suitable procedures of professional standards review, that the services for which payment may be made under the Social Security Act will conform to appropriate professional standards for the provision of health care and that payment for such services will be made— “(1) only when, and to the extent, medically necessary, as determined in the exercise of reasonable limits of professional discretion; and “(2) in the case of services provided by a hospital or other health care facility on an inpatient basis, only when and for such period as such services cannot, consistent with professionally recognized health care standards, effectively be provided on an outpatient basis or more economically in an inpatient health care facility of a different type, as determined in the exercise of reasonable limits of professional discretion. “Sec. 1152. “designation of professional standards review organizations (a) The Secretary shall (1) not later than January 1, 1974, establish throughout the United States appropriate areas with respect to which Professional Standards Review Organizations may be designated, and (2) at the earliest practicable date after designation of an area enter into an agreement with a qualified organization whereby such an organization shall be conditionally designated as the Professional Standards Review Organization for such area. If, on the basis of its performance during such period of conditional designation, the Secretary determines that such organization is capable of fulfilling, in a satisfactory manner, the obligations and requirements for a Professional Standards Review Organization under this part, he shall enter into an agreement with such organization designating it as the Professional Standards Review Organization for such area. “(b) For purposes of subsection (a), the term ‘qualified organization’ means— “(1) when used in connection with any area— “(A) an organization (i) which is a nonprofit professional association (or a component organization thereof), (ii) which is composed of licensed doctors of medicine or osteopathy engaged in the practice of medicine or surgery in such area, (iii) the membership of which, includes a substantial proportion of all such physicians in such area, (iv) which is organized in a manner which makes available professional competence to review health care services of the types and kinds with respect to which Professional Standards Review Organizations have review responsibilities under this part, (v) the membership of which is voluntary and open to all doctors of medicine or osteopathy licensed to engage in the practice of medicine or surgery in such area without requirement of membership in or payment of dues to any organized medical society or association, and (vi) which does not restrict the eligibility of any member for service as an officer of the Professional Standards Review Organization or eligibility for and assignment to duties of such Professional Standards Review Organization, or. subject to subsection (c) (i), “(B) such other public, nonprofit private, or other agency or organization, which the Secretary determines, in accordance with criteria prescribed by him in regulations, to be of professional competence and otherwise suitable; and “(2) an organization which the Secretary, on the basis of his examination and evaluation of a formal plan submitted to him by the association, agency, or organization (as well as on the basis of other relevant data and information), finds to be willing to perform and capable of performing, in an effective, timely, and objective manner and at reasonable cost, the duties, functions, and activities of a Professional Standards Review Organization required by or pursuant to this part. “(c) (1) The Secretary shall not enter into any agreement under this part under which there is designated as the Professional Standards Review Organization for any area any organization other than an organization referred to in subsection (b) (1) (A) prior to January 1, 1976, nor after such date, unless, in such area, there is no organization referred to in subsection (b) (1) (A) which meets the conditions specified in subsection (b)(2). “(2) Whenever the Secretary shall have entered into an agreement under this part under which there is designated as the Professional Standards Review Organization for any area any organization other than an organization referred to in subsection (b) (1) (A), he shall not renew such agreements with such organization if he determines that— “(A) there is in such area an organization referred to in subsection (b)(1) (A) which (i) has not been previously designated as a Professional Standards Review Organization, and (ii) is willing to enter into an agreement under this part under which such organization would be designated as the Professional Standards Review Organization for such area; “(B) such organization meets the conditions specified in subsection (b)(2); and “(C) the designation of such organization as the Professional Standards Review Organization for such area is anticipated to result in substantial improvement in the performance in such area of the duties and functions required of such organizations under this part. “(d) Any such agreement under this part with an organization Agreement expiration; prior termination. Post, p. 1432. (other than an agreement established pursuant to section 1154) shall be for a term of 12 months; except that, prior to the expiration of such term such agreement may be terminated— “(1) by the organization at such time and upon such notice to the Secretary as may be prescribed in regulations (except that notice of more than 3 months may not be required); or “(2) ‘by the Secretary at such time and upon such reasonable notice to the organization as may be prescribed in regulations, but only after the Secretary has determined (after providing such organization with an opportunity for a formal hearing on the matter) that such organization is not substantially complying with or effectively carrying out the provisions of such agreement. “(e) In order to avoid duplication of functions and unnecessary Waiver. review and control activities, the Secretary is authorized to waive any or all of the review, certification, or similar activities otherwise required under or pursuant to any provision of this Act (other than this part) where he finds, on the basis of substantial evidence of the effective performance of review and control activities by Professional Standards Review Organizations, that the review, certification, and similar activities otherwise so required are not needed for the provision of adequate review and control. “(f) (1) In the case of agreements entered into prior to January 1, Agreement notice. 1976, under this part, under which any organization is designated as the Professional Standards Review Organization for any area, the Secretary shall, prior to entering into any such agreement with any organization for any area, inform (under regulations of the Secretary) the doctors of medicine or osteopathy who are in active practice in such area of the Secretary’s intention to enter into such an agreement with such organization. “(2) If, within a reasonable period of time following the serving of such notice, more than 10 per centum of such doctors object to the Secretary’s entering into such an agreement with such organization on the ground that such organization is not representative of doctors in such area, the Secretary shall conduct a poll of such doctors to determine whether or not such organization is representative of such doctors in such area. If more than 50 per centum of the doctors responding to such poll indicate that such organization is not representative of such doctors in such area the Secretary shall not enter into such an agreement with such organization. “Sec. 1153. “review pending designation of professional standards review organization Pending the assumption by a Professional Standards Review Organization for any area, of full review responsibility, and pending a demonstration of capacity for improved review effort with respect to matters involving the provision of health care services in such area for which payment (in whole or in part) may be made, under this Act, any review with respect to such services which has not been designated by the Secretary as the full responsibility of such organization, shall be reviewed in the manner otherwise provided for under law. “Sec. 1154. “trial period for professional standards review organizations (a) The Secretary shall initially designate an organization as a Professional Standards Review Organization for any area on a conditional basis with a view to determining the capacity of such organization to perform the duties and functions imposed under this Plan, approval. part on Professional Standards Review Organizations. Such designation may not be made prior to receipt from such organization and approval by the Secretary of a formal plan for the orderly assumption and implementation of the responsibilities of the Professional Standards Review Organization under this part. “(b) During any such trial period (which may not exceed 24 months), the Secretary may require a Professional Standards Review Organization to perform only such of the duties and functions required under this part of Professional Standards Review Organization as he determines such organization to be capable of performing. The number and type of such duties shall, during the trial period, be progressively increased as the organization becomes capable of added responsibility so that, by the end of such period, such organization shall be considered a qualified organization only if the Secretary finds that it is substantially carrying out in a satisfactory manner, the activities and functions required of Professional Standards Review Organizations under this part with respect to the review of health care services provided or ordered by physicians and other practitioners and institutional and other health care facilities, agencies, and organizations. Any of such duties and functions not performed by such organization during such period shall be performed in the manner and to the extent otherwise provided for under law. “(c) Any agreement under which any organization is conditionally designated as the Professional Standards Review Organization for any area may be terminated by such organization upon 90 days notice to the Secretary or by the Secretary upon 90 days notice to such organization. “Sec. 1155. “duties and functions of professional standards review organizations (a) (1) Notwithstanding any other provision of law, hut consistent with the provisions of this part, it shall (subject to the provisions of subsection (g)) be the duty and function of each Professional Standards Review Organization for any area to assume, at the earliest date practicably, responsibility for the review of the professional activities in such area of physicians and other health care practitioners and institutional and noninstitutional providers of health care services in the provision of health care services and items for which payment may be made (in whole or in part.) under this Act for the purpose of determining whether— “(A) such services and items are or were medically necessary; “(B) the quality of such services meets professionally recognized standards of health care; and “(C) in case such services and items are proposed to be provided in a hospital or other health care facility on an inpatient basis, such services and items could, consistent with the provision of appropriate medical care, be effectively provided on an outpatient basis or more economically in an inpatient health care facility of a different type. “(2) Each Professional Standards Review Organization shall have the authority to determine, in advance, in the case of— “(A) any elective admission to a hospital, or other health care facility, or “(B) any other health care service which will consist of extended or costly courses of treatment, whether such service, if provided, or if provided by a particular health care practitioner or by a particular hospital or other health care facility, organization, or agency, would meet the criteria specified in clauses (A) and (C) of paragraph (1). “(3) Each Professional Standards Review Organization shall, in Case criteria, publication. accordance with regulations of the Secretary, determine and publish, from time to time, the types and kinds of cases (whether by type of health care or diagnosis involved, or whether in terms of other relevant criteria relating to the provision of health care services) with respect to which such organization will, in order most effectively to carry out the purposes of this part, exercise the authority conferred upon it under paragraph (2). “(4) Each Professional Standards Review Organization shall be Patient profiles, maintenance and review. responsible for the arranging for the maintenance of and the regular review of profiles of care and services received and provided with respect to patients, utilizing to the greatest extent practicable in such patient profiles, methods of coding which will provide maximum confidentiality as to patient identity and assure objective evaluation consistent with the purposes of this part. Profiles shall also be regularly reviewed on an ongoing basis with respect to each health care practitioner and provider to determine whether the care and services ordered or rendered are consistent with the criteria specified in clauses (A), (B), and (C) of paragraph (1). “(5) Physicians assigned responsibility for the review of hospital Hospital care, physician review. care may be only those having active hospital staff privileges in at least one of the participating hospitals in the area served by the Professional Standards Review Organization and (except as may be otherwise provided under subsection (e) (1) of this section) such physicians ordinarily should not be responsible for, but may participate in the review of care and services provided in any hospital in which such physicians have active staff privileges. “(6) No physician shall be permitted to review— “(A) health care services provided to a patient if he was directly or indirectly involved in providing such services, or “(B) health care services provided in or by an institution, organization, or agency, if he or any member of his family has, directly or indirectly, any financial interest in such institution, organization, or agency. Physician’s family. For purposes of this paragraph, a physician’s family includes only his spouse (other than a spouse who is legally separated from him under a decree of divorce, or separate maintenance), children (including legally adopted children), grandchildren, parents, and grandparents. “(b) To the extent necessary or appropriate for the proper performance of its duties and functions, the Professional Standards Review Organization serving any area is authorized in accordance with regulations prescribed by the Secretary to— “(1) make arrangements to utilize the services of persons who are practitioners of or specialists in the various areas of medicine (including dentistry), or other types of health care, which persons shall, to the maximum extent practicable, be individuals engaged in the practice of their profession within the area served by such organization; “(2) undertake such professional inquiry either before or after, or both before and after, the provision of services with respect to which such organization has a responsibility for review under subsection (a)(1); “(3) examine the pertinent records of any practitioner or provider of health care services providing services with respect to which such organization has a responsibility for review under subsection (a) (1); and “(4) inspect the facilities in which care is rendered or service: provided (which are located in such area) of any practitioner or provider. “(c) No Professional Standards Review Organization shall utilize the services of any individual who is not a duly licensed doctor of medicine or osteopathy to make final determinations in accordance with its duties and functions under this part with respect to the professional conduct of any other duly licensed doctor of medicine or osteopathy, or any act performed by any duly licensed doctor of medicine or osteopathy in the exercise of his profession. “(d) In order to familiarize physicians with the review functions and activities of Professional Standards Review Organizations and to promote acceptance of such functions and activities by physicians, patients, and other persons, each Professional Standards Review Organization, in carrying out its review responsibilities, shall (to the maximum extent consistent with the effective and timely performance of its duties and functions)— “(1) encourage all physicians practicing their profession in the area served by such Organization to participate as reviewers in the review activities of such Organizations; “(2) provide rotating physician membership of review committees on an extensive and continuing basis; “(3) assure that membership on review committees have the broadest representation feasible in terms of the various types of practice in which physicians engage in the area served by such Organization; and “(4) utilize, whenever appropriate, medical periodicals and similar publications to publicize the functions and activities of Professional Standards Review Organizations. “(e) (1) Each Professional Standards Review Organization shall Review committees. utilize the services of, and accept the findings of, the review committees of a hospital or other operating health care facility or organization located in the area served by such organization, but only when and only to the extent and only for such time that such committees in such hospital or other operating health care facility or organization have demonstrated to the satisfaction of such organization their capacity effectively and in timely fashion to review activities in such hospital or other operating health care facility or organization (including the medical necessity of admissions, types and extent of services ordered, and lengths of stay) so as to aid in accomplishing the purposes and responsibilities described in subsection (a)(1), except where the Secretary disapproves, for good cause, such acceptance. “(2) The Secretary may prescribe regulations to carry out the provisions Regulations. of this subsection. “(f) (1) An agreement entered into under this part between the Agreement requirements. Secretary and any organization under which such organization is designated as the Professional Standards Review Organization for any area shall provide that such organization will— “(A) perform such duties and functions and assume such responsibilities and comply with such other requirements as may be required by this part or under regulations of the Secretary promulgated to carry out the provisions of this part; and “(B) collect such data relevant to its functions and such information and keep and maintain such records in such form as the Secretary may require to carry out the purposes of this part and to permit access to and use of any such records as the Secretary may require for such purposes. “(2) Any such agreement with an organization under this part shall provide that the Secretary make payments to such organization equal to the amount of expenses reasonably and necessarily incurred, as determined by the Secretary, by such organization in carrying out or preparing to carry out the duties and functions required by such agreement. “(g) Notwithstanding any other provision of this part, the responsibility for review of health care services of any Professional Standards Review Organization shall be the review of health care services provided by or in institutions, unless such Organization shall have made a request to the Secretary that it be charged with the duty and function of reviewing other health care services and the Secretary shall have approved such request. “Sec. 1156. “norms of health care services for various illnesses or health conditions (a) Each Professional Standards Review Organization shall apply professionally developed norms of care, diagnosis, and treatment based upon typical patterns of practice in its regions (including typical lengths-of-stay for institutional care by age and diagnosis) as principal points of evaluation and review. The National Professional Standards Review Council and the Secretary shall provide such technical assistance to the organization as will be helpful in utilizing and applying such norms of care, diagnosis, and treatment. Where the actual norms of care, diagnosis, and treatment in a Professional Standards Review Organization area are significantly different from professionally developed regional norms of care, diagnosis, and treatment approved for comparable conditions, the Professional Standards Review Organization concerned shall be so informed, and in the event that appropriate consultation and discussion indicate reasonable basis for usage of other norms in the area concerned, the Professional Standards Review Organization may apply such norms in such area as are approved by the National Professional Standards Review Council. “(b) Such norms with respect to treatment for particular illnesses or health conditions shall include (in accordance with regulations of the Secretary)— “(1) the types and extent of the health care services which, taking into account differing, but acceptable, modes of treatment and methods of organizing and delivering care are considered within the range of appropriate diagnosis and treatment of such illness or health condition, consistent with professionally recognized and accepted patterns of care; “(2) the type of health care facility which is considered, consistent with such standards, to be the type in which health care services which are medically appropriate for such illness or condition can most economically be provided. “(c) (1) The National Professional Standards Review Council shall provide for the preparation and distribution, to each Professional Standards Review Organization and to each other agency or person performing review functions with respect to the provision of health care services under this Act, of appropriate materials indicating the regional norms to be utilized pursuant to this part. Such data concerning norms shall be reviewed and revised from time to time. The approval of the National Professional Standards Review Council of norms of care, diagnosis, and treatment shall be based on its analysis of appropriate and adequate data. “(2) Each review organization, agency, or person referred to in paragraph (1) shall utilize the norms developed under this section as a principal point of evaluation and review for determining, with respect to any health care services which have been or are proposed to be provided, whether such care and services are consistent, with the criteria Ante, p. 1433. specified in section 1155 (a)(1). “(d) (1) Each Professional Standards Review Organization shall— “(A) in accordance with regulations of the Secretary, specify the appropriate points in time after the admission of a patient for inpatient care in a health care institution, at which the physician attending such patient shall execute a certification stating that further inpatient care in such institution will be medically necessary effectively to meet the health care needs of such patient; and “(B) require that there be included in any such certification with respect to any patient such information as may be necessary to enable such organization properly to evaluate the medical necessity of the further institutional health care recommended by the physician executing such certification. “(2) The points in time at which any such certification will be required (usually, not later than the 50th percentile of lengths-of-stay for patients in similar age groups with similar diagnoses) shall be consistent with and based on professionally developed norms of care and treatment and data developed with respect to length of stay in health care institutions of patients having various illnesses, injuries, or health conditions, and requiring various types of health care services or procedures. “Sec. 1157. “submission of efforts by profesional standards review organizations If, in discharging its duties and functions under this part, any Professional Standards Review Organization determines that any health care practitioner or any hospital, or other health care facility, agency, or organization has violated any of the obligations imposed by section 1160, such organization shall report the Post, p. 1438. matter to the Statewide Professional Standards Review Council for the State in which such organization is located together with the recommendations of such Organization as to the action which should be taken with respect to the matter. Any Statewide, Professional Standards Review Council receiving any such report and recommendation shall review the same and promptly transmit such report and recommendation to the Secretary’ together with any additional comments or recommendations thereon as it deems appropriate. The Secretary may utilize a Professional Standards Review Organization, in lieu of a program review team as specified in sections 1862 and 1866, 79 Stat. 325; 81 Stat. 846. 42 USC 1395y, 1395cc. Ante, p. 1408. Ante, p. 1409. for purposes of subparagraph (C) of section 1862(d)(1) and subparagraph (F) of section 1866(b)(2). “Sec. 1158. “requirement of review approval as condition of payment of claims (a) Except as provided for in section 1159, no Federal funds appropriated under any title of this Act (other than title V) 81 Stat. 921. 42 USC 701. for the provision of health care services or items shall be used (directly or indirectly) for the payment, under such title or any program established pursuant thereto, of any claim for the provision of such services or items, unless the Secretary, pursuant to regulation determines that the claimant is without fault if— “(1) the provision of such services or items is subject to review under this part by any Professional St and aids Review Organization. or other agency; and “(2) such organization or other agency has, in the proper exercise of its duties and functions under or consistent with the purposes of this part, disapproved of the services or items giving rise to such claim, and has notified the practitioner or provider who provided or proposed to provide such services or items and the individual who would receive or was proposed to receive such services or items of its disapproval of the provision of such services or items. “(b) Whenever any Professional Standards Review Organization, in the discharge of its duties and functions as specified by or pursuant to this part, disapproves of any health care services or items furnished or to be furnished by any practitioner or provider, such organization shall, after notifying the practitioner, provider, or other organization or agency of its disapproval in accordance with subsection (a), promptly notify the agency or organization having responsibility for acting upon claims for payment for or on account of such services or items. “Sec. 1159. “hearings and review by secretary (a) Any beneficiary or recipient who is entitled to benefits under this Act (other than title V) or a provider or practitioner who is dissatisfied with a determination with respect to a claim made by a Professional Standards Review Organization in carrying out its responsibilities for the review of professional activities in accordance with paragraphs (1) and (2) of section 1155(a) shall, after being Ante, p. 1433. notified of such determination, be entitled to a reconsideration thereof by the Professional Standards Review Organization and, where the Professional Standards Review Organization reaffirms such determination in a State which has established a Statewide Professional Standards Review Council, and where the matter in controversy is $100 or more, such determination shall be reviewed by professional members of such Council and, if the Council so determined, revised. “(b) Where the determination of the Statewide Professional Standards Review Council is adverse to the beneficiary or recipient (or, in the absence of such Council in a State and where the matter in controversy is $100 or more), such beneficiary or recipient shall be entitled to a hearing thereon by the Secretary to the same extent as is provided 53 Stat. 1368. 42 USC 405. in section 205(b), and, where the amount in controversy is $1,000 or more, to judicial review of the Secretary’s final decision after such hearing as is provided in section 205(g). The Secretary will render a decision only after appropriate professional consultation on the matter. “(c) Any review or appeals provided under this section shall be in lieu of any review, hearing, or appeal under this Act with respect to the same issue. “Sec. 1160. “obligations of health care practitioners and providers of health care services; sanctions and penalties; hearings and review (a) (1) It shall be the obligation of any health care practitioner and any other person (including a hospital or other health care facility, organization, or agency) who provides health care services for which payment may be made (in whole or in part) under this Act, to assure that services or items ordered or provided by such practitioner or person to beneficiaries and recipients under this Act— “(A) will be provided only when, and to the extent, medically necessary; and “(B) will be of a quality which meets professionally recognized standards of health care; and “(C) will be supported by evidence of such medical necessity and quality in such form and fashion and at such time as may reasonably be required by the Professional Standards Review Organization in the exercise of its duties and responsibilities; and it shall be the obligation of any health care practitioner in ordering, authorizing, directing, or arranging for the provision by any other person (including a hospital or other health care facility, organization, or agency), of health care services for any patient of such practitioner, to exercise his professional responsibility with a view to assuring (to the extent of his influence or control over such patient, such person, or the provision of such services) that such services or items will be provided— “(D) only when, and to the extent, medically necessary; and “(E) will be of a quality which meets professionally recognized standards of health care. “(2) Each health care practitioner, and each hospital or other provider of health care services, shall have an obligation, within reasonable limits of professional discretion, not to take any action, in the exercise of his profession (in the case of any health care practitioner), or in the conduct of its business (in the case of any hospital or other such provider), which would authorize any individual to be admitted as an inpatient in or to continue as an inpatient in any hospital or other health care facility unless— “(A) inpatient care is determined by such practitioner and by such hospital or other provider, consistent with professionally recognized health care standards, to be medically necessary for the proper care of such individual; and “(B) (i) the inpatient care required by such individual cannot, consistent with such standards, be provided more economically in a health care facility of a different type; or “(ii) (in the case of a patient who requires care which can, consistent with such standards, be provided more economically in a health care facility of a different type) there is, in the area in which such individual is located, no such facility or no such facility which is available to provide care to such individual at the time when care is needed by him. “(b) (1) If after reasonable notice and opportunity for discussion Report and Recommendations. with the practitioner or provider concerned, any Professional Standards Review Organization submits a report and recommendations to the Secretary pursuant to section 1157 (which report and recommendations Ante, p. 1437. shall be submitted through the Statewide Professional Standards Review Council, if such Council has been established, which shall promptly transmit such report, and recommendations together with any additional comments and recommendations thereon as it deems appropriate) and if the Secretary determines that such practitioner or provider, in providing health care services over which such organization has review responsibility and for which payment (in whole or in part) may be made under this Act has— “(A) by failing, in a substantial number of cases, substantially to comply with any obligation imposed on him under subsection (a), or “(B) by grossly and flagrantly violating any such obligation in one or more instances. demonstrated an unwillingness or a lack of ability substantially to comply with such obligations, he (in addition to any other sanction provided under law) may exclude (permanently for such period as the Secretary’ may prescribe) such practitioner or provider from eligibility to provide such services on a reimbursable basis. “(2) A determination made by the Secretary under this subsection shall be effective at such time and upon such reasonable notice to the public and to the person furnishing the services involved as may be specified in regulations. Such determination shall be effective with respect to services furnished to an individual on or after the effective date of such determination (except that in the case of institutional health care services such determination shall be effective in the manner provided in title XVIII with respect to terminations of provider 42 USC 1395. agreements), and shall remain in effect until the Secretary finds and gives reasonable notice to the public that the basis for such determination has been removed and that there is reasonable assurance that it will not recur. “(3) In lieu of the sanction authorized by paragraph (1) ,the Secretary may require that (as a condition to the continued eligibility of such practitioner or provider to provide such health care services on a reimbursable basis) such practitioner or provider pay to the United States, in ease such acts or conduct involved the provision or ordering by such practitioner or provider of health care, services which were medically improper or unnecessary, an amount not in excess of the actual or estimated cost, of the medically improper or unnecessary services so provided, or (if less) $5,000. Such amount may be deducted from any sums owing by the United States (or any instrumentality thereof) to the person from whom such amount is claimed. “(4) Any person furnishing services described in paragraph (1) who is dissatisfied with a determination made by the Secretary under this subsection shall be entitled to reasonable notice and opportunity for a hearing thereon by the Secretary to the same extent as is provided 53 Stat. 1363. 42 USC 405. in section 205(b), and to judicial review of the Secretary’s final decision after such hearing as is provided in section 205 (g). “(c) It shall be the duty of each Professional Standards Review Organization and each Statewide Professional Standards Review Council to use such authority or influence it may possess as a professional organization, and to enlist the support of any other professional or governmental organization having influence or authority over health care practitioners and any other person (including a hospital or other health care facility, organization, or agency) providing health care services in the area served by such review organization, in assuring that each practitioner or provider (referred to in subsection (a)) providing health care services in such area shall comply with all obligations imposed on him under subsection (a). “Sec. 1161. “notice to practitioner or provider Whenever any Professional Standards Review Organization takes any action or makes any determination— “(a) which denies any request, by a health care practitioner or other provider of health care services, for approval of a health care service or item proposed to be ordered or provided by such practitioner or provider; or “(b) that any such practitioner or provider has violated any obligation imposed on such practitioner or provider under section 1160, such organization shall, immediately after taking such action or making such determination, give notice to such practitioner or provider of such determination and the basis therefor, and shall provide him with appropriate opportunity for discussion and review of the matter. “Sec. 1162. “statewide professional standards review councils; advisory groups to such councils (a) In any State in which there are located three or more Professional Standards Review Organizations, the Secretary shall establish a Statewide Professional Standards Review Council. “(b) The membership of any such Council for any State shall be appointed by the Secretary and shall consist of— “ (1) one representative from and designated by each Professional Standards Review Organization in the State; “ (2) four physicians, two of whom may be designated by the State medical society and two of whom may be designated by the State hospital association of such State to serve as members, on such Council; and “ (3) four persons knowledgeable in health care from such State whom the Secretary shall have selected as representatives of the public in such State (at least two of whom shall have been recommended for membership on the Council by the Governor of such State). “(c) It shall be the duty and function of the Statewide Professional Standards Review Council for any State, in accordance with regulations of the Secretary, (1) to coordinate the activities of, and disseminate information and data among the various Professional Standards Review Organizations within such State including assisting the Secre-tary in development of uniform data gathering procedures and operating procedures applicable to the several areas m a State (including, where appropriate, common data processing operations serving several or all areas) to assure efficient operation and objective evaluation of comparative performance of the several areas and, (2) to assist the Secretary in evaluating the performance of each Professional Standards Review Organization, and (3) where the Secretary finds it necessary to replace a Professional Standards Review Organization, to assist him in developing and arranging for a qualified replacement Professional Standards Review Organization. “(d) The Secretary is authorized to enter into an agreement with Payments. any such Council under which the Secretary shall make payments to such Council equal to the amount of expenses reasonably and necessarily incurred, as determined by the Secretary, by such Council in carrying out the duties and functions provided in this section. “(e) (1) The Statewide Professional Standards Review Council for any State (or in a State which does not have such Council, the Professional Standards Review Organizations in such State which have agreements with the Secretary) shall be advised and assisted in carrying out its functions by an advisory group (of not less than seven nor more than eleven members) which shall be made up of representatives of health care practitioners (other than physicians) and hospitals and other health care facilities which provide within the State health care services for which payment (in whole or in part) may be made under any program established by or pursuant to this Act. “(2) The Secretary shall by regulations provide the manner in Member selection, regulations. which members of such advisory group shall be selected by the Statewide Professional Standards Review Council (or Professional Standards Review Organizations in States without such Councils). “(3) The expenses reasonably and necessarily incurred, as determined Expenses. by the Secretary, by such group in carrying out it duties and functions under this subsection shall be considered to be expenses necessarily incurred by the Statewide Professional Standards Review Council served by such group. “Sec. 1163. “national professional standards review council (a) (1) There shall be established a National Professional Establishment; membership. Standards Review Council (hereinafter in this section referred to as the ‘Council’) which shall consist, of eleven physicians, not otherwise in the employ of the United States, appointed by the Secretary without regard to the provisions of title 5, United States Code, governing 5 USC 101 et seq. appointments in the competitive service. “(2) Members of the Council shall be appointed for a term of three Term of membership. years and shall be eligible for reappointment. “(3) The Secretary shall from time to time designate one of the members of the Council to serve as Chairman thereof. “(b) Members of the Council shall consist of physicians of recognized Qualifications. standing and distinction in the appraisal of medical practice. A majority of such members shall be physicians who have been recommended by the Secretary to serve on the Council by national organizations recognized by the Secretary as representing practicing physicians. The membership of the Council shall include physicians who have been recommended for membership on the Council by consumer groups and other health care interests. “(c) The Council is authorized to utilize, and the Secretary shall Consultants. make available, or arrange for, such technical and professional consultative assistance as may be required to carry out its functions, and the Secretary shall, in addition, make available to the Council such secretarial, clerical and other assistance and such pertinent data prepared by, for, or otherwise available to, the Department of Health, Education, and Welfare as the Council may require to carry out its functions. ‘(d) Members of the Council, while serving on business of the Council, shall be entitled to receive compensation at a rate fixed by the Secretary (but not in excess of the daily rate paid under GS–18 of the General Schedule under section 5332 of title 5, United States 5 USC 5332 note. Code), including traveltime; and while so serving away from their homes or regular places of business, they may be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5703 of title 5, United States Code, for persons in Government service employed intermittently. “(e) It shall be the duty of the Council to— “(1) advise the Secretary in the administration of this part; “(2) provide for the development and distribution, among Statewide Professional Standards Review Councils and Professional Standards Review Organizations of information and data which will assist such review councils and organizations in carrying out their duties and functions; “(3) review the operations of Statewide Professional Standards Review Councils .and Professional Standards Review Organizations with a view to determining the effectiveness and comparative performance of such review councils and organizations in carrying out the purposes of this part: and “(4) make or arrange for the making of studies and investigations with a view to developing and recommending to the Secretary and to the Congress measures designed more effectively to accomplish the purposes and objectives of this part. “(f) The National Professional Standards Review Council shall from time to time, but not less often than annually, submit to the Secretary and to the Congress a report on its activities and shall include in such report the findings of its studies and investigations together with any recommendations it may have with respect to the more effective accomplishment of the purposes and objectives of this part. Such report shall also contain comparative data indicating the results of review activities, conducted pursuant to this part, in each State and in each of the various areas thereof. “Sec. 1164. “application of this part to certain state programs receiving federal financial assistance (a) In addition to the requirements imposed by law as a condition of approval of a State plan approved under any title of this Act under which health care services are paid for in whole or part, with Federal funds, there is hereby imposed the requirement that provisions of this part shall apply to the operation of such plan or program. “(b) The requirement imposed by subsection (a) with respect to such State plans approved under this Act shall apply— “(1) in the case of any such plan where legislative action by the State legislature is not necessary to meet such requirement, on and after January 1, 1974; and “(2) in the case of any such plan where legislative action by the State legislature is necessary to meet such requirement, whichever of the following is earlier— “(A) on and after July 1, 1974, or “(B) on and after the first day of the calendar month which first commences more than ninety days after the close of the first regular session of the legislature of such State which begins after December 31, 1973. “Sec. 1165. “correlation of functions between professional standards review organizations and administrative instrumentalities The Secretary shall by regulations provide for such correlation of activities, such interchange of data and information, and such other cooperation consistent with economical, efficient, coordinated, and comprehensive implementation of this part (including, but not limited to usage of existing mechanical and other data-gathering capacity) between and among— “(a) (1) agencies and organizations which are parties to agreements entered into pursuant to section 1816, (2) carriers which 79 Stat. 297. 42 USC 1395h. 42 USC 1395u. are parties to contracts entered into pursuant to section 1842, and (3) any other public or private agency (other than a Professional Standards Review Organization) having review or control functions, or proved relevant data-gathering procedures and experience, and “(b) Professional Standards Review Organizations, as may be necessary or appropriate for the effective administration of title XVIII, or State plans approved under this Act. 42 USC 1395. “Sec. 1166. “prohibition against disclosure of information (a) Any data or information acquired by any Professional Standards Review Organization, in the exercise of its duties and functions, shall be held in confidence and shall not be disclosed to any person except (1) to the extent that may be necessary to carry out the purposes of this part or (2) in such cases and under such circumstances as the Secretary shall by regulations provide to assure adequate protection of the rights and interests of patients, health care practitioners, or providers of health care. “(b) It shall be unlawful for any person to disclose any such information Penalty. other than for such purposes, and any person violating the provisions of this section shall, upon conviction, be fined not more than $1,000, and imprisoned for not more than six months, or both, together with the costs of prosecution. “Sec. 1167. “limitation on liability for persons providing information, and for members and employees of professional standards review organizations, and for health care pract1tioners and providers (a) Notwithstanding any other provision of law, no person providing information to any Professional Standards Review Organization shall be held, by reason of having provided such information, to have violated any criminal law, or to be civilly liable under any law, of the United States or of any State (or political subdivision thereof) unless— “(1) such information is unrelated to the performance of the duties and functions of such Organization, or “(2) such information is false and the person providing such information knew, or had reason to believe, that such information was false. “(b) (1) No individual who, as a member or employee of any Professional Standards Review Organization or who furnishes profes-sional counsel or services to such organization, shall be held by reason of the performance by him of any duty, function, or activity authorized or required of Professional Standards Review Organizations under this part, to have violated any criminal law, or to be civilly liable under any law, of the United States or of any State (or political subdivision thereof) provided he has exercised due care. “(2) The provisions of paragraph (1) shall not apply with respect to any action taken by any individual if such individual, in taking such action, was motivated by malice toward any person affected by such action. “(c) No doctor of medicine or osteopathy and no provider (including directors, trustees, employees, or officials thereof) of health care services shall be civilly liable to any person under any law of the United States or of any State (or political subdivision thereof) on account of any action taken by him in compliance with or reliance upon professionally developed norms of care and treatment, applied by a Professional Standards Review Organization (which has been Ante, p. 1430. designated in accordance with section 1152(b)(1)(A)) operating in the area where such doctor of medicine or osteopathy or provider took such action but only if— “(1) he takes such action (in the case of a health care practitioner) in the exercise of his profession as a doctor of medicine or osteopathy (or in the case of a provider of health care services) in the exercise of Ills functions as a provider of health care services, and “(2) he exercised due care in all professional conduct taken or directed by him and reasonably related to, and resulting from, the actions taken in compliance with or reliance upon such professionally accepted norms of care and treatment. “Sec. 1168. “authorization for use of certain funds to administer the provisions of this part Expenses incurred in the administration of this part shall be payable from— “(a) funds in the Federal Hospital Insurance Trust Fund; “(b) funds in the Federal Supplementary Medical Insurance Trust Fund; and “(c) funds appropriated to carry out the health care provisions of the several titles of this Act; in such amounts from each of the sources of funds (referred to in subsections (a), (b), and (c)) as the Secretary shall deem to be fair and equitable after taking into consideration the costs attributable to the administration of this part with respect to each of such plans and programs. “Sec. 1169. “technical assistance to organizations desiring to be designated as professional standards review organizations The Secretary is authorized to provide all necessary’ technical and other assistance (including the preparation of prototype plans of organization and operation) to organizations described in section 1152(b) (1) which— “(a) express a desire to be designated as a Professional Standards Review Organization; and “(b) the Secretary determines have a potential for meeting the requirements of a Professional Standards Review Organization; to assist such organizations in developing a proper plan to be submitted to the Secretary and otherwise in preparing to meet the requirements of this part for designation as a Professional Standards be view Organization. “Sec. 1170. “exemptions or Christian science sanatoriums The provisions of this part shall not apply with respect to a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts.” Sec. 251. physical therapy services and other therapy services under medicare (a) (1) Section 1861(p) of the Social Security Act is amended by adding at the end thereof (after and below paragraph 81 Stat. 850. 42 USC 1395x. (4) (B)) the following new sentence: “The term ‘outpatient physical therapy services’ also includes physical therapy services furnished an individual by a physical therapist (in his office or in such individual’s home) who meets licensing and other standards prescribed by the Secretary in regulations, otherwise than under an arrangement with and under the supervision of a provider of services, clinic, rehabilitation agency, or public health agency, if the furnishing of such services meets such conditions relating to health and safety as the Secretary may find necessary.” (2) Section 1833 of such Act is amended by adding at the end Ante, p. 1424. thereof the following new subsection: “(g) In the case of services described in the next to last sentence of section 1861 (p), with respect to expenses incurred in any calendar year, no more than $100 shall be considered as incurred expenses for purposes of subsections (a) and (b).” (3) Section 1833(a) (2) of such Act (as amended by section 233(b) of this Act) is further amended by striking out the period at the end Ante, p. 1411. of subparagraph (B) and inserting in lieu thereof “; or”, and by adding after subparagraph (B) the following new subparagraph: “(C) if such services are services to which the next to last sentence of section 1861 (p) applies, the reasonable charges for such services.” (4) Section 1832(a)(2)(C) of such Act is amended by striking 81 Stat. 851. 42 USC 1395k. out “services.” and inserting in lieu thereof “services, other than services to which the next to last sentence of section 1861 (p) applies.” (b) (1) Section 1861 (p) of such Act (as amended by subsection (a)(1) of this section) is further amended by adding at the end thereof the following new sentence: “In addition, such term includes physical therapy services which meet the requirements of the first sentence of this subsection except that they are furnished to an individual as an inpatient of a hospital or extended care facility.” (2) Section 1835(a)(2)(C) of such Act is amended by striking 81 Stat. 851. 42 USC 1395n. out “on an outpatient basis”. (c) Section 1861 (v) of such Act (as amended by sections 221(c) (4) and 223(f) of this Act) is further amended by redesignating paragraphs Ante, p. 1394. (5) and (6) as paragraphs (6) and (7), respectively, and by inserting after paragraph (4) the following new paragraph: “(5) (A) Where physical therapy services, occupational therapy services, speech therapy services, or other therapy services or services of other health-related personnel (other than physicians) are furnished under an arrangement with a provider of services or other organization, specified in the first sentence of section 1861 (p) the amount included in any payment to such provider or other organization under this title as the reasonable cost of such services (as furnished under such arrangements) shall not exceed an amount equal to the salary which would reasonably have been paid for such services (together with any additional costs that would have been incurred by the provider or other organization) to the person performing them if they had been performed in an employment relationship with such provider or other organization (rather than under such arrangement) plus the cost of such other expenses (including a reasonable allowance for travel time and other reasonable types of expense related to any differences in acceptable methods of organization for the provision of such therapy) incurred by such person, as the Secretary may in regulations determine to be appropriate. “(B) Notwithstanding the provisions of subparagraph (A), if a provider of services or other organization specified in the first sentence 81 Stat. 850. 12 USC 1395x. of section 1861 (p) requires the services of a therapist on a limited part-time basis, or only to perform intermittent services, the Secretary may make payment on the basis of a reasonable rate per unit of service, even though such rate is greater per unit of time than salary related amounts, where he finds that such greater payment is, in the aggregate, less than the amount that would have been paid if such organization had employed a therapist on a full- or part-time salary basis.” (d) (1) The amendments made by subsection (a) shall apply with respect to services furnished on or after July 1, 1973. (2) The amendments made by subsection (b) shall apply with respect to services furnished on or after the date of enactment of this Act. (3) The amendments made by subsection (c) shall be effective with respect to accounting periods beginning after December 31, 1972. Sec. 252. coverage of supplies related to colostomies (a) Section 1861 (s) (8) of the Social Security Act is amended by inserting after “organ” the following: “(including colostomy bags and supplies directly related to colostomy care)”. (b) The amendment made by subsection (a) shall apply only with respect to items furnished on or after the date of the enactment of this Act. Sec. 255. coverage prior to application for medical assistance (a) Section 1902(a) of the Social Security Act (as Ante, pp. 1415, 1417. amended by sections 236(b) and 239(b) of this Act) is further amended— (1) by striking out “and” at the end of paragraph (32); (2) by striking out the period at the end of paragraph (33) and inserting in lieu thereof “; and”; and (3) by inserting after paragraph (33) the following new paragraph: “(34) provide that in the case of any individual who has been determined to be eligible for medical assistance under the plan, such assistance will be made available to him for care and services included under the plan and furnished in or after the third month before the month in which he made application for such assistance. if such individual was (or upon application would have been) eligible for such assistance at the time such care and services were furnished.” (b) The amendments made by subsection (a.) shall be effective July 1, 1973. Sec. 256. hospital admissions for dental services under medicare (a) Section 1814(a)(2) of the Social Security Act is amended by striking out “or” at the end of subparagraph (C), by Ante, p. 1413. adding “or” after the semicolon at the end of the subparagraph (D), and by inserting after subparagraph (D) the following new subparagraph: “(E) in the case of inpatient hospital services in connection with a dental procedure, the individual suffers from impairments of such severity as to require hospitalization;”. (b) Section 1861(c) of such Act is amended by inserting after “or 79 Stat. 321. 42 USC 1395x. any facial bone,” the following: “or (C) the certification required by section 1814(a) (2) (E) of this Act,”. (c) Section 1862(a) (12) of such Act is amended by inserting before 42 USC 1395y. the semicolon the following: “, except that payment may be made 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”. (d) The amendments made by this section shall apply with respect Effective date. to admissions occurring after the second month following the month in which this Act is enacted. Sec. 257. extension of or ace period for termination of supplementary medical insurance coverage where failure to pay premiums is die to good cause (a) Section 1838(b) of the Social Security Act is amended Ante, p. 1378. by striking out “(not in excess of 90 days)” in the third sentence, and by adding at the end thereof the following new sentence: “The grace period determined under the preceding sentence shall not exceed 90 days; except that it may be extended to not to exceed 180 days in any case where the Secretary determines that there was good cause for failure to pay the overdue premiums within such 90-day period.” (b) The amendments made by subsection (a) shall apply with Effective date. respect to nonpayment of premiums which become due and payable on or after the date of the enactment of this Act or which became payable within the 90-day period immediately preceding such date; and for purposes of such amendments any premium which became due and payable within such 90-day period shall be considered a premium becoming due and payable on the date of the enactment of this Act. Sec. 258. extension of time for filing claim for supplementary medical insurance benefits where delay is due to administrative error (a) Section 1842(b)(3) of the Social Security Act (as amended by section 224(a) of this Act) is further amended by adding Ante, p. 1395. at the end thereof the following new sentence: “The requirement in subparagraph (B) that a bill be submitted or request for payment be made by the close of the following calendar year shall not apply if (i) failure to submit the bill or request the payment by the close of such year is due to the error or misrepresentation of an officer, employee, fiscal intermediary, carrier, or agent of the Department of Health, Education, and Welfare performing functions under this title and acting within the scope of his or its authority, and (ii) the bill is submitted or the payment is requested promptly after such error or misrepresentation is eliminated or corrected.” (b) The amendment made by subsection (a) shall apply with Effective date. respect to bills submitted and requests for payment made after March 1968. Sec. 259. waiver of enrollment period requirements where individual’s rights were prejudiced by administrative error or inaction (a) Section 1837 of the Social Security Act (after the new Ante, p. 1378. subsections added by section 206(a) of this Act) is amended by adding at the end thereof the following new subsection: “(h) In any case where the Secretary finds that an individual’s enrollment or nonenrollment in the insurance program established by Ante, p. 1374. this part or part A pursuant to section 1818 is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Federal Government, or its instrumentalities, the Secretary may take such action (including the designation for such individual of a special initial or subsequent enrollment period, with a coverage period determined on the basis thereof and with appropriate adjustments of premiums) as may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction.” (b) The amendment made by subsection (a) shall be effective as of July 1, 1966. Sec. 260. elimination of provisions preventing enrollment in supplementary medical insurance program more than three years after first opportunity Section 1837 (b) of the Social Security Act is amended to read as follows: “(b) No individual may enroll under this part more than twice.” Sec. 261. waiver of recovery of incorrect payments from survivor who is without fault under medicare (a) Section 1870(c) of the Social Security Act is amended by striking out “and where” and inserting in lieu thereof the following: “or where the adjustment (or recovery) would be made by decreasing payments to which another person who is without fault is entitled as provided in subsection (b) (4), if”. (b) The amendment made by subsection (a) shall apply with respect to waiver actions considered after the date of the enactment of this Act. Sec. 262. requirement of minimum amount of claim to establish entitlement to hearing under supplementary medical insurance program (a) Section 1842(b) (3) (C) of the Social Security Act is amended by inserting after “a fair hearing by the carrier” the following: “, in any case where the amount in controversy is $100 or more,”. (b) The amendment made by subsection (a) shall apply with respect to hearings requested (under the procedures established under section 1842(b)(3)(C) of the Social Security Act) after the date of the enactment of this Act. Sec. 263. collection of supplementary medical insurance premiums from individuals entitled to both social security and railroad retirement benefits (a) Section 1840(a)(1) of the Social Security Act is amended by striking out “subsection (d)” and inserting in lieu thereof “subsections (b)(1) and (c)”. (b) Section 1840(b)(1) of such Act is amended by inserting 42 USC 1395s. “(whether or not such individual is also entitled for such month to a monthly insurance benefit under section 202)” after “1937”, and by striking out “subsection (d)” and inserting in lieu thereof “subsection (c)” (c) Section 1840 of such Act is further amended by striking out subsection (c), and by redesignating subsections (d) through (i) as subsections (c) through (h), respectively. (d) (1) Section 1840(e) of such Act (as so redesignated) is amended by striking out “subsection (d)” and inserting in lieu thereof “subsection (c)”. (2) Section 1840(f) of such Act (as so redesignated) is amended by striking out “subsection (d) or (f)” and inserting in lieu thereof “subsection (c) or (e)”. (3) Section 1840(h) of such Act (as so redesignated) is amended by sinking out “(c), (d), and (e)” and inserting in lieu thereof “(c), and (d)”. (4) Section 1841(h) of such Act is amended by striking out 42 USC 1395t. “1840(e)” and inserting in lieu thereof “1840(d)”. (5) Section 1842 of such Act is amended by adding at the end 42 USC 1395u. thereof the following new subsection: “(g) The Railroad Retirement Board shall, in accordance with such regulations as the Secretary may prescribe, contract with a carrier or carriers to perform the functions set out in this section with respect to individuals entitled to benefits as qualified railroad retirement beneficiaries pursuant to section 226(a) of this Act and section 21(b) of Ante, p. 1371. the Railroad Retirement Act of 1937.” 79 Stat. 340. 45 USC 228s–2. 42 USC 1395t. (e) Section 1841 of such Act is amended by adding at the end thereof the following new subsection: “(i) The Managing Trustee shall pay from time to time from the Trust Fund such amounts as the Secretary of Health, Education, and Welfare certifies are necessary to pay the costs incurred by the Railroad Retirement Board for services performed pursuant to section 1840(b) (1) and section 1842(g). During each fiscal year or after the close of such fiscal year, the Railroad Retirement Board shall certify to the Secretary the amount of the costs it incurred in performing such services and such certified amount shall be the basis for the amount of such costs certified by the Secretary to the Managing Trustee.” (f) The amendments made by this section with respect to collection Effective date. of premiums shall apply to premiums becoming due and payable after the fourth month following the month in which this Act is enacted. Sec. 264. prosthetic lenses furnished by optometrists under supplementary medical insurance program (a) Section 1861 (r) of the Social Security Act (as amended by sections 211(c)(2) and 256(b) of this Act) is further Ante, pp. 1384 1447. amended (1) by striking out “or (3)” and inserting in lieu thereof “(3)”, and (2) by inserting before the period at the end thereof the following: “, or (4) a doctor of optometry who is legally authorized to practice optometry by the State in which he performs such function, but only with respect to establishing the necessity for prosthetic lenses”. (b) The amendment made by subsection (a) shall apply only with Effective date. respect to services performed on or after the date of the enactment of this Act. Sec. 265. provision of medical social services not mandatory for extended care facilities Section 1861 (j) (11) of the Social Security Act (as redesignated Ante, pp. 1412, 1424. by section 234(d) of this Act) is amended by inserting before the semicolon at the end thereof the following: “, except that the Secretary shall not require as a condition of participation that medical social services be furnished in any such institution”. Sec. 266. refund of excess premiums under medicare Section 1870 of the Social Security Act is amended by adding at the end thereof the following new subsection: “(g) If an individual, who is enrolled under section 1818(c) of the Ante, p. 1374. 42 USC 1395p. Social Security Act or under section 1837, dies, and premiums with respect to such enrollment have been received with respect to such individual for any month after the month of his death, such premiums shall be refunded to the person or persons determined by the Secretary under regulations to have paid such premiums or if payment for such premiums was made by the deceased individual before his death, to the legal representative of the estate of such deceased individual, if any. If there is no person who meets the requirements of the preceding sentence such premiums shall be refunded to the person or persons in the priorities specified in paragraphs (2) through (7) of subsection (e).” Sec. 267. waiver of registered nurse requirement in skilled nursing facilities in rural areas Section 1861 (j) of the Social Security Act, as amended by Ante, pp. 1412, 1424. sections 234(d) and 246(b) of this Act, is further amended by adding at the end thereof the following new sentence: “To the extent that paragraph (6) of this subsection may be deemed to require that any skilled nursing facility engage the services of a registered professional nurse for more than 40 hours a week, the Secretary is authorized to waive such requirement if he finds that— “(A) such facility is located in a rural area and the supply of skilled nursing facility services in such area is not sufficient to meet the needs of individuals residing therein, “(B) such facility has one full-time registered professional nurse who is regularly on duty at such facility 40 hours a week, and “(C) such facility (i) has only patients whose physicians have indicated (through physicians’ orders or admission notes) that each such patient does not require the services of a registered nurse or a physician for a 48-hour period, or (ii) has made arrangements for a registered professional nurse or a physician to spend such time at such facility as may be indicated as necessary by the physician to provide necessary skilled nursing services on days when the regular full-time registered professional nurse is not on duty.” Sec. 268. exemption of christian science sanatoriums from certain nursing home requirements under medicaid (a) Section 1902(a) of the Social Security Act is amended by adding at the end thereof the following new sentence: “For purposes of paragraphs (9) (A), (29), (31), and (33), and of section Ante, p. 1415. 1903(i) (4), the terms ‘skilled nursing home’ and ‘nursing home’ do not include a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts.” (b) Section 1908(g) (1) of such Act is amended by inserting after 81 Stat. 908. 42 USC 1396g. “Secretary” the following: “, but does not include a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts”. (c) The amendments made by this section shall be effective on the Effective date. date of the enactment of this Act. Sec. 269. requirements for nursing home administrators Section 1908(d) of the Social Security Act is amended by striking out “No State” and inserting in lieu thereof the following; “No State shall be considered to have failed to comply with the provisions of section 1902(a) (29) because the agency or board of such 42 USC 1396a. State (established pursuant to subsection (b)) shall have granted any waiver, with respect to any individual who, during all of the three calendar years immediately preceding the calendar year in which the requirements prescribed in section 1902(a) (29) are first met by the State, has served as a nursing home administrator, of any of the standards developed, imposed, and enforced by such agency or board pursuant to subsection (c). No State”. Sec. 271. increase in limitation on payments to puerto rico and the virgin islands for medical assistance (a) Section 1108(c)(1) of the Social Security Act is 42 USC 1308. amended by striking out “$20,000,000” and inserting in lieu thereof “$30,000,000”. (b) Section 1108(c)(2) of such Act is amended by striking out “$650,000” and inserting in lieu thereof “$1,000,000”. (c) The amendments made by subsections (a) and (b) shall apply Effective date. with respect to fiscal years beginning after June 30, 1971. Sec. 271A. medical assistance in puerto rico, the virgin islands, and guam (a) Section 227 (b) of the Social Security Amendments of 1967 is amended by striking out “June 30, 1972” and inserting in 81 Stat. 903. 42 USC 1396a note. Effective date. lieu thereof “June 30, 1975”. (b) The amendment made by subsection (a) shall be effective from and after July 1, 1972. Sec. 272. extension of title v to american samoa and the trust territory of the pacific islands (a) Section 1101(a)(1) of the Social Security Act is 42 USC 1301. amended by adding at the end thereof the following, new sentence: “Such term when used in title V also includes American Samoa and the Trust Territory of the Pacific Islands.” (b) Section 1108(d) of such Act is amended by inserting, after 42 USC 1308. “allot such smaller amount to Guam”, the following: “, American Samoa, and the Trust Territory of the Pacific Islands”. (c) The amendments made by this section shall apply with respect Effective date. to fiscal years beginning after June 30, 1971. Sec. 273. inclusion of chiropractor services under medicare (a) Section 1861 (r) of the Social Security Act (as amended by sections 256(b) and 264(a) of this Act) is further Ante, p. 1449. amended by— (1) striking out “or (4)” and inserting in lieu thereof “(4)”, and (2) inserting before the period at the end thereof the following “, or (5) a chiropractor who is licensed as such by the State (or in a State which does not license chiropractors as such, is legally authorized to perform the services of a chiropractor in the jurisdiction in which he performs such services), and who meets uniform minimum standards promulgated by the Secretary, but 42 USC 1395x. only for the purpose of sections 1861(s) (1) and 1861 (s) (2) (A) and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation demonstrated by X-ray to exist) which he is legally authorized to perform by the State or jurisdiction in which such treatment is provided”. (b) The amendments made by this section shall be effective with respect to services furnished after June 30, 1973. Sec. 274. miscellaneous technical, and clerical amendments (a) Clause (A) of section 1902(a) (26) of the Social 42 USC 1396a. Security Act is amended by striking out “evaluation” and inserting in lieu thereof “evaluation)”, and by striking out “care)” and inserting in lieu thereof “care”. (b) Section 1908(d) of such Act is amended by striking out “subsection (b) (1)” and inserting in lieu thereof “subsection (c) (1)”. Sec. 275. chiropractors’ services under medicaid (a) Section 1905 of the Social Security Act is amended by adding after subsection (f), as added by section 247 of this Act, the following new subsection: “(g) If the State plan includes provision of chiropractors’ services, such services include only— “(1) services provided by a chiropractor (A) who is licensed as such by the State and (B) who meets uniform minimum standards promulgated by the Secretary under section 1861 (r) (5); and “(2) services which consist of treatment by means of manual manipulation of the spine which the chiropractor is legally authorized to perform by the State.” (b) The amendment made by this section shall be effective with respect to services furnished after June 30, 1973. Sec. 276. services of podiatric interns and residents under part a of medicare (a) Section 1861(b)(6), as added by section 227(a) of this Act, is amended by deleting “; or” and inserting in lieu thereof the following: “, or in the case of services in a hospital or osteopathic hospital by an intern or resident-in-training in the field of podiatry, approved by the Council on Podiatry Education of the American Podiatry Association; or”. (b) The amendment made by this section shall apply with respect, to accounting periods beginning after December 31, 1972. Sec. 277. use of consultants for extended care facilities Section 1864(a) of the Social Security Act is amended by adding at the end the following new sentence: “Any State agency which has such an agreement may (subject to approval of the Secre-tary) furnish to an extended care facility, after proper request by such facility, such specialized consultative services (which such agency is able and willing to furnish in a manner satisfactory to the Secretary) as such facility may need to meet one or more of the conditions specified in section 1861(j). Any such services furnished by a State agency 42 USC 1395x. shall be deemed to have been furnished pursuant to such agreement.” Sec. 278. designation of extended care facilities and skilled nursing homes as skilled nursing facilities (a) The following sections of the Social Security Act are amended by striking out “extended care facility”, “extended care facilities”, “skilled nursing home”, and “skilled nursing homes” each time they appear therein and inserting in lieu thereof “skilled nursing facility” or “skilled nursing facilities”, as the case may be, and by changing “an” to “a” as appropriate: (1) section 1814(a) (2) (C); Ante, p. 1425. (2) section 1814(a) (6); 42 USC 1395f. (3) section 1814(a) (7): (4) section 1861(a) (2); 42 USC 1395x. (5) section 1861(h); (6) section 1861 (i); (7) section 1861(j); (8) section 1861 (k); (9) section 1861(1); (10) section 1861 (m) (7); (11) section 1861 (n); (12) section 1861(u); (13) section 1861(v) (3); (14) section 1861 (w); (15) section 1861 (y); (16) section 1864(a); 42 USC 1395aa. (17) section 1866; 42 USC 1395cc. (18) section 1902(a) (13); 42 USC 1396a. (19) section 1902(a) (26); (20) section 1902(a) (28); Ante, p. 1424. (21) section 1905(a) (4); 42 USC 1396d. (22) section 1905(a) (5); (23) section 1905(a) (14); and Ante, p. 1459. (24) section 1121. 42 USC 1320a. (b) The following sections of the Social Security Act, as amended or added by the provisions of this Act, are further amended by striking out the terms “extended care facility”, “extended care facilities”, “skilled nursing home”, and “skilled nursing homes” each time they appear therein and inserting in lieu thereof “skilled nursing facility” or “skilled nursing facilities”, as the case may be, and by changing “an” to “a” as appropriate: (1) section 1903 (g) and (h) of the Social Security Act as added by section 207 of this Act; (2) section 402(a) (1) (E) of the Social Security Amendments of 1967 as amended by section 222 of this Act; (3) section 1876 of the Social Security Act as added by section 226(a) of this Act; (4) section 1814(h) of such Act as added by section 228(a) of this Act; (5) section 1903(h) of such Act as added by section 207(a)(1) of this Act; (6) section 1861 (z) of such Act as added by section 234(f) of this Act; (7) section 1903(i) (4) of such Act. as added by section 237(a) of this Act; (8) section 1877(c) of such Act as added by section 242(b) of this Act; (9) section 1909(c) of such Act as added by section 242(c) of this Act; (10) section 1861 (i) of such Act as amended by section 248 of this Act: (11) section 1861 (v) (1) (E) of such Act as added by section 249(b) of this Act; (12) section 1910 of such Act as added by section 249A of this Act; (13) section 1861(j) of such Act as amended by section 267 of this Act; (14) section 1902(a) of such Act as amended by section 268 of this Act; (15) section 1864(a) of such Act as amended by section 277 of this Act; (16) section 1903 (j) of such Act as added by section 225 of this Act; (17) section 1814(h) of such Act as added by section 228(a) of this Act; and (18) section 1866(a)(1) of such Act as amended by section 249A of this Act. Sec. 279. direct laboratory billing of patients (a) Section 1833(a) (1) of the Social Security Act (as Ante, p. 1384. amended by section 211(c)(4) of this Act) is further amended by— (1) striking out “and” before “(C)”; (2) inserting before the semicolon at the end thereof the following: “, and (D) with respect to diagnostic tests performed in a laboratory for which payment is made under this part to the laboratory, the amounts paid shall be equal to 100 percent of the negotiated rate for such tests (as determined pursuant to subsection (g) of this section)”. (b) Section 1833 of such Act is amended by adding at the end thereof the following subsection: “(g) With respect to diagnostic tests performed in a laboratory for which payment is made under this part to the laboratory, the Secretary is authorized to establish a payment rate which is acceptable to the laboratory and which would be considered the full charge for such tests. Such negotiated rate shall be limited to an amount not in excess of the total payment that would have been made for the services in the absence of such a rate.” Sec. 280. clarification of meaning of “physicians’ services” under title xix Section 1905(a) (5) of the Social Security Act is amended by inserting “furnished by a physician (as defined in section 1861 (r) (1))” after “physicians’ services”. Sec. 281. limitation on adjustment or recovery of incorrect payments under the medicare program (a) (1) Section 1870(b)(1) of the Social Security Act is amended by— (A) inserting “(A)” after “the Secretary determines”; and (B) inserting at the end of paragraph (1) the following: “(B) that such provider of services or other person was without fault with respect to the payment of such excess over the correct amount, or”. (2) Section 1870(b) of such Act is amended by adding at the end 42 USC 1395gg. the following new sentence: “For purposes of clause (B) of paragraph (1), such provider of services or such other person shall, in the absence of evidence to the contrary, be deemed to be without fault if the Secretary’s determination that more than such correct amount was paid was made subsequent to the third year following the year in which notice was sent to such individual that such amount had been paid; except that the Secretary may reduce such three-year period to not less than one year if he finds such reduction is consistent with the objectives of this title.” (b) Section 1870(c) of such Act (as amended by section 261 of this Act) is further amended by— (1) inserting “or title XVIII” after “title II”, and (2) adding at the end the following new sentence: “Adjustment or recovery of an incorrect, payment (or only such part of an incorrect payment as the Secretary determines to be inconsistent with the purposes of this title) against an individual who is without fault shall be deemed to be against equity and good conscience if (A) the incorrect payment was made for expenses incurred for items or services for which payment may not be made under this title by reason of the provisions of paragraph (1) or (9) of section 1862 and (B) if the Secretary’s determination 42 USC 1395y. that such payment was incorrect was made subsequent to the third year following the year in which notice of such payment was sent to such individual; except that the Secretary may reduce such three-year period to not less than one year if he finds such reduction is consistent with the objectives of this title.” (c) Section 1866(a)(1) of such Act (as amended by section 227(d)(2) of this Act) is further amended by— (1) redesignating subparagraph (B) as subparagraph (C), and (2) inserting after subparagraph (A) the following new subparagraph: “(B) not to charge any individual or any other person for items or services for which such individual is not entitled to have payment made under this title because payment for expenses incurred for such items or services may not be made by reason of the provisions of paragraph (1) or (9), but only if (i) such individual was without fault in incurring such expenses and (ii) the Secretary’s determination that such payment may not be made for such items and services was made after the third year following the year in which notice of such payment was sent to such individual; except that the Secretary may reduce such three-year period to not less than one year if he finds such reduction is consistent with the objectives of this title, and” (d) Section 1842(b) (3) (B) (ii) of such Act (as amended by section 211(c) (3) of this Act) is further amended by— (1) inserting “(I)” after “of which”; and (2) inserting after “service” the following: “and (II) the physician or other person furnishing such service agrees not to charge for such service if payment may not be made therefor by reason of the provisions of paragraph (1) of section 1862, and if the individual to whom such service was furnished was without fault in incurring the expenses of such service, and if the Secretary’s determination that payment (pursuant to such assignment) was incorrect and was made subsequent to the third year following the year in which notice of such payment was sent to such individual; except that the Secretary may reduce such three-year period to not less than one year if he finds such reduction is consistent with the objectives of this title.” (e) Section 1814(a) (1) of such Act is amended to read as follows: “(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;”. (f) Section 1835(a) (1) of such Act is amended to read as follows: “(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; and”. (g) The provisions of subsection (a)(1) shall apply with respect to notices of payment sent to individuals after the date of enactment of this Act. The provisions of subsections (a)(2), (b), (c), and (d) shall apply in the case of notices sent to individuals after 1968. The Provisions of subsections (e) and (f) shall apply in the case of services furnished (or deemed to have been furnished) after 1970. Sec. 283. coverage of outpatient speech pathology services under medicare (a) Section 1861 (p) of the Social Security Act is amended by adding at the end thereof the following new sentence: “The term ‘outpatient physical therapy services’ also includes speech pathology services furnished by a provider of services, a clinic, rehabilitation agency, or by a public health agency, or by others under an arrangement with, and under the supervision of, such provider, clinic, rehabilitation agency, or public health agency to an individual as an outpatient, subject to the conditions prescribed in this subsection.”. (b) Section 1835(a) (2) of such Act (as amended by section 251 of this Act) is further amended— (1) by striking out the period at the end of subparagraph (C) and inserting in lieu thereof “; and”; and (2) by adding after subparagraph (C) the following new subparagraph: “(D) in the case of outpatient speech pathology services, (i) such services are or were required because the individual needed speech pathology services (ii) a plan for furnishing such services has been established and is periodically reviewed by a physician, and (iii) such services are or were furnished while the individual is or was under the care of a physician.”. (c) The provisions of this section shall apply with respect to services rendered after December 31, 1972. Sec. 287. termination of medical assistance advisory council (a) Section 1906 of the Social Security Act is repealed. Repeal. 42 USC 1396e. Effective date. (b) The provisions of subsection (a) shall become effective on the first day of the third calendar month following the month in which this Act is enacted. Sec. 288. modification of the role of the health insurance benefits advisory council (a) Section 1867 (a) of the Social Security Act is amended 42 USC 1395dd. to read as follows: “(a) There is hereby created a Health Insurance Benefits Advisory Council which shall consist of 19 persons, not otherwise in the employ of the United States, appointed by the Secretary without regard to the provisions of title 5. United States Code, governing appointments 5 USC 101 et seq. in the competitive services. The Secretary shall from time to time appoint one of the members to serve as Chairman. The members shall include persons who are outstanding in fields related to hospital, medical, and other health activities, persons who are representative of organizations and associations of professional personnel in the field of medicine, and at least one person who is representative of the general public. Each member shall hold office for a term of four years, except that any member appointed to fill a vacancy occurring prior to the expiration of the term for which his predecessor was appointed shall be appointed for the remainder of such term. A member shall not be eligible to serve continuously for more than two terms. Members Per diem and travel expenses. of the Advisory Council, while attending meetings or conferences thereof or otherwise serving on business of the Advisory Council, shall be entitled to receive compensation at rates fixed by the Secretary, but not exceeding $100 per day, including traveltime, and while so serving away from their homes or regular places of business they may be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5703 of title 5, United States Code, for persons in the Government service employed intermittently. The Advisory Council shall meet as the Secretary deems necessary, but not less than annually.” (b) Section 1867(b) of such Act is amended to read as follows: “(b) It shall be the function of the Advisory Council to provide advice and recommendations for the consideration of the Secretary on matters of general policy with respect to this title and title XIX.” 42 USC 1395, 1396. (c) Section 1867 of such Act is further amended by striking out subsection (c). Sec. 289. authority of secretary to administer oaths in medicare proceedings Section 1874 of the Social Security Act is amended by 42 USC 1395kk. adding at the end thereof the following new subsection: “(c) In the course of any hearing, investigation, or other proceeding that he is authorized to conduct under this title, the Secretary may administer oaths and affirmations.” Sec. 290. withholding of federal payments under medicaid with respect to certain health care facilities Section 1903 of the Social Security Act is amended by adding Ante, pp. 1396, 1454. after subsection (i) thereof the following new subsection: “(j) (1) Notwithstanding the preceding provisions of this section, no payment shall be made to a State (except as provided under this subsection) with respect to expenditures incurred by it for services provided by any institution during any period that an order for suspension of payment (as authorized by this subsection) is effective with respect to such institution. “(2) The Secretary may issue a suspension of payment order with respect to any institution if— “(A) such institution (i) does not (at the time such order is issued) have in effect an agreement with the Secretary which is 42 USC 1395cc. entered into pursuant to section 18(56; and (ii) did (prior to the time such order is issued) have in effect such an agreement; and “(B) (i) the Secretary’ has been unable to collect (or make satisfactory arrangement for the collection of) amounts due on account of overpayments made to such institution under title 42 USC 1395. XVIII; or “(ii) the Secretary has been unable to obtain from such institution the data and information necessary to enable him to determine the amount (if any) of the overpayments made to such institution under title XVIII. “(3) Whenever the Secretary issues any order for suspension of payment under this subsection with respect to any institution, he shall submit a notice of such order to the single State agency (referred to in section 1902(a) (5)) of each State which he has reason to believe does or may utilize the services of such institution in providing medical assistance under a plan approved under this title. “(4) Any order for suspension of payment issued with respect to any institution under this subsection shall become effective, in the case of any state plan approved under this title, on the 60th day after the date the State agency (referred 42 USC 1396a. to in section 1902(a) (5)) administering or supervising the administration of such plan receives notice of such older submitted pursuant to paragraph (3). Any such order shall cease to be effective at such time as the Secretary is satisfied that the institution is participating in substantial negotiations which seek to remedy the conditions which gave rise to his order of suspension of payments, or that the amounts (referred to in paragraph (2)) are no longer due from such institution or that a satisfactory arrangement has been made for the payment by such institution of any such amounts. Upon the determination of the Secretary that any such order with respect to any such institution shall cease to be effective, he shall forthwith notify each State agency to which he has theretofore submitted notice under paragraph (3) with respect to such institution. “(5) Whenever any order which has been issued by the Secretary under the preceding provisions of this subsection with respect to an institution ceases to be effective, any payment to which any State would (except for the preceding provisions of this subsection) have been entitled under this section on account of services provided by such institution shall be made to such State for the month in which such order ceases to be effective.” Sec. 292. intermediate care services in states which do not have a medicaid program Section 4(d) of Public Law 92–223 (approved December 85 Stat. 810. 42 USC 1396a note. 28, 1971) is amended by inserting immediately before the period at the end thereof the following: “; except that the repeal made by subsection (c) shall not become effective in the case of any State, which on January 1, 1972 did not have in effect a State plan approved 42 USC 1396. under title XIX of the Social Security Act, until the first day of the first month (occurring after such date) that such State does have in effect a State plan approved under such title”. Sec. 293. required information relating to excess medicare tax payments by railroad employees (a) Section 6051(a) of the Internal Revenue Code of 1954 68A Stat. 747. 26 USC 6051. (relating to requirement of receipts for employees) is amended— (1) by striking out “section 3101, 3201, or 3402” in the matter preceding paragraph (1) and inserting in lieu thereof “section 3101 or 3402”; (2) by inserting “and” at the end of paragraph (5), and by striking out the comma at the end of paragraph (6) and inserting in lieu thereof a period; and (3) by striking out paragraphs (7) and (8). (b) Section 6051(c) ‘of such Code (relating to additional requirements (is amended by striking out “sections 3101 and 3201” in the second sentence and inserting in lieu thereof “section 3101”. (c) Section 6051 of such Code (relating to receipts for employees) is amended by adding at the end thereof the following new subsection: “(e) Railroad Employees.— “(1) Additional requirement.— Every person required to deduct and withhold tax under section 3201 from an employee shall include on or with the statement required to be furnished such employee under subsection (a) a notice concerning the provisions of this title with respect to the allowance of a credit or refund of the tax on wages imposed by section 3101 (b) and the tax on compensation imposed by section 3201 or 3211 which is treated as a tax on wages imposed by section 3101 (b). “(2) Information to be supplied to employees.— Each person required to deduct and withhold tax under section 3201 during any year from an employee who has also received wages during such year subject to the tax imposed by section 3101(b) shall, upon request of such employee, furnish to him a written statement showing— “(A) the total amount of compensation with respect to which the tax imposed by section 3201 was deducted, “(B) the total amount deducted as tax under section 3201, and “(C) the portion of the total amount deducted as tax under section 3201 which is for financing the cost of hospital insurance under part A of title XVIII of the Social Security Act.” 42 USC 1395c. “(d) The amendments made by this section shall apply in respect Effective date. to remuneration paid after December 31, 1971. Sec. 294. appointment and confirmation of administrator of social and rehabilitation service Appointments made on or after the date of enactment of this Act to the office of Administrator of the Social and Rehabilitation Service, within the Department of Health, Education, and Welfare, shall be made by the President, by and with the advice and consent of the Senate. Sec. 295. repeal of section 1903(b)(1) Section 1903(b) (1) of the Social Security Act is repealed. 42 USC 1396b. Sec. 297. coverage under medicaid of intermediate care furnished in mental and tuberculosis institutions (a) Section 1905(a) (14) of the Social Security Act is 42 USC 1396d. amended to read as follows: “(14) inpatient hospital services, skilled nursing home services, and intermediate care facility services for individuals 65 years of age or over in an institution for tuberculosis or mental diseases;” “(b) The amendment, made by this section shall apply with respect to services furnished after December 31, 1972. Sec. 298. independent review of intermediate care facility patients Section 1902(a) (31) (A) of the Social Security Act, as 85 Stat. 809. 42 USC 1396a. added by Public Law 92–223, is amended by striking out the phrase “which provides more than a minimum level of health care services.” Sec. 299. intermediate care, maintenance of effort in public institutions Section 1905(d) (3) of the Social Security Act, as added 42 USC 1396d. by Public Law 92–223, is amended to read as follows: “(3) the State or political subdivision responsible for the operation of such institution has agreed that the non-Federal expenditures in any calendar quarter prior to January 1, 1975, with respect to services furnished to patients in such institution (or distinct part thereof) in the State will not, because of payments made under this title, be reduced below the average amount expended for such services in such institution in the four quarters immediately preceding the quarter in which the State in which such institution is located elected to make such services available under its plan approved under this title.” Sec. 299A. disclosure of ownership of operations of intermediate care facilities Section 1902(a) of the Social Security Act, as amended by sections 236, 239, and 255 of this Act, is further amended— (1) by striking out “and” at the end of paragraph’ (33); (2) by striking out the period at the end of paragraph (34) and inserting in lieu thereof “; and”; and (3) by inserting after paragraph (34) the following new paragraph: “(35) effective January 1, 1973, provide that any intermediate care facility receiving payments under such plan must supply to the licensing agency of the State full and complete information as to the identity (A) of each person having (directly or indirectly) an ownership interest of 10 per centum or more in such intermediate care facility, (B) in case an intermediate care facility is organized as a corporation, of each officer and director of the corporation, and (C) in case an intermediate care facility is organized as a partnership, of each partner; and promptly report any changes which would affect the current accuracy of the information so required to be supplied.” Sec. 299B. treatment in mental hospitals for individuals under age 21 (a) Section 1905(a) of the Social Security Act is amended— (1) by striking the word “and” in paragraph (15); (2) by redesignating paragraph (15) as paragraph (17); (3) by redesignating paragraph (16) as paragraph (15); (4) by inserting after paragraph (15) the following new paragraph: “(16) effective January 1, 1973, inpatient psychiatric hospital services for individuals under 21, as defined in subsection (e);”. (b) Section 1905 of such Act, as amended by sections 212(a), 247 (b) and 275(e) of this Act, is further amended by adding after subsection Ante, p. 1452. (g) the following new subsection: “(h) (1) For purposes of paragraph (16) of subsection (a), the term Definition. ‘inpatient psychiatric hospital services for individuals under age 21’ includes only— “(A) inpatient services which are provided in an institution which is accredited as a psychiatric hospital by the Joint Commission on Accreditation of Hospitals; “(B) inpatient services which, in the case of any individual, involves active treatment (i) which meets such standards as may be prescribed pursuant to title XVIII in regulations by the Secretary, 42 USC 1395. and (ii) which a team, consisting of physicians and other personnel qualified to make determinations with respect to mental health conditions and the treatment thereof, has determined are necessary on an inpatient basis and can reasonably be expected to improve the condition, by reason of which such services are necessary, to the extent that eventually such services will no longer be necessary; and “(C) inpatient services which, in the case of any individual, are provided prior to (A) the date such individual attains age 21, or (B) in the case of an individual who was receiving such services in the period immediately preceding the date on which he attained age 21, (i) the date such individual no longer requires such services, or (ii) if earlier, the date such individual attains age 22; “(2) Such term does not include services provided during any calendar quarter under the State plan of any State if the total amount of the funds expended, during such quarter, by the State (and the political subdivisions thereof) from non-Federal funds for inpatient services included under paragraph (e)(1), and for active psychiatric care and treatment provided on an outpatient basis for eligible mentally ill children, is less than the average quarterly amount of the funds expended, during the 4-quarter period ending December 31, 1971, by the State (and the political subdivisions thereof) from non-Federal funds for such services,” (c) Section 1905(a) is further amended by striking out, in the part which follows paragraph (17) (as redesignated by subsection (a) of this section), “except that” and inserting in lieu thereof “except as otherwise, provided in paragraph (16),”. Sec. 299D. public disclosure of information concerning survey reports of an institution (a) Section 1864(a) of the Social Security Act is Ante, pp, 1452–1454. amended by adding at the end thereof the following new sentence: “Within 90 days following the completion of each survey of any health care facility, laboratory, clinic, agency, or organization by the appropriate State or local agency described in the first sentence of this subsection, the Secretary shall make public in readily available form and place the pertinent findings of each such survey relating to the compliance of each such health care facility, laboratory’, clinic, agency, or organization with (1) the statutory conditions of participation imposed under this title and (2) the major additional conditions which the Secretary finds necessary in the interest of health and safety of individuals who are furnished care or services by any such facility, laboratory, clinic, agency, or organization.”. (b) Section 1902(a) of the Social Security Act, as amended by sections Ante, p. 1460. 236, 239, 255, and 299A of this Act, is further amended— (1) by striking out “and” at the end of paragraph (35); (2) by striking out the period at the end of paragraph (36) and inserting in hen thereof “; and”; and (3) by inserting after paragraph (36) the following new paragraph: “(37) provide that within 90 days following the completion of each survey of any health care facility, laboratory, agency, clinic, or organization, by the appropriate State agency described in paragraph (9), such agency shall (in accordance with regulations of the Secretary) make public in readily available form and place the pertinent findings of each such survey relating to the compliance of each such health care facility, laboratory, clinic, agency, or organization with (A) the statutory conditions of participation imposed under this title, and (B) the major additional conditions which the Secretary finds necessary in the interest of health and safety of individuals who are furnished care or services by any such facility, laboratory, clinic, agency, or organization. (c) The provisions of this section shall be effective beginning January 1, 1973, or within 6 months following the enactment of this Act, whichever is later. Sec. 299E. family planning services mandatory under medicaid (a) Section 1903(a) of the Social Security Act, as Ante, p. 1428. amended by sections 235 and 249B of this Act, is further amended by redesignating paragraph (5) as paragraph (6), and by inserting after paragraph (4) the following new paragraph: “(5) an amount equal to 90 per centum of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the plan) which are attributable to the offering, arranging, and furnishing (directly or on a contract basis) of family planning services and supplies;”. (b) Section 1905(a)(4) of the Social Security Act is amended by adding after clause (B) the following: “and (C) family planning services and supplies furnished (directly or under arrangements with others) to individuals of child-bearing age (including minors who can be considered to be sexually active) who are eligible under the State plan and who desire such services and supplies.;”. (c) Section 402(a) (15) (B) of such Act is amended, effective January 1, 1973, (1) by adding after “in all appropriate cases” the following: “(including minors who can be considered to be sexually active)”, and (2) by adding after “family planning services are offered them” the following: “and are provided promptly (directly or under arrangements with others) to all individuals voluntarily requesting such services”. (d) Section 403 of such Act is amended by adding at the end thereof the following new sections: “(e) Notwithstanding any other provision of subsection (a), with respect to expenditures during any calendar quarter beginning after December 31, 1972 (as found necessary by the Secretary for the proper and efficient administration of the plan) which are attributable to the offering, arranging, and furnishing, directly or on a contract basis, of family planning services and supplies, the amount payable to any State under this part shall be 90 per centum of such expenditures. “(f) Notwithstanding’ any other provision of this section, the amount payable to any State under this part for quarters in a fiscal year shall with respect to quarters in fiscal years beginning after June 30, 1973, be reduced by 1 per centum (calculated without regard to any reduction under section 403(g)) of such amount if such State— Infra. “(1) in the immediately preceding fiscal year failed to carry out the provisions of section 402(a) (15) (B) as pertain to requiring Ante, p. 1462. the offering and arrangement for provision of family planning services; or “(2) in the immediately preceding fiscal year (but, in the case of the fiscal year beginning July 1, 1972, only considering the third and fourth quarters thereof), failed to carry out the provisions of section 402(a) (15) (B) of the Social Security Act with respect to any individual who, within such period or periods as the Secretary may prescribe., has been an applicant for or recipient of aid to families with dependent children under the plan of the State approved under this part.” Sec. 299F. penalty for failure to provide child health screening services under medicaid Section 403 of the Social Security Act is amended by adding at the end thereof the following: “(g) Notwithstanding any other provision of this section, the amount payable to any State under this part for quarters in a fiscal year shall with respect to quarters in fiscal years beginning after June 30, 1974, be reduced by 1 per centum (calculated without regard to any reduction under section 403(f)) of such amount if such State Supra. fails to— “(1) inform all families in the State receiving aid to families with dependent children under the plan of the State approved under this part of the availability of child health screening services under the plan of such State approved under title XIX, Ante, p. 1426. “(2) provide or arrange for the provision of such screening services in all cases where they are requested, or “(3) arrange for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment the need for which is disclosed by such child health screening services.” Sec. 299I. chronic renal disease considered to constitute disability Effective with respect to services provided on and after Effective date. July 1, 1973, section 226 of the Social Security Act (as amended by section 201(b)(5) of this Act) is amended by redesignating subsection Ante, p. 1372. (e) as subsection (f), and by inserting after subsection (d) the following new subsection: “(e) Notwithstanding the foregoing provisions of this section, every individual who— “(1) has not attained the age of 65; “(2) (A) is fully or currently insured (as such terms are defined in section 214 of this Act), or (B) is entitled to monthly insurance Ante, p. 1341. 42 USC 401. benefits under title II of this Act, or (C) is the spouse or dependent child (as defined in regulations) of an individual who is fully or currently insured, or (D) is the spouse or dependent child (as defined in regulations) of an individual entitled to monthly insurance benefits under title II of this Act; and “(3) is medically determined to have chronic renal disease and who requires hemodialysis or renal transplantation for such disease; shall be deemed to be disabled for purposes of coverage under parts A and B of Medicare subject to the deductible, premium, and copayment 42 USC 1395. provisions of title XVIII. “(f) Medicare eligibility on the basis of chronic kidney failure shall begin with the third month after the month in which a course of renal dialysis is initiated and would end with the twelfth month after the month in which the person has a renal transplant or such course of dialysis is terminated. “(g) The Secretary is authorized to limit reimbursement under Medicare for kidney transplant and dialysis to kidney disease treatment centers which meet such requirements as he may by regulation prescribe: Provided, That such requirements must include at least requirements for a minimal utilization rate for covered procedures and for a medical review board to screen the appropriateness of patients for the proposed treatment procedures.” Sec. 299K. elimination of coinsurance payment with respect to home health services under part b of medicare (a) Section 1833(a)(2) of the Social Security Act is amended by striking out “80 percent” and inserting in lieu thereof “with respect to home health services, 100 percent, and with respect to other services, 80 percent.” (b) The amendment made by subsection (a) shall apply to services furnished by home health agencies in accounting periods beginning after December 31, 1972. Sec. 299L. certification of intermediate care facilities and skilled nursing facilities located on an indian reservation (a) Section 1905(c) of the Social Security Act, as added 85 Stat. 809. 42 USC 1396d. by Public Law 92–223, is amended by adding after the penultimate sentence thereof the following: “The term ‘intermediate care facility’ also includes any institution which is located in a State on an Indian reservation and is certified by the Secretary as meeting the requirements of clauses (2) and (3) of this subsection and providing the care and services required under clauses (1).”. (b) Section 1905 of the Social Security Act, as amended by this Act, is amended by adding at the end thereof the following new subsection: “(h) For purposes of this title, the term ‘skilled nursing facility’ also includes any institution which is located in a State on an Indian reservation and is certified by the Secretary as being a qualified skilled 42 USC 1395x. nursing facility by meeting the requirements of section 1861(j).” Sec. 299O. determinations and appeals (a) Section 1869(b) of the Social Security Act is amended to read as follows: “(b) (1) Any individual dissatisfied with any determination under subsection (a) as to— “(A) whether he meets the conditions of section 226 of this Act 79 Stat. 333; 81 Stat. 854. 42 USC 426a. 42 USC 1395j. Ante, p. 1374. or section 103 of the Social Security Amendments of 1965, or “(B) whether he is eligible to enroll and has enrolled pursuant to the provisions of part B of this title, or section 1818, or section 1819, or “(C) the amount of benefits under part A (including a determination where such amount is determined to be zero) shall be entitled to a hearing thereon by the Secretary to the same extent as is provided in section 205(b) and to judicial review of the Secretary’s 42 USC 405. final decision after such hearing as is provided in section 205 (g). “(2) Notwithstanding the provisions of subparagraph (C) of paragraph (1) of this subsection, a hearing shall not be available to an individual by reason of such subparagraph (C) if the amount in controversy is less than $100; nor shall judicial review be available to an individual by reason of such subparagraph (C) if the amount in controversy is less than $1,000.” (b) (1) The provisions of subparagraphs (A) and (B) of section Effective dates. 1869(b) (1) of the Social Security Act, as amended by subsection (a) of this section, shall be effective on the date of enactment of this Act. (2) The provisions of paragraph (2) and of subparagraph (C) of paragraph (1) of section 1869(b) of the Social Security Act, as amended by subsection (a) of this section, shall be effective with respect to any claims under part A of title XVIII of such Act, filed— 42 USC 1395c. (A) in or after the month in which this Act is enacted, or (B) before the month in which this Act is enacted, but only if a civil action with respect to a final decision of the Secretary of Health, Education, and Welfare on such claim has not been commenced under such section 1869(b) before such month.

3. 1982

   Pub. L. 97–248 § 122(g)(4) · 96 Stat. 324

   Substituted · 42 U.S.C. § 1395bb(a)

   Pub. L. 97–248, § 122(g)(4), substituted “(o), or (dd)” for “or (o)”

   Source evidence

   Code amendment note
   Subsec. (a). Pub. L. 97–248, § 122(g)(4), substituted “(o), or (dd)” for “or (o)”.

   Enacted provision · exact public law section
   (4) Section 1865(a) of such Act is amended by striking out “"or (o)” 42 USC 1395bb. in the last sentence and inserting in lieu thereof “(o), or (dd)”.

4. 1982

   Pub. L. 97–248 § 128(d)(3) · 96 Stat. 324

   1. Substituted · 42 U.S.C. § 1395bb(b)

      Pub. L. 97–248, § 128(d)(3), substituted “a hospital” for “an institution”

   2. Substituted · 42 U.S.C. § 1395bb(b)

      Pub. L. 97–248, § 128(d)(3), substituted “the hospital” for “such institution”

   Source evidence

   Code amendment note
   Subsec. (b). Pub. L. 97–248, § 128(d)(3), substituted “a hospital” for “an institution” and “the hospital” for “such institution”.

   Enacted provision · exact public law section
   (3) Section 1865(b) of such Act is amended by striking out “an 42 USC 1395bb. institution” and “such institution” and inserting in lieu thereof “a hospital” and “the hospital”, respectively.

5. 1984

   Spending Reduction Act of 1984

   Pub. L. 98–369 § 2346(a) · 98 Stat. 494

   1. Substituted · 42 U.S.C. § 1395bb(a)

      Pub. L. 98–369, § 2346(a), in provisions following par. (4), substituted “section 1395k(a)(2)(F)(i), 1395x(e), 1395x(f), 1395x(j), 1395x(o), 1395x(p)(4)(A) or (B), paragraphs (11) and (12) of section 1395x(s), section 1395x(aa)(2), 1395x(cc)(2), or 1395x(dd)(2) of this title” for “section 1395x(e), (j), (o), or (dd) of this title”

   2. Substituted · 42 U.S.C. § 1395bb(a)

      Pub. L. 98–369, § 2346(a), in provisions following par. (4), substituted “entity” for “institution or agency” in two places

   Source evidence

   Code amendment note
   Subsec. (a). Pub. L. 98–369, § 2346(a), in provisions following par. (4), substituted “section 1395k(a)(2)(F)(i), 1395x(e), 1395x(f), 1395x(j), 1395x(o), 1395x(p)(4)(A) or (B), paragraphs (11) and (12) of section 1395x(s), section 1395x(aa)(2), 1395x(cc)(2), or 1395x(dd)(2) of this title” for “section 1395x(e), (j), (o), or (dd) of this title”, and substituted “entity” for “institution or agency” in two places.

   Enacted provision · exact public law section
   (a) The third sentence of section 1865(a) of the Social Security Act is amended— (1) by striking out “section 1861(e), (j), (o), or (dd)” and inserting in lieu thereof “section 1832(a)(2)(F)(i), 1861(e), 1861(f), 1861(j), 1861(o), 1861(p)(4)(A) or (B), paragraphs (11) and (12) of section 1861(s), section 1861(aa)(2), 1861(cc)(2), or 1861(dd)(2)”; and (2) by striking out “institution or agency” each place it appears and inserting in lieu thereof in each instance “entity”.

6. 1984

   Spending Reduction Act of 1984

   Pub. L. 98–369 § 2345(a) · 98 Stat. 494

   1. Struck · 42 U.S.C. § 1395bb(a)

      Pub. L. 98–369, § 2345(a), struck out “(on a confidential basis)” after “release to the Secretary” in par. (2)

   2. Inserted · 42 U.S.C. § 1395bb(a)

      Pub. L. 98–369, § 2345(a), inserted provision that the Secretary may not disclose any accreditation survey made and released to him by the Joint Commission on Accreditation of Hospitals, the American Osteopathic Association, or any other national accreditation body, of an entity accredited by such body, in provisions following par. (4)

   Target inherited from the preceding amendment note.

   Source evidence

   Code amendment note
   Pub. L. 98–369, § 2345(a), struck out “(on a confidential basis)” after “release to the Secretary” in par. (2), and inserted provision that the Secretary may not disclose any accreditation survey made and released to him by the Joint Commission on Accreditation of Hospitals, the American Osteopathic Association, or any other national accreditation body, of an entity accredited by such body, in provisions following par. (4).

   Enacted provision · exact public law section
   (a) Section 1865(a) of the Social Security Act is amended— (1) in paragraph (2), by striking out “(on a confidential basis)”; and (2) by adding at the end thereof the following new sentence: “The Secretary may not disclose any accreditation survey made and released to him by the Joint Commission on Accreditation of Hospitals, the American Osteopathic Association, or any other national accreditation body, of an entity accredited by such body.”.

7. 1986

   Omnibus Budget Reconciliation Act of 1986

   Pub. L. 99–509 § 9305(c)(3) · 100 Stat. 1874

   Inserted · 42 U.S.C. § 1395bb(a)

   Pub. L. 99–509, § 9305(c)(3), inserted “, requires a discharge planning process (or imposes another requirement which serves substantially the same purpose)” after “the same purpose)”, and “clause (A) or (B) of” after “comply also with” in second sentence

   Source evidence

   Code amendment note
   Subsec. (a). Pub. L. 99–509, § 9305(c)(3), inserted “, requires a discharge planning process (or imposes another requirement which serves substantially the same purpose)” after “the same purpose)”, and “clause (A) or (B) of” after “comply also with” in second sentence.

   Enacted provision · exact public law section
   (3) Effect of accreditation.— The second sentence of section 1865(a) of such Act (42 U.S.C. 1395bb(a)) is amended— (A) by inserting “, requires a discharge planning process (or imposes another requirement which serves substantially the same purpose),” after “the same purpose)”, and (B) by inserting “clause (A) or (B) of” after “comply also with”.

8. 1986

   Omnibus Budget Reconciliation Act of 1986

   Pub. L. 99–509 § 9320(h)(3) · 100 Stat. 1874

   Substituted · 42 U.S.C. § 1395bb(a)

   Pub. L. 99–509, § 9320(h)(3), substituted “paragraphs (12) and (13)” for “paragraphs (11) and (12)” in third sentence

   Target inherited from the preceding amendment note.

   Source evidence

   Code amendment note
   Pub. L. 99–509, § 9320(h)(3), substituted “paragraphs (12) and (13)” for “paragraphs (11) and (12)” in third sentence.

   Enacted provision · exact public law section
   (3) Sections 1864(a), 1865(a), 1902(a)(9)(C), and 1915(a)(1)(B)(ii)(I) of such Act (42 U.S.C. 1395aa(a), 1395bb(a), 1396a(a)(9)(C), 1396n(a)(1)(B)(ii)(I)) are each amended by striking “paragraphs (11) and (12)” and inserting “paragraphs (12) and (13)”.

9. 1988

   Medicare Catastrophic Coverage Act of 1988

   Pub. L. 100–360 § 411(d)(4)(B)(ii) · 102 Stat. 683

   1. Amended · 42 U.S.C. § 1395bb(a)

      Pub. L. 100–360, § 411(d)(4)(B)(ii), as amended by Pub. L. 100–485, § 608(d)(20)(D)

   2. Added · 42 U.S.C. § 1395bb(a)

      Pub. L. 100–360, § 411(d)(4)(B)(ii), as added Pub. L. 100–203, § 4025(b), see 1987 Amendment note below

   Source evidence

   Code amendment note
   Subsec. (a). Pub. L. 100–360, § 411(d)(4)(B)(ii), as amended by Pub. L. 100–485, § 608(d)(20)(D), added Pub. L. 100–203, § 4025(b), see 1987 Amendment note below.

   Enacted provision · exact public law section
   (ii) by inserting after subsection (a) the following new subsection: “(b) Conforming Amendment.— The last sentence of section 1865(a) of such Act (42 U.S.C. 1395bb(a)) is amended by inserting ‘(other than a survey with respect to a home health agency’ after ‘any accreditation survey’.”.

10. 1988

    Medicare Catastrophic Coverage Act of 1988

    Pub. L. 100–360 § 204(d)(3) · 102 Stat. 683

    Substituted · 42 U.S.C. § 1395bb(a)

    Pub. L. 100–360, § 204(d)(3), substituted “paragraphs (14) and (15)” for “paragraphs (13) and (14)” in third sentence

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    Pub. L. 100–360, § 204(d)(3), substituted “paragraphs (14) and (15)” for “paragraphs (13) and (14)” in third sentence.

    Enacted provision · exact public law section
    (3) Sections 1864(a), 1865(a), 1902(a)(9)(C), and 1915(a)(1)(B)(ii)(I) (42 U.S.C. 1395aa(a), 1395bb(a), 1396a(a)(9)(C), 1396n(a)(1)(B)(ii)(D) are each amended by striking “paragraphs (13) and (14)” and inserting “paragraphs (14) and (15)”.

11. 1988

    Medicare Catastrophic Coverage Act of 1988

    Pub. L. 100–360 § 204(c)(3) · 102 Stat. 683

    Inserted · 42 U.S.C. § 1395bb(a)

    Pub. L. 100–360, § 204(c)(3), inserted “1395m(e)(3),” after “1395k(a)(2)(F)(i),” in third sentence

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    Pub. L. 100–360, § 204(c)(3), inserted “1395m(e)(3),” after “1395k(a)(2)(F)(i),” in third sentence.

    Enacted provision · exact public law section
    (3) Section 1865(a) (42 U.S.C. 1395bb(a)) is amended by inserting “1834(e)(3),” after “1832(a)(2)(F)(i),”.

12. 1987

    Pub. L. 100–203 § 4072(d) · 101 Stat. 1330

    Substituted · 42 U.S.C. § 1395bb(a)

    Pub. L. 100–203, § 4072(d), substituted “paragraphs (13) and (14)” for “paragraphs (12) and (13)” in penultimate sentence

    Source evidence

    Code amendment note
    Subsec. (a). Pub. L. 100–203, § 4072(d), substituted “paragraphs (13) and (14)” for “paragraphs (12) and (13)” in penultimate sentence.

    Enacted provision · exact public law section
    (d) Conforming Amendments.— Sections 1864(a), 1865(a), 1902(a)(9)(C), and 1915(a)(1)(B)(ii)(I) of such Act (42 U.S.C. 1395aa(a), 1395bb(a), 1396a(a)(9)(C), 1396n(a)(1)(B)(ii)(I)) are each amended by striking out “paragraphs (12) and (13)” and inserting “paragraphs (13) and (14)”.

13. 1987

    Pub. L. 100–203 § 4025(b) · 101 Stat. 1330

    1. Added · 42 U.S.C. § 1395bb(a)

       Pub. L. 100–203, § 4025(b), as added by Pub. L. 100–360, § 411(d)(4)(B)(ii), as amended by Pub. L. 100–485, § 608(d)(20)(D)

    2. Inserted · 42 U.S.C. § 1395bb(a)

       Pub. L. 100–203, § 4025(b), as inserted “(other than a survey with respect to a home health agency)” after “survey” in last sentence

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    Pub. L. 100–203, § 4025(b), as added by Pub. L. 100–360, § 411(d)(4)(B)(ii), as amended by Pub. L. 100–485, § 608(d)(20)(D), inserted “(other than a survey with respect to a home health agency)” after “survey” in last sentence.

    Enacted provision · exact public law section
    (b) Effective Date.— The amendment made by subsection (a) 42 USC 1395aa note. shall apply with respect to agreements entered into or renewed on or after the date of enactment of this Act.

14. 1989

    Medicare Catastrophic Coverage Repeal Act of 1989

    Pub. L. 101–234 title II § 201(a) · 103 Stat. 1979

    Repealed · 42 U.S.C. § 1395bb(a)

    Pub. L. 101–234 repealed Pub. L. 100–360, § 204(c)(3), (d)(3), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 and 1989 Amendment notes

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    Pub. L. 101–234 repealed Pub. L. 100–360, § 204(c)(3), (d)(3), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 and 1989 Amendment notes.

    Enacted provision · exact public law section
    (a) In General.— (1) General rule.— Except as provided in paragraph (2), sections 201 through 208 of MCCA are repealed and the provisions 42 USC 1320a-7a, 1320C-3 and note, 1395b-T note, 1395b, 1395k and notes, 1395l, 1395m and notes, 1395n, 1395u and notes, 1395W-2, 1395w-3, 1395x and notes, 1395y, 1395z, 1395aa-1395bb, 1395cc, 1395mm, 1395ll note, 1395ww note, 1396a, 1396b, 1396n. of law amended or repealed by such sections are restored or revived as if such sections had not been enacted. (2) Exception.— Paragraph (1) shall not apply to subsections (g) and (m)(4) of section 202 of MCCA.

15. 1989

    Omnibus Budget Reconciliation Act of 1989

    Pub. L. 101–239 § 6115(c) · 103 Stat. 2106

    Substituted · 42 U.S.C. § 1395bb(a)

    Pub. L. 101–239, § 6115(c), substituted “paragraphs (15) and (16)” for “paragraphs (14) and (15)”

    Source evidence

    Code amendment note
    Subsec. (a). Pub. L. 101–239, § 6115(c), substituted “paragraphs (15) and (16)” for “paragraphs (14) and (15)”.

    Enacted provision · exact public law section
    (c) Conforming Amendments.— Sections 1864(a), 1865(a), 1902(a)(9)(C), and 1915(a)(1)(B)(ii)(I) of such Act (42 U.S.C. 1395aa(a), 1395bb(a), 1396(a)(9)(C), 1396n(a)(1)(B)(ii)(I)) are each amended by 42 USC 1396a. striking “paragraphs (14) and (15)” and inserting “paragraphs (15) and (16)”.

16. 1989

    Omnibus Budget Reconciliation Act of 1989

    Pub. L. 101–239 § 6019(b) · 103 Stat. 2106

    Inserted · 42 U.S.C. § 1395bb(a)

    Pub. L. 101–239, § 6019(b), inserted before period at end “, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary”

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    Pub. L. 101–239, § 6019(b), inserted before period at end “, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary”.

    Enacted provision · exact public law section
    (b) Authorizing Secretary to Release Certain Information.— Section 1865(a) of such Act is further amended by striking the period at the end of the last sentence and inserting the following: ”, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary.”.

17. 1989

    Omnibus Budget Reconciliation Act of 1989

    Pub. L. 101–239 § 6003(g)(3)(C)(iv) · 103 Stat. 2106

    Substituted · 42 U.S.C. § 1395bb(a)

    Pub. L. 101–239, § 6003(g)(3)(C)(iv), substituted “1395x(dd)(2), or 1395x(mm)(1) of this title” for “or 1395x(dd)(2) of this title” in third sentence

    Target inherited from the preceding amendment note.

    Source evidence

    Code amendment note
    Pub. L. 101–239, § 6003(g)(3)(C)(iv), substituted “1395x(dd)(2), or 1395x(mm)(1) of this title” for “or 1395x(dd)(2) of this title” in third sentence.

    Enacted provision · exact public law section
    (iv) The third sentence of section 1865(a) of such Act (42 U.S.C. 1395bb(a)) is amended by striking “or 1861(dd)(2)” and inserting “1861(dd)(2), or 1861(mm)(1)”.

18. 1989

    Omnibus Budget Reconciliation Act of 1989

    Pub. L. 101–239 § 6019(a) · 103 Stat. 2106

    1. Amended · 42 U.S.C. § 1395bb(a)(2)

       Pub. L. 101–239, § 6019(a), designated existing provisions as subpar. (A)

    2. Struck · 42 U.S.C. § 1395bb(a)(2)

       Pub. L. 101–239, § 6019(a), struck out “(if it is included within a survey described in section 1395aa(c) of this title)” after “such institution”

    3. Inserted · 42 U.S.C. § 1395bb(a)(2)

       Pub. L. 101–239, § 6019(a), inserted “, together with any other information directly related to the survey as the Secretary may require (including corrective action plans)” after “by such Commission”

    4. Added · 42 U.S.C. § 1395bb(a)(2)

       Pub. L. 101–239, § 6019(a), added subpar. (B)

    Source evidence

    Code amendment note
    Subsec. (a)(2). Pub. L. 101–239, § 6019(a), designated existing provisions as subpar. (A), struck out “(if it is included within a survey described in section 1395aa(c) of this title)” after “such institution”, inserted “, together with any other information directly related to the survey as the Secretary may require (including corrective action plans)” after “by such Commission”, and added subpar. (B).

    Enacted provision · exact public law section
    (a) Requiring All Institutions and JCAHO to Release Surveys to Secretary.— Section 1865(a)(2) of the Social Security Act (42 U.S.C. 1395bb(a)(2)) is amended— (1) by striking “(2) such institution” and inserting “(2)(A) such institution”; (2) by striking “(if it is included within a survey described in section 1864(c))”; (3) by striking the comma at the end and inserting the following: “, together with any other information directly related to the survey as the Secretary may require (including corrective action plans),”; and (4) by adding at the end the following new subparagraph: “(B) such Commission releases such a copy and any such information to the Secretary,”.

19. 1989

    Omnibus Budget Reconciliation Act of 1989

    Pub. L. 101–239 § 6019(c) · 103 Stat. 2106

    Struck · 42 U.S.C. § 1395bb(b)

    Pub. L. 101–239, § 6019(c), struck out “following a survey made pursuant to section 1395aa(c) of this title” after “if the Secretary finds”

    Source evidence

    Code amendment note
    Subsec. (b). Pub. L. 101–239, § 6019(c), struck out “following a survey made pursuant to section 1395aa(c) of this title” after “if the Secretary finds”.

    Enacted provision · exact public law section
    (c) Permitting Secretary to Withdraw Hospital’s Status Based Upon Information Other Than Surveys.— Section 1865(b) of such Act is amended by striking “following a survey made pursuant to section 1864(c)”.

20. 1990

    Omnibus Budget Reconciliation Act of 1990

    Pub. L. 101–508 title IV § 4163(c)(3) · 104 Stat. 1388

    Inserted · 42 U.S.C. § 1395bb(a)

    Pub. L. 101–508 inserted “1395m(c)(3),” after “1395k(a)(2)(F)(i),” in second sentence

    Source evidence

    Code amendment note
    Subsec. (a). Pub. L. 101–508 inserted “1395m(c)(3),” after “1395k(a)(2)(F)(i),” in second sentence.

    Enacted provision · exact public law section
    (3) Section 1865(a) of such Act (42 U.S.C. 1395bb(a)) is amended by inserting “T834(c)(3),” after “1832(a)(2)(F)(i),”.

21. 1994

    Social Security Act Amendments of 1994

    Pub. L. 103–432 title I § 145(c)(4) · 108 Stat. 4398

    Struck · 42 U.S.C. § 1395bb(a)

    Pub. L. 103–432 struck out “1395m(c)(3),” after “conditions of section 1395k(a)(2)(F)(i),” in closing provisions

    Source evidence

    Code amendment note
    Subsec. (a). Pub. L. 103–432 struck out “1395m(c)(3),” after “conditions of section 1395k(a)(2)(F)(i),” in closing provisions.

    Enacted provision · exact public law section
    (4) The third sentence of section 1865(a) (42 U.S.C. 1395bb(a)) is amended by striking “1834(c)(3),”.

22. 1996

    Pub. L. 104–134 § 101(d)(tV)(s516)(b)(2) · 110 Stat. 1321

    1. Struck · 42 U.S.C. § 1395bb(a)

       Pub. L. 104–134, § 101(d) [title V, § 516(b)(2), (3)], struck out after second sentence: “In addition, if the Secretary finds that accreditation of an entity by the American Osteopathic Association or any other national accreditation body provides reasonable assurance that any or all of the conditions of section 1395k(a)(2)(F)(i), 1395x(e), 1395x(f), 1395x(j), 1395x(o), 1395x(p)(4)(A) or (B), paragraphs (15) and (16) of section 1395x(s), section 1395x(aa)(2), 1395x(cc)(2), 1395x(dd)(2), or 1395x(mm)(1) of this title, as the case may be, are met, he may, to the extent he deems it appropriate, treat such entity as meeting the condition or conditions with respect to which he made such finding.”

    2. Redesignated · 42 U.S.C. § 1395bb(a)

       Pub. L. 104–134, § 101(d) [title V, § 516(b)(2), (3)], redesignated fourth sentence as subsec. (c)

    Source evidence

    Code amendment note
    Subsec. (a). Pub. L. 104–134, § 101(d) [title V, § 516(b)(2), (3)], struck out after second sentence: “In addition, if the Secretary finds that accreditation of an entity by the American Osteopathic Association or any other national accreditation body provides reasonable assurance that any or all of the conditions of section 1395k(a)(2)(F)(i), 1395x(e), 1395x(f), 1395x(j), 1395x(o), 1395x(p)(4)(A) or (B), paragraphs (15) and (16) of section 1395x(s), section 1395x(aa)(2), 1395x(cc)(2), 1395x(dd)(2), or 1395x(mm)(1) of this title, as the case may be, are met, he may, to the extent he deems it appropriate, treat such entity as meeting the condition or conditions with respect to which he made such finding.” and redesignated fourth sentence as subsec. (c).

    Enacted provision · exact public law section
    Section 101. For programs, projects or activities in the Departments of Commerce, Justice, and State, the Judiciary, and Related Agencies Appropriations Act, 1996, provided as follows, to be effective as if it had been enacted into law as the regular appropriations Act:

23. 1996

    Pub. L. 104–134 § 101(d)(tV)(s516)(b)(3) · 110 Stat. 1321

    Redesignated · 42 U.S.C. § 1395bb(b)

    Pub. L. 104–134, § 101(d) [title V, § 516(b)(3)], added subsec. (b). Former subsec. (b) redesignated (d)

    Source evidence

    Code amendment note
    Subsec. (b). Pub. L. 104–134, § 101(d) [title V, § 516(b)(3)], added subsec. (b). Former subsec. (b) redesignated (d).

    Enacted provision · exact public law section
    Section 101. For programs, projects or activities in the Departments of Commerce, Justice, and State, the Judiciary, and Related Agencies Appropriations Act, 1996, provided as follows, to be effective as if it had been enacted into law as the regular appropriations Act:

24. 1996

    Pub. L. 104–134 § 101(d)(tV)(s516)(b)(2) · 110 Stat. 1321

    Redesignated · 42 U.S.C. § 1395bb(c)

    Pub. L. 104–134, § 101(d) [title V, § 516(b)(2)], redesignated fourth sentence of subsec. (a) as subsec. (c)

    Source evidence

    Code amendment note
    Subsec. (c). Pub. L. 104–134, § 101(d) [title V, § 516(b)(2)], redesignated fourth sentence of subsec. (a) as subsec. (c).

    Enacted provision · exact public law section
    Section 101. For programs, projects or activities in the Departments of Commerce, Justice, and State, the Judiciary, and Related Agencies Appropriations Act, 1996, provided as follows, to be effective as if it had been enacted into law as the regular appropriations Act:

25. 1996

    Pub. L. 104–134 § 101(d)(tV)(s516)(b)(1) · 110 Stat. 1321

    1. Redesignated · 42 U.S.C. § 1395bb(d)

       Pub. L. 104–134, § 101(d) [title V, § 516(b)(1), (c)(2)(A)], redesignated subsec. (b) as (d)

    2. Substituted · 42 U.S.C. § 1395bb(d)

       Pub. L. 104–134, § 101(d) [title V, § 516(b)(1), (c)(2)(A)], substituted “a provider entity” for “a hospital”

    3. Substituted · 42 U.S.C. § 1395bb(d)

       Pub. L. 104–134, § 101(d) [title V, § 516(b)(1), (c)(2)(A)], substituted “the entity” for “the hospital”

    4. Substituted · 42 U.S.C. § 1395bb(d)

       Pub. L. 104–134, § 101(d) [title V, § 516(b)(1), (c)(2)(A)], substituted “the conditions or requirements the entity has been treated as meeting pursuant to subsection (a) or (b)(1) of this section” for “the requirements of the numbered paragraphs of section 1395x(e) of this title”

    Source evidence

    Code amendment note
    Subsec. (d). Pub. L. 104–134, § 101(d) [title V, § 516(b)(1), (c)(2)(A)], redesignated subsec. (b) as (d) and substituted “a provider entity” for “a hospital”, “the entity” for “the hospital” in two places, and “the conditions or requirements the entity has been treated as meeting pursuant to subsection (a) or (b)(1) of this section” for “the requirements of the numbered paragraphs of section 1395x(e) of this title”.

    Enacted provision · exact public law section
    Section 101. For programs, projects or activities in the Departments of Commerce, Justice, and State, the Judiciary, and Related Agencies Appropriations Act, 1996, provided as follows, to be effective as if it had been enacted into law as the regular appropriations Act:

26. 1996

    Pub. L. 104–134 § 101(d)(tV)(s516)(c)(2)(B) · 110 Stat. 1321

    Added · 42 U.S.C. § 1395bb(e)

    Pub. L. 104–134, § 101(d) [title V, § 516(c)(2)(B)], added subsec. (e)

    Source evidence

    Code amendment note
    Subsec. (e). Pub. L. 104–134, § 101(d) [title V, § 516(c)(2)(B)], added subsec. (e).

    Enacted provision · exact public law section
    Section 101. For programs, projects or activities in the Departments of Commerce, Justice, and State, the Judiciary, and Related Agencies Appropriations Act, 1996, provided as follows, to be effective as if it had been enacted into law as the regular appropriations Act:

27. 2003

    Medicare Prescription Drug, Improvement, and Modernization Act of 2003

    Pub. L. 108–173 title VII § 736(a)(12) · 117 Stat. 2066

    Substituted · 42 U.S.C. § 1395bb(b)(3)(B)

    Pub. L. 108–173 substituted “sections” for “section”

    Source evidence

    Code amendment note
    Subsec. (b)(3)(B). Pub. L. 108–173 substituted “sections” for “section”.

    Enacted provision · exact public law section
    (12) Section 1865(b)(3)(B) (42 U.S.C. 1395bb(b)(3)(B)) is amended by striking “section 1819 and 1861(j)” and inserting “sections 1819 and 1861(j)”.

28. 2008

    Medicare Improvements for Patients and Providers Act of 2008

    Pub. L. 110–275 § 125(a) · 122 Stat. 2494

    1. Redesignated · 42 U.S.C. § 1395bb(a)

       Pub. L. 110–275, § 125(a), redesignated subsec. (b) as (a)

    2. Struck · 42 U.S.C. § 1395bb(a)

       Pub. L. 110–275, § 125(a), struck out former subsec. (a) which provided criteria necessary for an institution to meet certain requirements enumerated in section 1395x(e) of this title

    Source evidence

    Code amendment note
    Subsec. (a). Pub. L. 110–275, § 125(a), redesignated subsec. (b) as (a) and struck out former subsec. (a) which provided criteria necessary for an institution to meet certain requirements enumerated in section 1395x(e) of this title.

    Enacted provision · exact public law section
    (a) Revocation.— Section 1865 of the Social Security Act (42 U.S.C. 1395bb) is amended— (1) by striking subsection (a); and (2) by redesignating subsections (b), (c), (d), and (e) as subsections (a), (b), (c), and (d), respectively.

    Effective date note
    Pub. L. 110–275, title I, § 125(d), July 15, 2008, 122 Stat. 2520, provided that:

29. 2008

    Medicare Improvements for Patients and Providers Act of 2008

    Pub. L. 110–275 § 125(b)(1)(A) · 122 Stat. 2494

    Substituted · 42 U.S.C. § 1395bb(a)(1)

    Pub. L. 110–275, § 125(b)(1)(A), substituted “If” for “In addition, if”

    Source evidence

    Code amendment note
    Subsec. (a)(1). Pub. L. 110–275, § 125(b)(1)(A), substituted “If” for “In addition, if”.

    Enacted provision · exact public law section
    (A) in subsection (a)(1), as redesignated by subsection (a)(2), by striking “In addition, if” and inserting “If”;

    Effective date note
    Pub. L. 110–275, title I, § 125(d), July 15, 2008, 122 Stat. 2520, provided that:

30. 2008

    Medicare Improvements for Patients and Providers Act of 2008

    Pub. L. 110–275 § 125(a) · 122 Stat. 2494

    1. Redesignated · 42 U.S.C. § 1395bb(b)

       Pub. L. 110–275, § 125(a), (b)(1)(B), redesignated subsec. (c) as (b)

    2. Substituted · 42 U.S.C. § 1395bb(b)

       Pub. L. 110–275, § 125(a), (b)(1)(B), substituted “released to the Secretary by” for “released to him by the Joint Commission on Accreditation of Hospitals,”

    3. Redesignated · 42 U.S.C. § 1395bb(b)

       Pub. L. 110–275, § 125(a), (b)(1)(B), struck out the comma after “Osteopathic Association”. Former subsec. (b) redesignated (a)

    Source evidence

    Code amendment note
    Subsec. (b). Pub. L. 110–275, § 125(a), (b)(1)(B), redesignated subsec. (c) as (b), substituted “released to the Secretary by” for “released to him by the Joint Commission on Accreditation of Hospitals,”, and struck out the comma after “Osteopathic Association”. Former subsec. (b) redesignated (a).

    Enacted provision · exact public law section
    (a) Revocation.— Section 1865 of the Social Security Act (42 U.S.C. 1395bb) is amended— (1) by striking subsection (a); and (2) by redesignating subsections (b), (c), (d), and (e) as subsections (a), (b), (c), and (d), respectively.

    Effective date note
    Pub. L. 110–275, title I, § 125(d), July 15, 2008, 122 Stat. 2520, provided that:

31. 2008

    Medicare Improvements for Patients and Providers Act of 2008

    Pub. L. 110–275 § 125(a) · 122 Stat. 2494

    1. Redesignated · 42 U.S.C. § 1395bb(c); 42 U.S.C. § 1395bb(d)

       Pub. L. 110–275, § 125(a), (b)(1)(C), (D), redesignated subsecs. (d) and (e) as (c) and (d), respectively

    2. Redesignated · 42 U.S.C. § 1395bb(c); 42 U.S.C. § 1395bb(d)

       Pub. L. 110–275, § 125(a), (b)(1)(C), (D), substituted “pursuant to subsection (a)(1)” for “pursuant to subsection (a) or (b)(1)”. Former subsec. (c) redesignated (b)

    Source evidence

    Code amendment note
    Subsecs. (c), (d). Pub. L. 110–275, § 125(a), (b)(1)(C), (D), redesignated subsecs. (d) and (e) as (c) and (d), respectively, and substituted “pursuant to subsection (a)(1)” for “pursuant to subsection (a) or (b)(1)”. Former subsec. (c) redesignated (b).

    Enacted provision · exact public law section
    (a) Revocation.— Section 1865 of the Social Security Act (42 U.S.C. 1395bb) is amended— (1) by striking subsection (a); and (2) by redesignating subsections (b), (c), (d), and (e) as subsections (a), (b), (c), and (d), respectively.

    Effective date note
    Pub. L. 110–275, title I, § 125(d), July 15, 2008, 122 Stat. 2520, provided that:

32. 2008

    Medicare Improvements for Patients and Providers Act of 2008

    Pub. L. 110–275 § 125(a) · 122 Stat. 2494

    Redesignated · 42 U.S.C. § 1395bb(e)

    Pub. L. 110–275, § 125(a), redesignated subsec. (e) as (d)

    Source evidence

    Code amendment note
    Subsec. (e). Pub. L. 110–275, § 125(a), redesignated subsec. (e) as (d).

    Enacted provision · exact public law section
    (a) Revocation.— Section 1865 of the Social Security Act (42 U.S.C. 1395bb) is amended— (1) by striking subsection (a); and (2) by redesignating subsections (b), (c), (d), and (e) as subsections (a), (b), (c), and (d), respectively.

    Effective date note
    Pub. L. 110–275, title I, § 125(d), July 15, 2008, 122 Stat. 2520, provided that:

33. 2018

    Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act

    Pub. L. 115–123 § 50403(a)(1)(A)(i) · 132 Stat. 64

    Struck · 42 U.S.C. § 1395bb(a)(1)

    Pub. L. 115–123, § 50403(a)(1)(A)(i), struck out “or the conditions and requirements under section 1395rr(b) of this title” after “section 1395m(j) of this title” in introductory provisions

    Source evidence

    Code amendment note
    Subsec. (a)(1). Pub. L. 115–123, § 50403(a)(1)(A)(i), struck out “or the conditions and requirements under section 1395rr(b) of this title” after “section 1395m(j) of this title” in introductory provisions.

    Enacted provision · exact public law section
    (i) in paragraph (1), in the matter preceding subparagraph (A), by striking “or the conditions and requirements under section 1881(b)”; and

34. 2018

    Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act

    Pub. L. 115–123 § 50403(a)(1)(A)(ii) · 132 Stat. 64

    Inserted · 42 U.S.C. § 1395bb(a)(4)

    Pub. L. 115–123, § 50403(a)(1)(A)(ii), inserted “(including a renal dialysis facility)” after “facility”

    Source evidence

    Code amendment note
    Subsec. (a)(4). Pub. L. 115–123, § 50403(a)(1)(A)(ii), inserted “(including a renal dialysis facility)” after “facility”.

    Enacted provision · exact public law section
    (ii) in paragraph (4), by inserting “(including a renal dialysis facility)” after “facility”; and

35. 2018

    Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act

    Pub. L. 115–123 § 50403(a)(1)(B) · 132 Stat. 64

    Added · 42 U.S.C. § 1395bb(e)

    Pub. L. 115–123, § 50403(a)(1)(B), added subsec. (e)

    Source evidence

    Code amendment note
    Subsec. (e). Pub. L. 115–123, § 50403(a)(1)(B), added subsec. (e).

    Enacted provision · exact public law section
    (B) by adding at the end the following new subsection: “(e) With respect to an accreditation body that has received approval from the Secretary under subsection (a)(3)(A) for accreditation of provider entities that are required to meet the conditions and requirements under section 1881(b), in addition to review and oversight authorities otherwise applicable under this title, the Secretary shall (as the Secretary determines appropriate) conduct, with respect to such accreditation body and provider entities, any or all of the following as frequently as is otherwise required to be conducted under this title with respect to other accreditation bodies or other provider entities: “(1) Validation surveys referred to in subsection (d). “(2) Accreditation program reviews (as defined in section 488.8(c) of title 42 of the Code of Federal Regulations, or a successor regulation). “(3) Performance reviews (as defined in section 488.8(a) of title 42 of the Code of Federal Regulations, or a successor regulation).” .

36. 2020

    Department of Homeland Security Appropriations Act, 2021

    Pub. L. 116–260 div. CC title IV § 407(a)(2) · 134 Stat. 1182

    Inserted · 42 U.S.C. § 1395bb(b)

    Pub. L. 116–260 inserted “or, beginning on December 27, 2020, a hospice program” after “home health agency”

    Source evidence

    Code amendment note
    Subsec. (b). Pub. L. 116–260 inserted “or, beginning on December 27, 2020, a hospice program” after “home health agency”.

    Enacted provision · exact public law section
    Sec. 407. The functions of the Federal Law Enforcement Training Centers instructor staff shall be classified as inherently governmental for purposes of the Federal Activities Inventory Reform Act of 1998 (31 U.S.C. 501 note).

51 of 56 references resolved to an enrolled provision · 5 partial